35. Femoral hernias: types, anatomy, diagnosis, complications and treatment

Femoral hernias: types, anatomy, diagnosis, complications and treatment

The femoral canal is the medial compartment of the femoral sheath, below the inguinal ligament and medial to the femoral vein.
Femoral ring boundaries: anterior—inguinal ligament; posterior—pectineal ligament/pectineus fascia; medial—lacunar ligament; lateral—femoral vein.
The femoral canal contains lymphatics and the deep inguinal lymph node (Cloquet node). A femoral hernia passes through the femoral ring into the canal and may emerge through the saphenous opening.

Femoral hernias are more common in women, particularly older women, but can occur in any sex. They are associated with weakness or widening of the femoral ring.
The narrow, rigid femoral ring creates a high risk of incarceration and strangulation. The sac may contain preperitoneal fat, omentum or small bowel.

Presentation is a small groin lump below the inguinal ligament, usually inferolateral to the pubic tubercle. It may be difficult to distinguish from inguinal hernia clinically.
Symptoms include discomfort or pain, especially on standing or straining. A small femoral hernia may be overlooked, particularly in patients with obesity.
Ultrasound can confirm an equivocal lump; CT is useful in suspected obstruction or strangulation. Diagnosis may be made at emergency operation.
Differential diagnoses include inguinal hernia, lymphadenopathy, saphena varix, femoral artery aneurysm, lipoma and abscess.

Femoral hernias have a relatively high risk of incarceration, bowel obstruction and strangulation; an apparently small lump may conceal significant bowel compromise.
Repair is generally recommended even when minimally symptomatic. Approaches include open infra-inguinal, trans-inguinal or preperitoneal repair, and laparoscopic TEP/TAPP repair.
Emergency surgery is required for irreducibility, obstruction or strangulation. Resuscitate, administer antibiotics when indicated, assess bowel viability and resect non-viable bowel.
Complications include wound infection, seroma, chronic pain, femoral vein injury, mesh infection and recurrence. Avoid confusing a femoral hernia with an inguinal hernia because the anatomical repair differs.