Femoral Hernia

A femoral hernia passes through the femoral ring into the femoral canal, below the inguinal ligament and medial to the femoral vein.

The femoral ring is bounded by:

• Inguinal ligament anteriorly
• Pectineal ligament posteriorly
• Lacunar ligament medially
• Femoral vein laterally

Its rigid narrow boundaries explain the high risk of incarceration and strangulation.

Femoral hernias are substantially more common in women and are frequently mistaken clinically for inguinal hernias.

The typical finding is a small groin swelling below the inguinal ligament, usually inferolateral to the pubic tubercle.

The lump may be difficult to identify in obese patients or during emergency obstruction.

Femoral hernias often first present with:

• Acute groin pain
• Small bowel obstruction
• Irreducible groin mass
• Strangulated bowel

Richter type entrapment may strangulate only part of the bowel circumference, allowing continued passage of stool despite evolving bowel necrosis.

Clinical examination should specifically assess the femoral canal in every groin hernia, particularly in women.

Ultrasound: useful for an elective uncertain groin lump.

CT abdomen and pelvis: preferred when femoral hernia presents with bowel obstruction or possible strangulation; identify bowel entering the femoral canal and assess viability.

A diagnosed femoral hernia should generally be repaired rather than observed because the narrow neck creates a substantial risk of acute incarceration and strangulation.

Women with groin hernias should normally undergo timely repair rather than watchful waiting. Minimally invasive preperitoneal repair is particularly useful because it visualises and covers both inguinal and femoral defects. Recent large analyses show markedly worse outcomes when women present for emergency rather than elective repair.

Elective repair usually uses mesh placed over the femoral component of the myopectineal orifice.

TEP or TAPP provides excellent access in stable elective disease.

Open approaches remain appropriate where minimally invasive expertise is unavailable or emergency anatomy dictates.

An acutely painful irreducible femoral hernia requires urgent surgical assessment. Do not persist with taxis when strangulation is suspected.

At operation, release the constricting femoral ring carefully while protecting the femoral vein. Division of the lacunar ligament can facilitate reduction but carries a risk of bleeding from an aberrant obturator vessel, the corona mortis.

Assess the entrapped bowel after reduction. Nonviable bowel requires resection.

Synthetic mesh remains reasonable in a clean field and can be considered after bowel resection when there is no gross enteric contamination.