What are the management options for a femoral hernia?

Management of Femoral Hernia

Femoral hernias require prompt surgical repair regardless of symptoms due to their high risk of strangulation and associated mortality, with laparoscopic approaches preferred in stable patients and open repair reserved for emergencies or unstable patients. 1, 2

Diagnosis and Assessment

• Femoral hernias occur predominantly in females (71% of cases) with a female-to-male ratio of 8:1 2, 3
• More than 50% of femoral hernias are diagnosed during strangulation, making early detection critical 4
• CT scan is the diagnostic gold standard for complicated hernias, though most can be diagnosed clinically 1, 5
• Femoral hernias carry a significantly higher risk of strangulation (10x higher) compared to other hernia types 4

Surgical Management Options

Timing of Intervention

• Immediate surgical intervention is mandatory when intestinal strangulation is suspected (grade 1C recommendation) 1
• Early detection and repair of femoral hernias is crucial as delayed treatment (>24 hours) significantly increases mortality rates 1
• Femoral hernia is an independent risk factor for requiring bowel resection (OR = 8.31, P < 0.001) 1

Surgical Approaches

• For stable patients: Laparoscopic repair (TEP or TAPP) is preferred due to:

  • Faster recovery and return to normal activities 5, 3
  • Lower complication rates (6% vs 25% in emergency cases) 2
  • Better visualization of hernia contents and intestinal viability 6
  • Lower postoperative morbidity compared to open procedures 3

• For unstable patients or emergency situations: Open surgical approach is recommended:

  • McVay technique is commonly used (used in 79 of 83 cases in one study) 2
  • Mesh plug repair is an alternative option for smaller defects 2, 4
  • Laparotomy may be required in cases with suspected bowel strangulation 2

Repair Techniques

• Mesh repair is strongly recommended over tissue repair to reduce recurrence rates 7
• For clean surgical fields (no intestinal strangulation), synthetic mesh is recommended 7
• For strangulated hernias requiring bowel resection, herniorrhaphy repair should be preferred over mesh to reduce infection risk 4
• The modified Lichtenstein, Plug®, or TAPP techniques are recommended for femoral rings larger than 15mm 4
• For smaller femoral rings (<15mm), the Lytle procedure is recommended 4

Special Considerations

• Risk factors affecting morbidity include:

  • Symptomatic periods lasting longer than 8 hours 1
  • Presence of comorbid disease 1
  • High ASA scores 1
  • Presence of strangulation or necrosis 1

• Damage Control Surgery (DCS) should be considered for critically unstable patients with:

  • Severely injured abdominal organs requiring reassessment 1
  • Risk of abdominal compartment syndrome 1
  • Inability to close the defect 1

Outcomes and Complications

• Emergency surgery carries significantly higher morbidity (25%) compared to elective repair (6%) 2
• Overall complication rate is approximately 15% 2
• Recurrence rates are low (2.4% in one study) when appropriate repair techniques are used 2
• Mortality risk increases significantly with delayed treatment, especially in elderly patients 2, 1