Overview
Definition:
Groin hernias in women encompass protrusions of abdominal contents through congenital or acquired weaknesses in the abdominal wall, specifically in the inguinal and femoral regions
While inguinal hernias are more common overall, femoral hernias are proportionally more frequent in women and carry a higher risk of strangulation
Distinguishing between these types is crucial for appropriate surgical management and to minimize complications.
Epidemiology:
Groin hernias occur less frequently in women than in men, with reported incidences ranging from 2-10% of all groin hernias
Indirect inguinal hernias are the most common type in women, similar to men
However, femoral hernias constitute a larger proportion of hernias in women (up to 20-30%) compared to men, due to anatomical differences in the female pelvis and femoral canal
The peak incidence is typically between 40-60 years of age, though they can occur at any age.
Clinical Significance:
Accurate differentiation between femoral and inguinal hernias in women is vital due to the higher risk of incarceration and strangulation in femoral hernias
The narrowness of the femoral canal and its proximity to the inguinal ligament make it a common site for bowel to become trapped
Early diagnosis and surgical repair are essential to prevent potentially life-threatening complications, making this a high-yield topic for surgical trainees preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
A palpable bulge or lump in the groin area
Pain or discomfort, often worsened by standing, coughing, or straining
A dragging sensation in the groin
Nausea and vomiting, especially if incarcerated or strangulated
Fever and increased abdominal pain may indicate strangulation or bowel obstruction
Sudden, severe pain at the hernia site with inability to reduce the bulge suggests strangulation.
Signs:
A visible or palpable bulge in the groin, which may be reducible
Tenderness on palpation of the bulge
Cough impulse may be present
In strangulated hernias, the bulge may be tense, erythematous, and exquisitely tender
Signs of intestinal obstruction: abdominal distension, absent bowel sounds, and tenderness.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on history and physical examination
Definitive diagnosis is often confirmed intraoperatively
Imaging may be used in ambiguous cases or when complications are suspected
No formal criteria exist beyond clinical suspicion and examination findings.
Diagnostic Approach
History Taking:
Detailed history of the bulge: onset, duration, location, any associated pain or discomfort
Factors that exacerbate or relieve symptoms
History of previous abdominal surgeries or pregnancies
Any episodes of incarceration or strangulation
Review of systems for symptoms of bowel obstruction or systemic illness
Red flags: sudden onset of severe pain, irreducible bulge, fever, vomiting.
Physical Examination:
Palpation of the groin, carefully differentiating between inguinal and femoral regions
Attempt gentle reduction of the bulge
Assess for tenderness, induration, and signs of inflammation
Perform Valsalva maneuver to elicit or enlarge the bulge
A digital rectal examination may be useful if bowel involvement is suspected
Examination of the contralateral groin is important to rule out bilateral hernias.
Investigations:
Ultrasound (USG) of the groin is the most useful imaging modality to confirm the diagnosis and differentiate between inguinal and femoral hernias, especially in obese patients or when the physical examination is equivocal
It can visualize fascial defects and herniated contents
CT scan may be considered if bowel obstruction or strangulation is strongly suspected
Laboratory tests (CBC, electrolytes, renal function) are important for preoperative assessment and if systemic illness is present.
Differential Diagnosis:
Femoral hernia: typically inferior to the inguinal ligament
Inguinal hernia: located above the inguinal ligament
Lymphadenopathy: enlarged lymph nodes in the groin
Saphena varix: dilated saphenous vein
Femoral artery aneurysm: pulsatile mass
Hematoma: collection of blood
Hydrocele of the canal of Nuck (in females): fluid-filled sac
Abscess.
Management
Initial Management:
For uncomplicated hernias, surgical repair is the definitive management
For incarcerated hernias, attempts at closed reduction under sedation and analgesia should be made cautiously
If reduction is unsuccessful or if signs of strangulation are present, urgent surgical exploration is indicated.
Medical Management:
Not applicable for the definitive treatment of hernias
Analgesics and antiemetics may be used for symptom management of incarcerated or strangulated hernias prior to surgery.
Surgical Management:
Surgical repair is indicated for all symptomatic hernias in women and often for asymptomatic hernias due to the high risk of complications
Femoral hernias require urgent repair due to the high incidence of strangulation
Surgical options include open repair (e.g., Lichtenstein tension-free repair, Shouldice repair) or laparoscopic repair (e.g., TAPP, TEP)
Laparoscopic repair may offer advantages for bilateral groin hernias and recurrent hernias
Mesh is typically used for reconstruction to reinforce the abdominal wall
For femoral hernias, a low approach is usually preferred, with careful attention to reducing contents and ligating the sac as close to its origin as possible.
Supportive Care:
Preoperative optimization of nutritional status and management of comorbidities
Postoperative pain management
Monitoring for wound complications and signs of recurrence
Early mobilization to prevent deep vein thrombosis.
Complications
Early Complications:
Incarceration: herniated contents cannot be reduced
Strangulation: compromised blood supply to herniated contents, leading to bowel ischemia or necrosis
Bowel obstruction
Wound infection
Hematoma
Seroma
Urinary retention.
Late Complications:
Hernia recurrence
Chronic pain
Mesh-related complications (infection, erosion, migration) if mesh is used
Injury to adjacent structures (e.g., femoral vessels, vas deferens – though rare in women).
Prevention Strategies:
Prompt surgical repair of all symptomatic hernias
Careful surgical technique to minimize tissue damage and ensure adequate mesh fixation if used
Preoperative optimization of patient health
Appropriate postoperative care to promote healing and early mobilization.
Prognosis
Factors Affecting Prognosis:
The prognosis is generally excellent with timely surgical repair of uncomplicated hernias
Factors negatively impacting prognosis include delayed presentation, strangulation, and comorbid conditions
Strangulated hernias carry a higher morbidity and mortality risk.
Outcomes:
Successful repair leads to resolution of symptoms and prevention of future complications
Recurrence rates vary depending on the surgical technique and patient factors, but are generally low with modern mesh repairs
Laparoscopic repair may have a slightly lower recurrence rate for some types of hernias.
Follow Up:
Routine follow-up is recommended to monitor for recurrence and any late complications
The frequency and duration of follow-up depend on the surgical approach and individual patient factors, but typically involve a review at 2-6 weeks postoperatively and then as needed
Patients should be educated on recognizing signs of recurrence or complications.
Key Points
Exam Focus:
Femoral hernias are more common proportionally in women and have a higher risk of strangulation than inguinal hernias
The key anatomical difference is the location: femoral hernia is below the inguinal ligament, while inguinal hernia is above
Urgent surgical repair is indicated for incarcerated and strangulated hernias
Ultrasound is the investigation of choice for equivocal cases.
Clinical Pearls:
Always examine the groin carefully in women presenting with groin masses or pain, even if they deny a bulge
Consider a hernia in any woman with unexplained groin discomfort or a palpable mass
Do not underestimate the risk of strangulation in femoral hernias
treat them with urgency
Laparoscopic repair can be advantageous for bilateral hernias or in obese patients.
Common Mistakes:
Misdiagnosing a femoral hernia as an inguinal hernia or vice versa due to inadequate physical examination
Delaying surgical intervention in suspected strangulated hernias
Failing to consider other differentials for groin masses
Inadequate preoperative assessment for comorbidities that may affect surgical outcomes.