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.

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.

Inguinal Hernia

Also known as: Groin hernia

An inguinal hernia is protrusion of preperitoneal fat, peritoneal sac or abdominal contents through the inguinal region above the inguinal ligament.

It is classified anatomically as:

Indirect: enters through the deep inguinal ring lateral to the inferior epigastric vessels.
Direct: protrudes through the posterior wall of the inguinal canal medial to the inferior epigastric vessels.

The distinction is anatomically important but usually does not alter the principle of elective mesh repair.

The major complications are acute irreducibility, bowel obstruction and strangulation.

Typical presentation is a groin swelling that increases with standing, coughing or straining and reduces when supine or with gentle pressure.

Pain is usually a dragging or aching discomfort rather than severe pain.

Examine standing and supine. Assess:

Site relative to the pubic tubercle and inguinal ligament
Reducibility
Cough impulse
Extension into the scrotum
Contralateral groin
Features of bowel obstruction or strangulation

An acutely painful irreducible hernia with vomiting, abdominal distension, focal tenderness, overlying skin change or systemic toxicity should be considered strangulated until proven otherwise.

Repair symptomatic inguinal hernias when the patient is fit for surgery.

Watchful waiting is reasonable in men with an asymptomatic or minimally symptomatic reducible hernia. The risk of an acute event is low, but symptoms frequently progress. Long term data show approximately 71% ultimately undergo repair by 10 years, predominantly because of increasing pain.

Elective repair should usually use a flat synthetic mesh.

The major options are:

Lichtenstein repair: open anterior tension free mesh repair.
TEP repair: totally extraperitoneal placement of mesh in the preperitoneal space.
TAPP repair: transabdominal access followed by preperitoneal mesh placement.

TEP and TAPP provide similar effective repairs when performed by experienced surgeons. Minimally invasive repair is particularly useful for bilateral hernias, recurrent hernia after previous anterior repair and women because the entire myopectineal orifice, including the femoral canal, is visualised.

For recurrence after previous anterior repair, use a posterior preperitoneal approach where possible. For recurrence after previous posterior repair, an anterior approach avoids operating through the same scarred plane.

Mesh plugs should not be used routinely.

Acute irreducibility without evidence of strangulation may undergo gentle manual reduction with adequate analgesia and sedation. Observe after successful reduction and arrange definitive repair. Do not attempt forceful reduction when strangulation is suspected.

Failure of reduction or suspected strangulation requires emergency surgery.

At emergency operation, assess bowel viability before completing the repair. Nonviable bowel requires resection. A macroporous synthetic mesh can still be considered when bowel resection occurs without gross enteric contamination. Gross faecal contamination or established infection requires a more cautious individualised approach to prosthetic material.

Femoral Hernia

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management