Femoral Hernia

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DEFINITION
An abnormal protrusion of abdominal contents through a deformity in their surroundings into the inner thigh.

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INCIDENCE

Sex
F 2-3:1 M.
Age
Older age group.
Especially after a period of weight loss.
More common in parous females.
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AETIOLOGY

Anatomy
The femoral ring forms the mouth of the femoral canal.
Margins:
- medial = lacunar ligament
- anterior = inguinal ligament
- posterior = pectineal ligament
- laterally = femoral vein
- base = thin reflection of transversalis fascia.
- normally only admits the tip of a little finger.
The femoral canal normally contains lymph vessels, fat and a lymph node.

Pathogenesis
Disruption of the transversalis fascia allows abdominal contents to enter the femoral canal.
- the canal narrows significantly inferiorly.
- hence hernia forced inferiorly, then  anteriorly, then superiorly and superficially towards the groin.
Here it may easily be mistaken for an inguinal hernia.

Risk factors
Not congenital.
Either weakness at the femoral ring.
Or / and increase in intraabdominal pressure.

Women get them because of their broader pelvis, coupled with a medially-shifted insertion of iliopubic tract, which creates a wider orifice at the femoral canal.

See inguinal hernia card for typical contributory factors.
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BIOLOGICAL BEHAVIOUR

Natural History
60% on right, 30% left, 10% bilateral.
May become irreducible, obstructed, strangulated &c.
Unyielding margins mean

Complications
Femoral hernia is most common site for a Richter's hernia.

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MANIFESTATIONS

Symptoms
Local
Pain in the groin.
A lump.

Complications
See hernia card - similar complications.

Signs
May be difficult to palpate.
May be no cough impulse.

Note
In trying to reduce the hernia, must press down, then back, then up.
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INVESTIGATIONS
Clinical.
Imaging
Erect CXR, supine abdomen as necessary.
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MANAGEMENT

Conservative
Truss has no role - cannot prevent the hernia from entering the femoral ring.

Surgical
Risk of strangulation means surgical treatment always advised.
Open the sac.
Reduce it, and its contents.
Herniorrhaphy to prevent recurrence.
Approach depends on hernia, complications & surgeon.
- "surgery for femoral hernias should be straightforward and much ink has been wasted writing about the best surgical technique" (Hill)

Low Lockwood Approach
Small uncomplicated herniae
- incision below inguinal ligament.
High Supra Inguinal Approach
Large, complicated or emergency operations.
Various incisions possible.
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References
Hill, J.  Surgical Emergencies.

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