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Femoral Hernia

From WikiSM

Other Names

  • Femoral Hernia

Background

  • This page refers to a femoral hernia, which is when abdominal viscera herniates through the femoral ring into the femoral canal

History

  • Needs to be updated

Epidemiology

  • 4 to 8 times more common in women than men[1]
    • Note: inguinal hernias are still more common in females
  • Rare, only 2% to 4% of groin hernias are femora hernias[2]
  • Incidence and prevalence is increasing in Asian countries[3]
  • Most commonly seen in males in lower and middle income group

Introduction

(a) A femoral hernia is localized at the medial side of the femoral vessels, caudal to the inguinal canal. (b) Incision of the external oblique fascia, just above the ‘pink triangle’, formed by the diversion of the vessels of this fascia towards the external inguinal orifice.[4]
Diagram of the femoral sheath and its contents.[5]

General

  • Rare form of groin hernia where the defect is below the Inguinal Ligament in the Femoral Triangle
  • Associated with increased risk of complications including strangulation and obstruction
  • Most commonly seen in older patients, age 40 to 70, and the diagnosis is usually late
  • Management is considered surgical given high risk of complications

Terminology

  • Reduction en Masse: hernia sac is reduced but the bowel is still incarcerated within the reduced sac[6]
    • Causes a risk of progression to ischemia and necrosis despite reduction
    • “Classically” describing an Inguinal Hernia
  • Richter Hernia: only the antimesenteric border of the bowel wall is herniated[7]
    • Also described as a “partial enterocele”
    • May not cause obstruction as bowel contents can pass through the intraperitoneal portion of the bowel
    • High risk of incarceration and strangulation of the herniated portion
  • Littre Hernia: hernia contains a meckel diverticulum[8]
  • De Garengeot Hernia: femoral hernia containing the appendix[9]
    • May be confused with an amyand hernia (inguinal hernia containing the appendix)[10]
  • Sliding Hernia: A retroperitoneal organ is included as part of the hernia sac[11]
    • Most common male organs: sigmoid colon, cecum
    • Most common female organs: ovary and fallopian tube (ligate the round ligament and return the ovary at surgery)

Etiology

  • Not well understood
  • Theoretically due to increased abdominal pressure causes weakness over the anterior abdominal wall
  • More commonly occurs on the right side rather than the left[12]

Anatomy of the Femoral Canal

Risk Factors

  • Female gender
  • Increasing age
  • Pregnancy with a higher risk in multiparous women
  • Increased intraabdominal pressure (weight lifting, chronic constipation)

Differential Diagnosis

Differential Diagnosis Groin Pain

Clinical Features

History

  • Groin bulge below and lateral to he pubic tubercle
  • Groin pain and discomfort, may be worsened by coughing or straining
  • Symptoms of bowel obstruction including nausea and vomiting, constipation
  • Overlying skin can develop erythema, ischemia, or ulceration due to excessive pressure

Physical Exam: Physical Exam Groin

  • Examine the groin to identify the exact location of the lump
  • Femoral hernia: inferolateral to the pubic tubercle
  • Inguinal hernia: superomedial to the pubic tubercle
  • Femoral hernias are typically not reducible due to "tightness" of the femoral ring

Special Tests

Evaluation

Left groin hernia is present and containing fat, swirling fluid, and surrounding inflammation. The hernia sac arises below the origin of the inferior epigastric vasculature, and the hernia compresses the femoral vein medially.[13]
Short-axis image reveals herniated fat lying medial to the femoral vein. No fat herniation at the rest. [14]

Clinical

  • Generally considered a clinical diagnosis
  • Often difficult to differentiate from an inguinal hernia on physical exam
  • Hernia found inferior to the inguinal ligament and medial to the femoral vessels
  • Small hernias may be difficult to palpate
  • More difficult to diagnose in females and obese
  • Up to 40% present as an emergency[15]

Radiographs

CT

  • Most useful imaging modality
  • Useful to characterize large and complex defects
  • Can evaluate for obstruction, ischemia, etc

US

  • Inexpensive and allows for dynamic evaluation with Valsalva maneuver
  • Limited due to operator dependency

MRI

  • May be indicated in chronic cases in which the diagnosis is uncertain

Laboratory

  • In the event of a surgical emergency, a CBC, metabolic panel, coag panel and type and cross should be obtained

Classification

  • Not applicable

Management

Treatment algorithm for femoral hernia[16]

Nonoperative

  • Referral to general surgeon
  • All should undergo early surgical repair regardless of symptoms
  • Higher risk of incarceration and strangulation preclude watchful waiting

Operative

  • Indications
    • All
  • Technique
    • Open hernia repair
    • Minimally invasive/ laparoscopic

Rehab and Return to Play

Rehabilitation

  • There are no evidence based rehabilitation guideliness

Return to Play/ Work

  • Needs to be updated
  • At the discretion of the surgeon

Prognosis and Complications

Prognosis

  • In patients presenting with signs of strangulation/obstruction, there is a high morbidity and mortality[17]

Complications

  • Risk factors for complications
    • Increasing age
    • Female gender
    • High ASA score
    • Presence of comorbidities
  • Strangulation[18]
    • 22% at 3 months, 45% at 21 months
    • 40% present emergently as incarceration/strangulation
  • Recurrence
    • Higher risk for recurrence than after inguinal hernia repairs
    • Due partially to increased rates of emergency surgery and overall complications

See Also

References

  1. ↑ Nilsson, E., et al. "Hernia surgery in a defined population: a prospective three year audit." The European journal of surgery= Acta chirurgica 163.11 (1997): 823-829.
  2. ↑ Rutkow, Ira M., and Alan W. Robbins. "Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States." Surgical Clinics of North America 73.3 (1993): 413-426.
  3. ↑ Ma, Qiuyue, et al. "The global, regional, and national burden and its trends of inguinal, femoral, and abdominal hernia from 1990 to 2019: findings from the 2019 Global Burden of Disease Study–a cross-sectional study." International Journal of Surgery 109.3 (2023): 333-342.
  4. ↑ De Gols, Johan, et al. "Extended Lichtenstein repair for an additional femoral canal hernia." Journal of Clinical Medicine 13.18 (2024): 5386.
  5. ↑ Mahabadi, Navid, Valerie Lew, and Michael Kang. "Anatomy, Abdomen and Pelvis, Femoral Sheath." (2018).
  6. ↑ Mynter H. Reduction En Masse. Buffalo Med Surg J. 1888 Dec;28(5):245-250.
  7. ↑ Treves, Frederick. "Richter's hernia or partial enterocele." Medico-Chirurgical Transactions 70 (1887): 149.
  8. ↑ Pinto J, Viana CM, Pereira A, Falcão J. Littré's hernia. BMJ Case Rep. 2019 Feb 28;12(2):e228784.
  9. ↑ Kalles, V., et al. "De Garengeot’s hernia: a comprehensive review." Hernia 17.2 (2013): 177-182.
  10. ↑ Lee CH, Chien LJ, Shen CY, Su YJ. Amyand's hernia. Am J Med Sci. 2022 Oct;364(4):e8-e9.
  11. ↑ Komorowski AL, Moran-Rodriguez J, Kazi R, Wysocki WM. Sliding inguinal hernias. Int J Surg. 2012;10(4):206-8.
  12. ↑ Hachisuka, T. (2003). Femoral hernia repair. In Surgical Clinics of North America, 83(5), 1189–1205).
  13. ↑ Case courtesy of Mohammad Taghi Niknejad, Radiopaedia.org, rID: 83876
  14. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 173338
  15. ↑ Dahlstrand, U. (2018). Femoral hernia. In Management of Abdominal Hernias: Fifth Edition (pp. 305–314).
  16. ↑ Kumar, H. R. "An Update on the Management of Femoral Hernias: Narrative Review Article." SAR J Surg 5.5 (2024): 43-48.
  17. ↑ Ogbuanya, A. U. O., Olisa, F. U., Ewah, R. L., Nweke, O., & Ugwu, N. B. (2020). Femoral Hernia: Epidemiology and challenges of management in a sub-saharan African Country. Asian Journal of Medical Sciences, 11(6), 77–83.
  18. ↑ Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991 Oct;78(10):1171-3.
Created by:
John Kiel on 22 July 2025 16:56:14
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Last edited:
23 July 2025 15:12:46
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