Femoral hernia

Overview:

• Femoral hernias are acquired downward protrusions of peritoneum into the potential space of the femoral canal
• 33% of groin hernias in women and 5% in men
• Rare in children
• 20% are bilateral

History:

• Patient is typically a middle-aged or elderly female, often of thin build
• Intermittent lump in the groin
• However, a major problem is that she may not have noticed the lump and the first clinical presentation is with strangulation (which occurs in 20%)

Signs:

In a small hernia, a cough impulse is rare

A larger hernia may be seen to bulge on straining just below the medial part of the inguinal ligament

An irreducible hernia is a lump whose consistency varies according to its contents, which may straddle the inguinal ligament

In consequence, it can be difficult to distinguish from an inguinal hernia; although the upper medial border of a femoral hernia is always below and lateral to the pubic tubercle

Strangulation:

• In contrast to a strangulated inguinal hernia, in a strangulated femoral hernia, there are often no localising symptoms and signs and the lump is often small, unimpressive and overlooked by the patient
• The classic presentation is that of small bowel obstruction
• It is not unheard of for a femoral hernia to only be diagnosed after gut perforation with spreading peritonitis

Management:

• All femoral hernias should be repaired without delay because of their great risk of strangulation
• In elective operations, repair is usually by direct incision over the hernia, excision of the sac and sutured closure of the femoral canal
• For operation on a patient with obstruction or strangulation, it may be necessary to open the abdomen to find the segment of gut that has been trapped, should it reduce before it can be dealt with