Femoral Hernia: Signs, Diagnosis & Surgical Treatment Options

• MC type of Hernia in males and Females - Indirect inguinal hernia.
• Femoral hernia is more common in females.
• MC on the Right side.
• Bilateral in 20% of cases.
• MC in Multipara patients.
• TRUSS - Not to be used in femoral hernia.

Femoral Canal & Ring

Femoral Canal is rigid & Narrow→Increased risk of strangulation →Femoral Triangle

Investigations

• No specific Investigations needed
• CT OR USG is done
• CT scanning in cases of bowel obstruction primarily to exclude malignancy, but it can identify an obstructing femoral hernia missed by clinicians.

Approaches of Repair Depend on Incision

• Sub inguinal incision - Lockwood
• Inguinal incision - Lothiessen
• Supra inguinal incision - Mc evedy

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Clinical Presentation

• Swelling located below and lateral to pubic tubercle
• Swelling in Groin region & heaviness
• Pain discomfort
• Nausea and vomitings

Treatment of Choice

1. Henry's procedure
2. Midline abdominal extraperitoneal femoral hernioplasty

Variants of Femoral Hernia

1. Laugier's: Hernia through gap in Lacunar ligament.
2. Cloquet: Hernia located behind pectineus fascia.
3. Narath Hernia: Seen in congenital dislocation of Hip
   1. Lateral displacement of Sac.
   2. Sac is located behind femoral vessels

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Surgery Procedure for Femoral Hernia

 There are three open approaches and appropriate cases can be managed laparoscopically.

They are :

• Low Approach
• Inguinal Approach
• High Approach

1. Low Approach (Lockwood)

This is the simplest operation for a femoral hernia but suitable only when there is no risk of bowel resection. A small incision can be made in the medial lacunar ligament to aid reduction but there may be an abnormal branch of the obturator artery just deep to it, which can bleed. The femoral vein, lateral to the hernia, needs to be protected.

2. The Inguinal Approach (Lotheissen)

The initial incision is identical to Bassini's or Lichtenstein's operation into the inguinal canal. The spermatic cord (or round ligament) is mobilized, and the transversalis fascia opens from deep inguinal ring to the pubic tubercle. A femoral hernia lies immediately below this incision and can be reduced by a combination of pulling from above and pushing from below. If necessary, the peritoneum can be opened to help with reduction. Once reduced, the neck of the hernia is closed with sutures or a mesh plug, protecting the iliac vein throughout. The layers are closed as for an inguinal hernia, and the surgeon may place a mesh into the inguinal canal to protect against the development of an inguinal hernia. 

3. High Approach (Mcevedy) 

This more complex operation is ideal in emergency situations where the risk of bowel strangulation is high. It requires regional or general anesthesia. The anterior rectus sheath is incised, and the rectus muscle is displaced medially. The femoral hernia is reduced, the sac opened to allow careful inspection of the bowel, and a decision is made regarding the need for bowel resection. This approach is  performed if required.

4. Laparoscopic Approach

Both the TEP and TAPP approaches can be used for a femoral hernia and a standard mesh inserted. This is ideal for reducible femoral hernias presenting electively, but not for emergency cases or irreducible hernia.

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FAQ’S

Q. What are the risks of surgery?

Ans. The risk of surgery includes infection, bleeding, and recurrence of the hernia. 

Q. What lifestyle should I continue to prevent from hernia?

Ans. An Diet change, maintain BMI, and regular exercise to help abdominal wall strength  help to decrease risk. 

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