Femoral Hernia - Symptoms, Causes, Diagnosis, and Treatment

What Is a Femoral Hernia?

It is a bulge in the groin due to the protrusion of the abdominal contents into the femoral canal (located in the front of the thigh). It is more common in women due to their wider pelvis. Compared to an inguinal hernia, a femoral hernia is relatively uncommon, yet it is essential to know it because it has the highest rate of strangulation. Strangulation is a life-threatening medical condition in which the blood vessels of the protruded organs are compressed, leading to congestion, pain, and infarction (death of the tissue from the failure of the blood supply).

Femoral hernia is more common on the right side due to developmental delay in the obliteration of the abdominal wall that evaginated (processus vaginalis) in fetal life. The incidence of femoral hernia increases with age, and nearly 15 to 20 percent of them get strangulated.

What Is a Femoral Canal?

It is one of the three compartments in the femoral sheath. When the thigh is flexed, a triangular depression appears in the anterior superior third of the thigh; this is known as the femoral triangle. This triangle is surrounded on all sides by muscle and ligaments except in the middle, which is occupied by a hollow tube-like structure known as a femoral sheath.

This femoral sheath is divided into three compartments-

• The lateral compartment contains the femoral artery.

• The intermediate compartment contains the femoral vein.

• The medial compartment, also known as the femoral canal, contains one lymph node and lymphatic vessels.

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The femoral sheath is a casing made up of connective tissue, it is an extension of the abdominal connective tissue that lines most of the abdominal cavity. It is a transition point between the abdomen and the thigh and contains key vascular structures.

The femoral canal is the medial compartment of the femoral sheath, and its superior border has an opening called the femoral ring. A femoral hernia happens when this femoral ring loses its rigidity leading to the protruding of the upper abdominal contents into the femoral canal.

What Causes Femoral Hernia?

A femoral hernia occurs when there is a defect in the surrounding walls, the defect can be a loose femoral ring or a lack of sufficient muscle around the femoral canal to hold it in its place. The defects, when combined with predisposing factors, increase the incidence of femoral hernia. The predisposing factors are-

• Raised intra-abdominal pressure due to heavy lifting or chronic constipation.

• Obesity and increasing age.

• Pregnancy and childbirth.

• Gender (females are more prone to femoral hernia due to their wider pelvis).

What Are the Symptoms of Femoral Hernia?

One-third of the patients who are affected by a femoral hernia are asymptomatic, and symptoms appear when the hernia starts getting incarcerated and strangulated. Incarceration means the hernia does not disappear when direct pressure is applied, and strangulation is when the vascular supply of the herniated organs starts getting compromised, leading to their death. The symptoms of a femoral hernia are-

• Painful hard lump or mass in the groin area.

• Nausea or vomiting.

• Abdominal pain and enlargement.

• A decrease or absence in bowel movement happens when the herniated organ is the small or large intestine.

• Paresthesias (burning or prickling sensation) due to the compression of the nearby sensory nerves.

An incarcerated and strangulated femoral hernia is a surgical emergency due to its high chances of bowel infarction.

What Tests Are Done to Diagnose a Femoral Hernia?

Physical examination is sufficient to diagnose a femoral hernia. However, radiologic investigations are performed because they help to plan the surgery, which is the only treatment option. The investigations are-

• Ultrasound - It helps to assess the space between the femoral vein and the femoral canal.

• Computed Tomographic Scan - A computed tomographic (CT) scan shows the characteristic funnel shape of the femoral hernia, thereby confirming the diagnosis; it also helps to assess the extent of the compressed femoral vein.

A femoral hernia is a time-dependent risk; due to the critical nature of the condition, further investigations are usually not requested.

How Is a Femoral Hernia Treated?

Surgery is the only treatment option that is always done immediately after diagnosis. The surgery can be done by any one of the four approaches, they are-

• Infra-inguinal Approach- Also known as the low approach, after anesthesia, an incision is made one centimeter below or parallel to the inguinal ligament, followed by dissection of the femoral canal and reduction of the hernial sac. It is the preferred method for elective repair of the femoral hernia.

• Open Preperitoneal Approach- Also known as the high approach, an incision is given above the pubic bone, the femoral canal is then opened, and the strangulated part of the hernial sac (containing the bowel) is removed, and the ends of the healthy bowel are rejoined. The femoral canal is then closed with a prosthetic mesh to prevent a recurrence, and the incision is sutured. It is the preferred technique in an emergency.

• Minimally Invasive or Laparoscopic or Robot-Assisted Approach- Instead of one single incision, several incisions are made along the pubic bone. A laparoscope (an optic-fiber instrument that transmits real-time video to a monitor in the operating room) is inserted through one incision, and the underlying anatomy is observed. Special surgical instruments are inserted through the accessory incisions, and the surgeon pulls back the hernia back into its place. As with open surgery, a prosthetic mesh is also placed in the laparoscopic technique to strengthen the weak spot in the femoral canal through which the hernia came through. After the repair, the incisions are sutured off.

What Are the Complications of a Femoral Hernia Surgery?

Infection and recurrence are the most frequently seen complications in hernia repair. Infection from the prosthetic mesh is a serious complication and should be avoided in patients with a compromised bowel, enterotomy, and gross contamination.

Risk factors are responsible for recurrence, for example- smoking or form of tobacco use, collagen tissue disorders, diabetes, poor nutritional status, etc. Other complications include urinary retention, seroma (fluid build-up under the surface of the skin), and orchitis (inflammation of one or both testicles).

Conclusion:

Hernia repair surgery is a well-tolerated procedure, and it is usually performed as an elective procedure after a routine physical examination. This decreases the chances of incarceration and strangulation, which will put the patient in life-threatening conditions. The risks and benefits should be discussed before the operation so, in case of recurrence, the patient will seek prompt treatment.

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