Makindo Medical Notes

Due to a high incidence of complications, femoral hernias often require emergency surgery.

About

• A femoral hernia occurs due to a weakness in the abdominal wall, allowing abdominal contents to enter the femoral canal.
• Herniated material can include peritoneum, fat, and sometimes small bowel, increasing the risk of strangulation due to the narrow neck.

Risk Factors

• Occurs in both males and females, but women are 10 times more likely to develop a femoral hernia.
• Attributed to the wider bone structure of the female pelvis.
• Other risk factors: Obesity, heavy lifting, chronic coughing, straining with urination or defecation, COPD, and ascites.

Types of Femoral Hernias

• Reducible: Herniated material can be pushed back into the abdominal cavity.
• Non-reducible (Incarcerated): Herniated material cannot be pushed back, leading to potential obstruction.
• Strangulated: Compromised blood supply to the bowel, leading to ischemia. This is a surgical emergency.

Clinical Presentation

• Swelling lies below the inguinal ligament and emerges below and lateral to the pubic tubercle.
• Most femoral hernias cause no symptoms, though tenderness may suggest strangulation.
• Groin discomfort may worsen with standing, heavy lifting, or straining.
• Abdominal pain, nausea, and vomiting indicate complications and need urgent evaluation.

Investigations

• Imaging studies, such as ultrasonography, CT, or MRI, can help in diagnosing femoral hernias.

Management

• Acute Presentation: Supportive care (ABC, IV fluids, analgesia, and Nil by Mouth) with urgent surgical review if pain or signs of incarceration/strangulation are present. Strangulated bowel may require IV antibiotics to prevent necrosis and gangrene.
• Delayed Treatment: May lead to fatal complications. Severe cases may need laparotomy and resection of necrotic bowel tissue, while others may benefit from conservative observation if no obstruction is present.

Open Hernia Repair

• Open hernia repair (herniorrhaphy) is typically done under local anaesthesia through an incision.
• The hernia is reduced, and repair involves suturing the inguinal ligament to the pectineal ligament with strong non-absorbable sutures or placing a mesh plug in the femoral ring.

Laparoscopic Femoral Hernia Repair

• Performed under general anaesthesia with several small incisions in the lower abdomen to insert a laparoscope.
• The hernia is repaired with synthetic mesh, offering a less invasive approach and shorter recovery time.
• Open surgery may be necessary if the hernia is very large or if the patient has a history of pelvic surgery.

Potential Complications

• General Anaesthesia Risks: Common issues include nausea, vomiting, urinary retention, sore throat, and headache, while serious risks include MI, stroke, pneumonia, and blood clots.
• DVT/PE: Early mobilization post-surgery helps reduce the risk of blood clots and pneumonia.
• Hernia Recurrence: A common complication that may necessitate a second operation.
• Bleeding: Rare but may lead to significant swelling and bruising. Severe bleeding may require surgical intervention.
• Wound Infection: Risk is low (<2%), but postoperative infection may need antibiotics and additional care.
• Painful Scar: Some patients experience sharp, tingling pain near the incision, which typically resolves but may require local anaesthetic if persistent.
• Injury to Internal Organs: Although rare, accidental injury to organs such as the intestine, bladder, or blood vessels can occur and may lead to further surgical procedures.

References

• Anatomy of Femoral Hernias - Kenhub