From the Guidelines
An obstructed femoral hernia requires immediate surgical intervention to prevent complications such as bowel ischemia, perforation, and peritonitis, and the patient should be prepared for emergency surgery after initial stabilization with IV fluids, pain management, and antibiotics. The preferred surgical approach is typically a low inguinal (McEvedy) or infrainguinal approach, allowing access to the femoral canal from above 1. During surgery, the constricting femoral ring is divided, the hernia contents are examined for viability, and non-viable tissue is resected with primary anastomosis if needed.
Key Considerations
- The hernia is then repaired using either a tissue repair or mesh technique, though mesh may be avoided if bowel resection was necessary due to infection risk 1.
- Postoperatively, patients require pain control, early mobilization, and gradual diet advancement.
- Femoral hernias occur more commonly in women and have a high risk of strangulation due to the narrow, rigid femoral ring.
- The mortality rate for emergency femoral hernia repair with bowel resection can reach 15%, highlighting the importance of prompt diagnosis and treatment to prevent complications 1.
Predictive Factors
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1.
- Elevated D-dimer levels measured upon admission were found to correlate strongly with intestinal ischaemia 1.
- An arterial blood lactate level of 2.0 mmol/L or greater was a useful predictor of non-viable bowel strangulation 1.
Surgical Approach
- The use of a synthetic mesh in emergency prosthetic repair can be performed without any increase in 30-day wound-related morbidity and is associated with a significant lower risk of recurrence, regardless of the size of hernia defect 1.
From the Research
Obstructed Femoral Hernia
- An obstructed femoral hernia is a serious condition that can lead to bowel obstruction or strangulation, requiring emergency surgery 2.
- Femoral hernias account for 2% to 4% of groin hernias and are more common in women, with a higher risk of strangulation and bowel obstruction 2.
- The symptoms of an obstructed femoral hernia can be non-specific, making diagnosis challenging, but may include abdominal pain, nausea, vomiting, and generalized tenderness and distention 2.
Diagnostic Challenges
- Obturator hernias, which can coexist with femoral hernias, are notorious for their diagnostic difficulty, often presenting with subtle signs such as medial thigh pain and no palpable lump 3, 4.
- Preoperative CT imaging can be helpful in diagnosing obstructed femoral hernias, but may not always correlate with operative findings, emphasizing the need for a high index of suspicion and early surgical intervention 3, 2.
Treatment and Outcomes
- Early surgical intervention is critical in the treatment of obstructed femoral hernias, with a significant reduction in morbidity and mortality achievable through prompt referral, quick preoperative workup, and urgent operation 5, 6.
- The length of hospital stay and overall morbidity and mortality rates are significantly higher for patients with bowel obstruction secondary to femoral hernia compared to those without bowel obstruction 5.
- Factors such as oral anticoagulant intake and a duration of symptoms longer than 3 days are associated with an increased risk of intestinal ischemia in patients with incarcerated femoral hernia 6.