Smouldering myeloma is a disease classified as intermediate in a spectrum of step-wise progressive diseases termed plasma cell dyscrasias. In this spectrum of diseases, a clone of plasma cells secreting monoclonal paraprotein (also termed myeloma protein or M protein) causes the relatively benign disease of monoclonal gammopathy of undetermined significance. This clone proliferates and may slowly evolve into more aggressive sub-clones that cause smouldering multiple myeloma. Further and more rapid evolution causes the overtly malignant stage of multiple myeloma and can subsequently lead to the extremely malignant stage of secondary plasma cell leukemia. Thus, some patients with smouldering myeloma progress to multiple myeloma and plasma cell leukemia. Smouldering myeloma, however, is not a malignant disease. It is characterised as a pre-malignant disease that lacks symptoms but is associated with bone marrow biopsy showing the presence of an abnormal number of clonal myeloma cells, blood and/or urine containing a myeloma protein, and a significant risk of developing into a malignant disease. Diagnosis
Smouldering myeloma is characterised by:
Serum paraprotein >30 g/L or urinary monoclonal protein ≥500 mg per 24 h AND/OR
Clonal plasma cells >10% and <60% on bone marrow biopsy AND
No evidence of end organ damage that can be attributed to plasma cell disorder AND
No myeloma-defining event (>60% plasma cells in bone marrow OR Involved/Uninvolved light chain ratio>100)

Treatment
Treatment for multiple myeloma is focused on therapies that decrease the clonal plasma cell population and consequently decrease the signs and symptoms of disease. If the disease is completely asymptomatic (i.e.
With minimally invasive surgery, one or more small incisions are made that allow the surgeon to use a surgical camera and small tools to repair the hernia.Either open or minimally invasive surgery may be performed under general or regional anesthesia, depending on the extent of the intervention needed. Three approaches have been described for open surgery:

Lockwood’s infra-inguinal approach
Lotheissen‘s trans-inguinal approach
McEvedy’s high approachThe infra-inguinal approach is the preferred method for elective repair. The trans-inguinal approach involves dissecting through the inguinal canal and carries the risk of weakening the inguinal canal. McEvedy’s approach is preferred in the emergency setting when strangulation is suspected. This allows better access to and visualization of the bowel for possible resection. In any approach, care should be taken to avoid injury to the urinary bladder which is often a part of the medial part of the hernial sac. Repair is either performed by suturing the inguinal ligament to the pectineal ligament using strong non-absorbable sutures or by placing a mesh plug in the femoral ring. With either technique care should be taken to avoid any pressure on the femoral vein. Postoperative outcome
Patients undergoing elective surgical repair do very well and may be able to go home the same day. However, emergency repair carries a greater morbidity and mortality rate and this is directly proportional to the degree of bowel compromise. Epidemiology
Femoral hernias are more common in multiparous females, which results from elevated intra-abdominal pressure that dilates the femoral vein and in turn stretches femoral ring.