What is the most appropriate management for an elderly female patient with an asymptomatic femoral hernia?

Management of Asymptomatic Femoral Hernia in Elderly Female

Open repair with mesh (Option B) is the most appropriate management for this elderly female patient with an asymptomatic femoral hernia, as femoral hernias carry an unacceptably high risk of emergency presentation with strangulation and bowel resection, which is associated with 10-fold increased mortality. 1

Rationale Against Observation

Observation is inappropriate for femoral hernias, even when asymptomatic, due to the following critical factors:

• Femoral hernias have a 35.9% emergency presentation rate, compared to only 4.9% for inguinal hernias 1
• Women face a substantially higher risk of emergency surgery (40.6% vs 28.1% in men), and this patient is female 1
• Emergency femoral hernia repair requires bowel resection in 22.7% of cases, compared to only 5.4% in inguinal hernias 1
• Emergency operations carry a 10-fold increased mortality risk, while elective repair mortality does not exceed that of the general population 1
• Emergency repairs result in significantly increased in-patient stay, early complication rates, and small bowel resection rates 2
• Conservative management is identified as a key contributing factor in treatment delays that lead to worse outcomes 2

Surgical Approach Selection

Open Repair with Mesh is Preferred Over Laparoscopic Repair

While laparoscopic repair is theoretically feasible, open preperitoneal mesh repair is the evidence-based standard for femoral hernias in elderly patients:

• Open preperitoneal mesh techniques result in fewer re-operations (hazard ratio 0.28; 95% CI 0.12-0.65) compared to suture repairs 1
• Mesh repair should be used in all femoral hernias to prevent the high recurrence rates seen with suture techniques 1
• Local anesthesia can be used for open mesh repair in elderly patients, making it safer than general anesthesia required for laparoscopic approaches 3
• Local anesthetic mesh hernia repair is safe and effective in elderly patients, with no perioperative mortality in a series of 221 elderly patients (mean age 74 years) 3

Laparoscopic Approach Considerations

Laparoscopic TEP repair has limited evidence specifically for femoral hernias in elderly patients:

• Only case reports exist for laparoscopic femoral hernia repair in high-risk patients, without large-scale outcome data 4
• Laparoscopic repair requires general anesthesia, which increases risk in elderly patients with comorbidities 3
• The learning curve and technical demands are higher for laparoscopic femoral hernia repair compared to open approaches 5

Specific Technical Recommendations

When performing open mesh repair:

• Use a preperitoneal approach (Stoppa, Wantz, or plug technique) rather than anterior approaches 1
• Mesh reinforcement is mandatory as primary suture repair has unacceptably high recurrence rates 1
• Local anesthesia should be strongly considered in this elderly patient to minimize perioperative risk 3
• Bilateral exploration should be performed as contralateral femoral hernias are common 6

Critical Clinical Pitfall

The most dangerous error is delaying surgical repair in femoral hernias, even when asymptomatic. The natural history of femoral hernias is progression to incarceration and strangulation, with devastating consequences in elderly patients 1, 2. Age should not be a barrier to elective repair, as this policy avoids the complications of emergency operation 3.