Overview
Definition:
A femoral hernia is an anterior abdominal wall defect occurring when abdominal contents protrude through the femoral canal, medial to the femoral vein and under the inguinal ligament.
Epidemiology:
Femoral hernias are less common than inguinal hernias, accounting for approximately 3-5% of all groin hernias
They are more prevalent in women, particularly older multiparous women, and are associated with a higher risk of strangulation
Risk factors include increased intra-abdominal pressure, obesity, and chronic straining
Recurrence rates vary based on the surgical technique.
Clinical Significance:
Femoral hernias are clinically significant due to their narrow neck and proximity to vital structures, leading to a high risk of incarceration and strangulation, often presenting as surgical emergencies
Prompt diagnosis and surgical repair are crucial to prevent life-threatening complications such as bowel obstruction, perforation, and sepsis
Understanding the anatomical principles and surgical approaches is vital for successful outcomes.
Clinical Presentation
Symptoms:
A reducible bulge in the groin, typically below the inguinal ligament, that may disappear when lying down
Pain or discomfort in the groin, especially with straining or standing
Nausea and vomiting may occur if incarcerated or strangulated
Signs of bowel obstruction may be present in strangulated hernias, including severe pain, abdominal distension, and inability to pass flatus or stool.
Signs:
A visible or palpable bulge in the femoral region, often more apparent when the patient stands
The bulge may be tender to palpation
Reducible: The bulge can be manually pushed back into the abdominal cavity
Irreducible: The bulge cannot be reduced
Incarcerated: The hernia is irreducible, but there is no compromised blood supply
Strangulated: The incarcerated hernia has compromised blood supply, leading to ischemia and potential necrosis of the contents
Signs of peritonitis may be present if strangulation leads to bowel perforation.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on history and physical examination findings
Imaging modalities are used to confirm diagnosis, assess the extent of the hernia, and rule out differential diagnoses, especially in cases of suspected incarceration or strangulation
There are no formal diagnostic criteria beyond clinical suspicion and confirmation through investigations.
Diagnostic Approach
History Taking:
Detailed history of the onset, duration, and progression of the bulge
Character of any pain or discomfort
Association with activities that increase intra-abdominal pressure (coughing, straining, lifting)
Previous surgical history in the groin or abdomen
Episodes of nausea, vomiting, or bowel changes
Red flags: sudden onset of severe pain, irreducible bulge, fever, signs of sepsis, or bowel obstruction.
Physical Examination:
Patient should be examined in both supine and standing positions
Palpate for a bulge in the groin, femoral region, and scrotum
Attempt reduction of any bulge
Assess for tenderness, irreducibility, and signs of strangulation (erythema, edema, severe tenderness)
A digital rectal examination may be helpful to rule out rectal pathology or to assess for a posterior wall defect
Examine the contralateral groin for any occult hernias.
Investigations:
Ultrasound of the groin is the initial imaging modality of choice to confirm the presence and contents of the hernia, and to distinguish it from other groin masses
CT scan of the abdomen and pelvis is useful for complex cases, suspected incarceration or strangulation, and to evaluate for associated intra-abdominal pathology
MRI may be used in specific situations but is less common than ultrasound or CT for initial diagnosis.
Differential Diagnosis:
Inguinal hernia, saphena varix, lymphadenopathy, femoral lymph node enlargement, psoas abscess, iliacus hematoma, undescended testis, undescended ovary, adenomyoma, incarcerated inguinal hernia, incarcerated umbilical hernia, lipoma, abscess, cyst, tumor of the thigh or groin.
Management
Initial Management:
For reducible femoral hernias, surgical repair is indicated electively
For incarcerated or strangulated femoral hernias, immediate surgical intervention is required
Pain management with analgesics
If bowel obstruction is present, NPO status, nasogastric tube decompression, and intravenous fluid resuscitation are necessary
Broad-spectrum antibiotics should be administered in suspected strangulation or perforation.
Surgical Management:
Surgical repair is the definitive treatment
Options include: Open repair: Using the inguinal ligament approach (e.g., McEvedy repair, Lockwood repair) or a low approach
Inguinal ligament repair often involves approximating the transversalis fascia to the pectineal ligament
Mesh repair is commonly performed to reinforce the posterior wall and reduce recurrence
Laparoscopic repair: Transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approaches can be used, though less commonly for isolated femoral hernias due to anatomical challenges
The choice of approach depends on surgeon preference, patient factors, and the presence of other concurrent hernias.
Postoperative Care:
Monitor for pain, nausea, and vomiting
Encourage early mobilization to prevent deep vein thrombosis and pulmonary complications
Wound care as per protocol
Advise on activity restrictions (e.g., avoiding heavy lifting for 4-6 weeks)
Monitor for signs of infection, recurrence, or complications
Pain management with oral analgesics as needed
Diet as tolerated.
Complications
Early Complications:
Wound infection, hematoma, seroma, urinary retention, nerve injury (e.g., femoral nerve), vascular injury (e.g., femoral vessels), injury to bowel or bladder, recurrence of hernia, mesh infection, mesh migration, ileus.
Late Complications:
Chronic groin pain, meshoma, fistula formation, persistent seroma, recurrence of hernia, strangulation of contents within the mesh, adhesions.
Prevention Strategies:
Meticulous surgical technique, careful anatomical dissection, appropriate mesh selection and placement, adequate wound closure, judicious use of drains if necessary, and patient education on activity restrictions
For incarcerated/strangulated hernias, prompt surgical intervention is key
Using prosthetic mesh reinforcement can significantly reduce recurrence rates for most hernia types.
Prognosis
Factors Affecting Prognosis:
The most critical factor is whether the hernia is strangulated
Prognosis is excellent for elective repair of reducible hernias
Factors influencing outcomes include patient comorbidities, surgeon experience, technique used, and the presence of complications like strangulation or perforation.
Outcomes:
For elective repairs, outcomes are generally excellent with low morbidity and recurrence rates
Strangulated femoral hernias have a higher morbidity and mortality due to the risk of intestinal compromise
Recurrence rates are generally low, especially with modern mesh-reinforced repairs, but can be higher with certain techniques or in patients with significant risk factors.
Follow Up:
Routine follow-up is recommended at 2 weeks, 6 weeks, and 6 months post-operatively to assess wound healing, patient recovery, and to screen for early signs of recurrence
Long-term follow-up may be advised for high-risk patients or those with complicated repairs
Patients should be educated to report any new groin pain or swelling.
Key Points
Exam Focus:
Femoral hernias are rare, more common in women, and have a high risk of strangulation due to the narrow neck and fixed anatomical boundaries
Anatomical landmarks for repair are crucial: inguinal ligament, pectineal ligament, femoral vein, and lacunar ligament
Mesh repair is the standard for reducing recurrence.
Clinical Pearls:
Always examine the groin in both standing and supine positions
Consider a saphena varix in the differential for a pulsatile groin mass
If bowel resection is required due to strangulation, consider a temporary stoma
Recognize that in incarcerated femoral hernias, the risk of damage to the femoral vein is low but direct pressure can occur.
Common Mistakes:
Misdiagnosing a femoral hernia as an inguinal hernia, delaying repair of incarcerated hernias, failing to adequately reinforce the posterior wall with mesh, and inadequate patient counseling regarding post-operative activity restrictions leading to early recurrence.