[24] Femoral Hernia

Question 1

What is a femoral hernia?

Answer 1

When abdominal viscera or omentum passes through the femoral ring and into the potential space of the femoral canal

Question 2

What % of abdominal hernias are femoral hernias?

Answer 2

5%

Question 3

Who are femoral hernias more common in?

Answer 3

Females (3:1)

Question 4

Why are femoral hernias more common in females?

Answer 4

It is secondary to the wider anatomy of the female bony pelvis

Question 5

Can femoral herniation occur in a child?

Answer 5

It is very rare

Question 6

What is the femoral canal?

Answer 6

An anatomical compartment

Question 7

Where is the femoral canal located?

Answer 7

In the anterior thigh

Question 8

What does the femoral canal contain?

Answer 8

Lymphatic vessels
Lymph nodes
Some loose connective tissue

Question 9

What makes up the superior border of the femoral canal?

Answer 9

The femoral ring

Question 10

What is the femoral ring covered by?

Answer 10

The femoral septum (a connective tissue layer)

Question 11

Why are femoral hernias very prone to complications requiring urgent surgical interventions?

Answer 11

Due to the rigidity of the borders of the femoral ring, especially the concave margin of the lacunar ligament

Question 12

What are the main risk factors for developing a femoral hernia?

Answer 12

Female gender
Increasing age
Pregnancy
Increased intra-abdominal pressure

Question 13

Give two examples of causes of increased intra-abdominal pressure leading to a femoral hernia?

Answer 13

Heavy lifting

Chronic constipation

Question 14

How will femoral hernias commonly present?

Answer 14

As a lump in the groin

Question 15

What % of femoral hernia cases present as an emergency?

Answer 15

Around 30%

Question 16

Why is it important to identify the exact location of the lump in the groin?

Answer 16

In order to decide what type of hernia is present

Question 17

Where in the groin is a femoral hernia lump found?

Answer 17

Infero-lateral to the pubic tubercle, and medial to the femoral pulse

Question 18

Where in the groin is an inguinal hernia lump found?

Answer 18

Superomedial to the pubic tubercle

Question 19

When is a femoral hernia often misdiagnosed as an inguinal hernia?

Answer 19

If it migrates superiorly to the inguinal ligament

Question 20

Is a femoral hernia likely to be reducible?

Answer 20

No, due to the tightness of the femoral ring

Question 21

What are the differential diagnoses for a lump in the groin?

Answer 21

Low presentation of an inguinal hernia
Femoral canal lipoma
Femoral lymph noed
Saphena varix
Femoral artery aneurysm
Athletic Pubalgia

Question 22

What are the features of a saphena varix?

Answer 22

Disappears when lying flat
Palpable thrill when coughing
Presence of varicose veins elsewhere

Question 23

What is athletic pubalgia?

Answer 23

A small tear in the rectus sheath, through which impingement of the abdominal wall musculature occurs

Question 24

Who is athletic pubalgia common in?

Answer 24

Young athletes

Question 25

Which patients with femoral hernias require surgical intervention?

Answer 25

All patients will eventually need surgical intervention

Question 26

What is the result of all patients with a femoral hernia eventually needing surgical intervention?

Answer 26

Routine pre-operative investigations should be performed if possible

Question 27

How is a diagnosis of femoral hernia usually made?

Answer 27

Clinical

Question 28

What is the gold standard of diagnosis for a femoral hernia?

Answer 28

Ultrasound scan

Question 29

How accurate are ultrasound scans in identifying the specific type of hernia?

Answer 29

96%

Question 30

What is the limitation of ultrasound scans in identifying hernias?

Answer 30

Operator dependant

Question 31

What should be done if there is significant doubt in the diagnosis of femoral hernia, or evidence of complications?

Answer 31

The lump should be surgically explored

Question 32

Why should all femoral hernias be surgically managed?

Answer 32

Due to the increased risk of strangulation

Question 33

What does surgical intervention for femora hernias involve?

Answer 33

Reduction of the hernia, then surgical narrowing of the femoral ring with the use of interrupted sutures

Question 34

What care should be taken during surgical narrowing of the femoral ring?

Answer 34

To avoid narrowing the femoral vein in the process

Question 35

What surgical approaches can be taken for the management of a femoral hernia?

Answer 35

Low approach | High approach

Question 36

How is a low approach to femoral hernia repair done?

Answer 36

The incision is made below the inguinal ligament

Question 37

What is the advantage of a low approach in femoral hernia repair?

Answer 37

It doesn't interfere with inguinal structures

Question 38

What is the disadvantage of a low approach in femoral hernia repair?

Answer 38

It results in limited space for the removal or any compromised small bowel

Question 39

How is a high approach to femoral hernia repair done?

Answer 39

The incision is made above the inguinal ligament, via the posterior wall of the inguinal canal

Question 40

Where is a high approach to femoral hernia repair the preferred intervention?

Answer 40

In an emergency intervention

Question 41

Why is a high approach to femoral hernia repair preferred in an emergency intervention?

Answer 41

Due to the easy access to the compromised small bowel

Question 42

What is the main limitation of a high approach to femoral hernia repair?

Answer 42

The need to repair the inguinal canal on closure, thus providing a new area of weakness and potential secondary herniation

Question 43

What are the serious complications of a hernia that require urgent intervention?

Answer 43

Incarceration Obstruction Strangulation

Question 44

What is meant by an incarcerated hernia?

Answer 44

The contents of the hernia are unable to return to their original cavity

Question 45

What happens in obstruction caused by a hernia?

Answer 45

The bowel lumen becomes obstructed, leading to the clinical features of bowel obstruction

Question 46

What is a strangulated hernia?

Answer 46

Compression of the hernia compromises the blood supply, leading to the bowel becoming ischaemic

Question 47

How will a hernia that has become strangulated present?

Answer 47

As a irreducible and tender, tense lump, with the pain often being out of proportion to clinical signs This may be accompanied with clinical features of obstruction

Question 48

Why is a strangulated hernia a surgical emergency?

Answer 48

Due to the time-dependant risk of bowel infarction

Question 49

How is a diagnosis of strangulated hernia made?

Answer 49

Typically a clinical one | Due to the time critical nature of the condition, further imaging will rarely be requested

Question 50

What does the specific management for strangulated hernias depend on?

Answer 50

The type of hernia involved

Question 51

How does the mortality from a strangulated hernia differ from elective hernia repairs?

Answer 51

It is much higher

Question 52

What is the risk of strangulation of femoral hernias?

Answer 52

The risk increases with time following diagnosis - after 3 months, the risk is 22%, and reaches 45% after 21 months

Question 53

What other risks are increased in strangulated femoral hernia repair compared to elective repair?

Answer 53

Bowel resection Wound infection Cardiorespiratory complications