What is the recommended treatment for a femoral hernia?

Management of Femoral Hernia

Immediate surgical repair is the recommended treatment for femoral hernias due to their high risk of strangulation and associated mortality. 1

Diagnosis and Assessment

• Femoral hernias are relatively uncommon but have the highest rate of incarceration and strangulation among abdominal hernias 2
• CT scan is the gold standard for diagnosing complicated hernias, though most can be diagnosed clinically 1
• Female patients are more commonly affected with a female to male ratio of 8:1 3

Timing of Intervention

• Immediate surgical intervention is mandatory when intestinal strangulation is suspected (grade 1C recommendation) 4, 1
• Early detection and repair is crucial as delayed treatment (>24 hours) significantly increases mortality rates 4, 1
• Femoral hernia is an independent risk factor for requiring bowel resection (OR = 8.31, P < 0.001) 4, 1

Surgical Approach Options

Open Repair Techniques

• Several approaches exist for open femoral hernia repair 5:
  • Lockwood's infra-inguinal approach
  • Lotheissen's trans-inguinal approach
  • McEvedy's high approach
• A single skin incision 1 cm above the medial half of the inguinal ligament can allow access to all approaches depending on operative findings 5

Laparoscopic Repair

• Laparoscopic approaches include 6, 3:
  • Totally extraperitoneal (TEP) repair
  • Transabdominal preperitoneal (TAPP) repair
• Laparoscopic repair shows lower wound infection rates and shorter hospital stays 7
• Allows for evaluation of hernia content viability and repair of occult contralateral hernias 4
• Conversion rates to open repair are low (3.2-6.5%) 3

Mesh vs. Non-Mesh Repair

• Mesh repair is strongly recommended over tissue repair to reduce recurrence rates 1, 8
• Mesh repair probably reduces the risk of hernia recurrence compared to non-mesh repair (RR 0.46,95% CI 0.26 to 0.80) 8
• For clean surgical fields (no intestinal strangulation), synthetic mesh is recommended (grade 1A recommendation) 4, 1
• For clean-contaminated fields (CDC Class II) with intestinal strangulation and/or bowel resection without gross enteric spillage, synthetic mesh can still be safely used 4, 7
• For contaminated/dirty fields (CDC Classes III and IV) with bowel necrosis or gross enteric spillage, primary repair is recommended for small defects (<3 cm), while biological mesh may be used when direct suture is not feasible (grade 2C recommendation) 4, 7

Special Considerations

• Risk factors affecting morbidity include 4, 1:
  • Symptomatic periods lasting longer than 8 hours
  • Presence of comorbid disease
  • High ASA scores
  • Presence of strangulation or necrosis
• Emergency surgery significantly increases morbidity and mortality, especially in elderly patients 2
• For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome (grade 2C recommendation) 4

Postoperative Care

• Short-term antimicrobial prophylaxis is recommended for clean surgical fields (CDC wound class I) (grade 2C recommendation) 4
• 48-hour antimicrobial prophylaxis is recommended for cases with intestinal strangulation and/or concurrent bowel resection (CDC wound classes II and III) (grade 2C recommendation) 4
• Antimicrobial therapy is recommended for patients with peritonitis (CDC wound class IV) (grade 2C recommendation) 4

Clinical Pitfalls and Caveats

• Femoral hernias are often misdiagnosed as inguinal hernias 2
• Delay in diagnosis and treatment significantly increases morbidity and mortality 4, 1
• Mesh repair is superior to non-mesh repair for reducing recurrence, but may slightly increase the risk of seroma formation 8
• Local anesthesia can be used effectively for emergency inguinal hernia repair in the absence of bowel gangrene (grade 1C recommendation) 4