Overview
Definition:
Incarceration of a femoral hernia occurs when abdominal contents, typically bowel or omentum, become trapped within the femoral sac, unable to be reduced back into the peritoneal cavity
This represents a surgical emergency due to the high risk of strangulation and subsequent bowel compromise.
Epidemiology:
Femoral hernias are less common than inguinal hernias, accounting for approximately 3-5% of all groin hernias
They are significantly more common in women than men, often presenting in older individuals due to factors like multiparity, increased intra-abdominal pressure, and weakened pelvic floor structures
Incarceration rates are higher in femoral hernias compared to inguinal hernias due to the narrow and rigid nature of the femoral canal.
Clinical Significance:
Incarcerated femoral hernias are a critical surgical emergency
Delayed diagnosis and treatment can lead to strangulation, which implies compromised blood supply to the entrapped viscus
This can result in bowel ischemia, necrosis, perforation, peritonitis, sepsis, and a high risk of mortality
Prompt recognition and surgical intervention are paramount to prevent these life-threatening complications and ensure optimal patient outcomes.
Clinical Presentation
Symptoms:
Sudden onset of severe, persistent pain in the groin or medial thigh, often radiating to the abdomen
A palpable, irreducible, tender lump in the femoral region
Nausea and vomiting, especially if bowel is involved
Signs of intestinal obstruction like abdominal distension, constipation, and obstipation
Fever may indicate strangulation or perforation.
Signs:
A tender, irreducible bulge in the femoral canal, typically below the inguinal ligament and lateral to the pubic tubercle
Erythema or edema over the bulge may suggest inflammation or impending strangulation
Abdominal examination may reveal distension, tenderness, and bowel sounds altered or absent in cases of obstruction
Vital signs may be unstable in cases of sepsis or shock.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the presence of a tender, irreducible mass in the femoral region associated with symptoms of bowel obstruction or significant pain
Imaging modalities like ultrasound or CT scan can confirm the diagnosis, delineate the extent of involvement, and assess for signs of strangulation, such as bowel wall thickening, fluid, or lack of enhancement.
Diagnostic Approach
History Taking:
Detailed history of onset, duration, and character of pain
Previous episodes of reducible groin swellings
Presence of nausea, vomiting, abdominal pain, or changes in bowel habits
Any prior abdominal surgeries or medical conditions predisposing to hernias
Identify red flags like fever, severe pain, or signs of systemic illness.
Physical Examination:
A systematic examination of the groin and abdominal regions is essential
Palpate for the hernia bulge, noting its location, size, tenderness, and reducibility
Perform a digital rectal examination to rule out rectal pathology and assess for fecal impaction
Examine the entire abdomen for distension, tenderness, and bowel sounds.
Investigations:
Laboratory investigations usually include a complete blood count (CBC) to assess for leukocytosis, electrolytes, renal function tests (RFTs), and liver function tests (LFTs)
Imaging: Ultrasound is often the initial modality of choice for superficial structures, demonstrating the incarcerated sac and its contents
CT scan of the abdomen and pelvis is highly sensitive and specific, providing detailed anatomical information, assessing for bowel viability, and ruling out other intra-abdominal pathologies
It can confirm bowel wall thickening, mesenteric edema, and signs of ischemia.
Differential Diagnosis:
Other conditions presenting as a groin mass include inguinal hernia (direct or indirect), saphena varix, lymphadenopathy (inguinal lymph node enlargement due to infection or malignancy), femoral artery aneurysm, psoas abscess, and undescended testis in pediatric cases
Differentiating from these conditions relies on careful history, physical examination, and targeted investigations.
Management
Initial Management:
Immediate management involves resuscitation, fluid replacement, analgesia, and nasogastric tube insertion for gastric decompression if vomiting or obstruction is present
The patient should be made NPO (nil per os)
Broad-spectrum intravenous antibiotics should be administered, especially if strangulation or perforation is suspected.
Surgical Management:
Emergency surgical repair is indicated for all incarcerated femoral hernias
The approach can be open or laparoscopic
The primary goal is to reduce the contents, assess viability, and repair the defect
If strangulation is present with non-viable bowel, resection and anastomosis or stoma formation may be necessary
The femoral defect is typically repaired using a prosthetic mesh or by approximating the inguinal ligament to the pectineal ligament (e.g., using the McVay technique).
Supportive Care:
Postoperatively, continuous monitoring of vital signs, fluid balance, and pain control is crucial
Nasogastric tube output should be monitored, and oral intake advanced as tolerated
Wound care and early mobilization are important to prevent complications like deep vein thrombosis and chest infections
Close observation for signs of anastomotic leak or wound infection is essential.
Complications
Early Complications:
Bowel strangulation with resultant ischemia, necrosis, and perforation
Sepsis and septic shock
Wound infection
Recurrence of hernia
Damage to surrounding structures like the femoral artery or nerve
Ileus
Anastomotic leak if bowel resection was performed.
Late Complications:
Chronic groin pain
Nerve entrapment syndromes
Mesh infection or extrusion (if mesh used)
Recurrence of hernia
Adhesions leading to bowel obstruction
Persistent lymphedema.
Prevention Strategies:
Prompt surgical intervention for incarcerated hernias is the primary prevention strategy
Meticulous surgical technique, careful handling of tissues, and appropriate tension-free repair (often with mesh) can minimize recurrence
Postoperative management focusing on preventing infection and promoting early recovery also aids in reducing complications.
Prognosis
Factors Affecting Prognosis:
The primary determinant of prognosis is the presence and extent of strangulation
Earlier intervention in the absence of strangulation generally leads to excellent outcomes
Factors such as patient comorbidities, severity of sepsis, and the need for bowel resection significantly influence morbidity and mortality.
Outcomes:
In uncomplicated incarcerated femoral hernias requiring urgent repair, the prognosis is generally good with low morbidity
However, if strangulation and bowel compromise occur, morbidity and mortality rates increase significantly
Patients requiring bowel resection have a higher risk of complications.
Follow Up:
Postoperative follow-up should include assessment of wound healing, pain management, and functional recovery
Patients should be advised on recognizing symptoms of recurrence or complications
Routine follow-up is typically for 1-2 weeks post-discharge, with longer-term review as dictated by the complexity of the repair and patient recovery.
Key Points
Exam Focus:
Femoral hernias are more common in women and have a higher rate of incarceration and strangulation than inguinal hernias due to the narrow, rigid femoral canal
Incarceration is a surgical emergency requiring immediate operative intervention
Recognize the signs of strangulation (severe pain, irreducibility, systemic illness).
Clinical Pearls:
Always consider a femoral hernia in any woman with a groin lump and bowel symptoms
A high index of suspicion is crucial for prompt diagnosis
When performing a femoral hernia repair, carefully identify and protect the femoral vein and artery
Consider a mesh repair for definitive closure, especially in younger patients or those with a large defect, to reduce recurrence.
Common Mistakes:
Delaying surgical intervention due to misdiagnosis or underestimation of severity
Inadequate assessment of bowel viability during surgery
Performing a repair under tension without mesh in older patients, leading to recurrence
Neglecting to identify and protect vital structures in the femoral region
Failing to consider and manage intestinal obstruction aggressively.