Femoral Hernia

Richard Davis Winters, MD
The Operative Review of Surgery. 2023; 1:310-313.

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Table of Contents

Definitions and Descriptors
Presentation and Diagnosis
Treatment

References

Definitions and Descriptors

Basics

  • Definition: Hernia Through the Femoral Canal
  • 4x More Common in Women 1
    • Inguinal Hernias are Still the Most Common in Females Overall
  • Highest Risk of Strangulation 2
    • 22% Risk at 3 Months
    • 45% Risk at 21 Months
    • 40% Present Emergently as Incarceration or Strangulation 3

Additional Descriptors

  • Reduction en Masse: Hernia Sac is Reduced but the Bowel is Still Incarcerated within the Reduced Sac 4
    • Causes a Risk of Progression to Ischemia and Necrosis Despite Reduction
    • “Classically” Describing an Inguinal Hernia 4
  • Richter Hernia: Only the Antimesenteric Border of the Bowel Wall is Herniated 5
    • Also Described as a “Partial Enterocele” 5
    • 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 6
  • De Garengeot Hernia: Femoral Hernia Containing the Appendix 7
    • May Be Confused with an Amyand Hernia (Inguinal Hernia Containing the Appendix) 8
  • Sliding Hernia: A Retroperitoneal Organ is Included as Part of the Hernia Sac 9
    • Most Common Organs:
      • Males: Sigmoid Colon and Cecum
      • Females: Ovary and Fallopian Tube (Ligate the Round Ligament and Return the Ovary at Surgery)

Other Groin Hernias

Femoral Hernia Seen on Laparoscopy 12

Reduction en Masse 4

Richter Hernia 13

Presentation and Diagnosis

Presentation

  • Groin Bulge
  • Groin Pain and Discomfort
    • May be Worsened by Coughing or Straining
  • Symptoms of Bowel Obstruction
    • Nausea and Vomiting
    • Constipation
  • Risk for Bowel Incarceration, Strangulation, and Necrosis
  • Overlying Skin Can Develop Erythema, Ischemia, or Ulceration Due to Excessive Pressure

Diagnosis

  • Generally 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
  • Imaging May Be Required if Uncertain
    • US – More Cost Effective and Allows Dynamic Assessment with Valsalva (Operator Dependent)
    • CT – Allows Better Evaluation of Large and Complex Defects

Femoral Hernia Seen on CT Medial to the Femoral Vessels 14

Treatment

Treatment

  • All Should Undergo Early Surgical Repair Regardless of Symptoms
  • Higher Risk of Incarceration and Strangulation Preclude Watchful Waiting
  • Higher Risk for Recurrence Than After Inguinal Hernia Repairs 15,16
    • Due Partially to Increased Rates of Emergency Surgery and Overall Complications

Surgical Technique

  • *See Inguinal Hernia Repair
  • Open Hernia Repair
    • Open Hernia Repairs are Traditionally Done by a McVay Repair
      • May Require Division of the Inguinal Ligament to Reduce Bowel
    • Bassini and Lichtenstein Repairs Do Not Close the Femoral Canal
    • Other Open Options:
      • Trans-Inguinal Preperitoneal (TIPP/Kugel) Repair
      • Anterior Mesh Plug
  • Minimally Invasive (Laparoscopic/Robotic) Hernia Repair
    • Generally Preferred Over Open Repairs for Elective Cases if Possible 17,18
      • Lower Recurrence Rates
      • Better to Identify Occult Hernias

McVay Repair

References

  1. Nilsson E, Kald A, Anderberg B, Bragmark M, Fordell R, Haapaniemi S, Heuman R, Lindhagen J, Stubberöd A, Wickbom J. Hernia surgery in a defined population: a prospective three year audit. Eur J Surg. 1997 Nov;163(11):823-9.
  2. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991 Oct;78(10):1171-3.
  3. McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based management of groin hernia in primary care–a systematic review. Fam Pract. 2000 Oct;17(5):442-7.
  4. Mynter H. Reduction En Masse. Buffalo Med Surg J. 1888 Dec;28(5):245-250.
  5. Treves F. Richter’s Hernia or Partial Enterocele. Med Chir Trans. 1887;70:149-67.
  6. Pinto J, Viana CM, Pereira A, Falcão J. Littré’s hernia. BMJ Case Rep. 2019 Feb 28;12(2):e228784.
  7. Kalles V, Mekras A, Mekras D, Papapanagiotou I, Al-Harethee W, Sotiropoulos G, Liakou P, Kastania A, Piperos T, Mariolis-Sapsakos T. De Garengeot’s hernia: a comprehensive review. Hernia. 2013 Apr;17(2):177-82.
  8. Lee CH, Chien LJ, Shen CY, Su YJ. Amyand’s hernia. Am J Med Sci. 2022 Oct;364(4):e8-e9.
  9. Komorowski AL, Moran-Rodriguez J, Kazi R, Wysocki WM. Sliding inguinal hernias. Int J Surg. 2012;10(4):206-8.
  10. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. 1993 Jun;73(3):413-26.
  11. Lockhart K, Dunn D, Teo S, Ng JY, Dhillon M, Teo E, van Driel ML. Mesh versus non-mesh for inguinal and femoral hernia repair. Cochrane Database Syst Rev. 2018 Sep 13;9(9):CD011517.
  12. Tainaka T, Uchida H, Ono Y, Tanano A, Shirota C, Yokota K, Murase N, Makita S, Shirotsuki R. A new modification of laparoscopic percutaneous extraperitoneal closure procedure for repairing pediatric femoral hernias involving a special needle and a wire loop. Nagoya J Med Sci. 2015 Aug;77(3):531-5. (License: CC BY-NC-ND 4.0)
  13. Abo-elmagd A, Ahmed K. Richter Paraumbilical Hernia Managed by Invagination: A Case Report and Review of Literature. Am J Surg Case Reports. 2019. (License: CC Unspecified)
  14. Sucandy I, Kolff JW. Incarcerated femoral hernia in men: incidence, diagnosis, and surgical management. N Am J Med Sci. 2012 Nov;4(11):617-8. (License: CC BY-NC-SA 3.0)
  15. Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson U. Emergency femoral hernia repair: a study based on a national register. Ann Surg. 2009 Apr;249(4):672-6.
  16. Glassow F. Femoral hernia. Review of 2,105 repairs in a 17 year period. Am J Surg. 1985 Sep;150(3):353-6.
  17. Bay-Nielsen M, Kehlet H, Strand L, Malmstrøm J, Andersen FH, Wara P, Juul P, Callesen T; Danish Hernia Database Collaboration. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet. 2001 Oct 6;358(9288):1124-8.
  18. Andresen K, Bisgaard T, Kehlet H, Wara P, Rosenberg J. Reoperation rates for laparoscopic vs open repair of femoral hernias in Denmark: a nationwide analysis. JAMA Surg. 2014 Aug;149(8):853-7.