Summary

A Femoral Hernia is the protrusion of abdominal viscera (usually omentum or small bowel) through the Femoral Canal. Although less common than inguinal hernias (accounting for only 3-5% of all hernias), they are clinically critical because they have the highest risk of strangulation. The femoral ring is small and rigid, leading to entrapment. 50% of cases present as acute emergencies. [1,2]

Key Facts

• Anatomic Landmark: The femoral hernia emerges Below and Lateral to the Pubic Tubercle. (Inguinal hernias emerge Above and Medial).
• Gender: Female > Male (4:1 ratio). The female pelvis is wider, making the femoral canal larger. However, inguinal hernias are still the most common hernia in women overall.
• Urgency: Unlike inguinal hernias, "watchful waiting" is never an option. Diagnosis = Indication for Repair.

Clinical Pearls

The "Richter's Hernia": Femoral hernias are notorious for causing a Richter's Hernia, where only the antimesenteric border (one side) of the bowel wall becomes strangulated. This causes ischaemia/perforation without necessarily causing full bowel obstruction initially. The patient may be vomiting but still passing flatus, misleading the clinician.

McEvedy's Approach: In an emergency with suspected strangulated bowel, the McEvedy (High) incision is preferred. It is a vertical incision over the rectus sheath that allows excellent access to the peritoneal cavity to inspect and resect dead bowel if needed.

The Boundaries (NAVY): Remember the femoral sheath contents correlate to Nerve, Artery, Vein, Y-fronts (Canal). The Canal is medial to the vein.

• Position: Check relation to Pubic Tubercle. (Find pubic symphysis, move lateral to the tubercle).
  • Above and Medial = Inguinal.
  • Below and Lateral = Femoral.
• Cough Impulse: Often ABSENT in femoral hernias because the neck is so tight.
• Reducibility: Often IRREDUCIBLE. Do not force it (risk of reducing dead bowel - "reduction en masse").

Differential Diagnosis

• Lymph Node: Cloquet's node (reactive lymphadenitis).
• Saphena Varix: Dilation of saphenous vein at SFJ. (Disappears on lying down, has a thrill on coughing).
• Femoral Artery Aneurysm: Pulsatile.
• Psoas Abscess.

The "Crown of Death"

In 20-30% of the population, there is an anatomical variant called the Aberrant Obturator Artery.

• Normal: Obturator artery arises from the Internal Iliac Artery.
• Aberrant: Arises from the External Iliac or Inferior Epigastric artery.
• Path: It descends into the pelvis, running directly over the Lacunar Ligament.
• The Disaster: During emergency repair of a strangulated femoral hernia, the surgeon must incise the Lacunar Ligament to release the tight neck. If the Corona Mortis is present, it is cut.
• Result: Torrential arterial haemorrhage in a deep, narrow hole. The vessel retracts into the pelvis.
• Management: Compression, Extension of incision (McEvedy), or Retroperitoneal approach to ligate the vessel.

Injury to Femoral Vein

The Femoral Vein forms the Lateral Border of the canal.

• In Lockwood's approach, blindly putting sutures deep to close the canal can pierce the vein.
• Result: DVT or Haemorrhage.
• Pearl: Always protect the vein with a retractor (or your finger) while suturing.

The Femoral Triangle (Scarpa's)

• Superior: Inguinal Ligament.
• Medial: Adductor Longus.
• Lateral: Sartorius.
• Floor: Iliopsoas, Pectineus, Adductor Longus.
• Contents (Lateral to Medial - NAVY):
  • Femoral Nerve.
  • Femoral Artery.
  • Femoral Vein.
  • Y-fronts (Femoral Canal / Lymphatics).

The Femoral Sheath

A funnel-shaped prolongation of the abdominal fascia.

• Anterior Wall: Transversalis Fascia.
• Posterior Wall: Iliacus Fascia.
• Contains Artery, Vein, and Canal. (Nerve is OUTSIDE the sheath!).

Return to Activity

• Walking: Day 1.
• Driving: 1-2 weeks.
• Sport: 4-6 weeks (Gentle jogging). 6-8 weeks (Contact sport).

Landmark Trials

1. Swedish Hernia Register:
   • Femoral hernias account for disproportionately high mortality in emergency surgery.
   • Women are commonly misdiagnosed.
2. Danish Hernia Database:
   • Laparoscopic repair for femoral hernia has lower recurrence rate than open mesh plug.
   • Reason: Laparoscopy gives a better view of the pectineal ligament for secure fixation.

(As per original - restored)

What is a Femoral Hernia?

It is a small lump in the groin caused by a piece of bowel or fat poking through a natural weak spot called the femoral canal. This canal runs next to the main blood vessels of your leg.

Why do I need surgery?

Unlike other hernias, femoral hernias rarely go back in on their own and have a very high chance of getting stuck ("strangulated"). This cuts off the blood supply to the bowel, which is a life-threatening emergency. We operate quickly to prevent this.

What does the operation involve?

It is a 30-45 minute procedure under general anaesthetic. We push the lump back in and stitch the hole closed or use a small mesh patch. You usually go home the same day.

(Emergency cases with bowel damage require a bigger cut and a few days in hospital).

(As per original)

Common Exam Questions

1. Anatomy: "Medial border of femoral canal?"
   • Answer: Lacunar Ligament (Gimbernat's).
2. Diagnosis: "Lump below pubic tubercle?"
   • Answer: Femoral Hernia.
3. Complication: "Richter's Hernia?"
   • Answer: Strangulation of only the antimesenteric wall of the bowel.
4. Surgery: "Approach for strangulation?"
   • Answer: McEvedy (Vertical).

Viva Points

• Corona Mortis: "Crown of Death". Abnormal obturator artery on lacunar ligament. Bleeds heavily if cut.
• Saphena Varix: Differentiate from hernia by fluid thrill and disappearance on lying flat.

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.