From the Guidelines
Surgical repair for an obstructed femoral hernia should be performed immediately to prevent strangulation and reduce morbidity and mortality rates. The procedure should be done urgently, as delayed diagnosis and treatment can lead to septic complications and high mortality rates 1. The surgical approach typically involves either an open repair or laparoscopic technique, with the McVay repair or mesh placement being common methods.
Preoperative Management
Preoperatively, the patient should receive:
- Appropriate antibiotics such as cefazolin 1-2g IV
- Adequate fluid resuscitation
- Pain management
Surgical Approach
The surgeon will make an incision in the groin area, reduce the herniated contents, inspect the bowel for viability, resect any necrotic tissue if present, and then repair the hernia defect.
- If the bowel is viable, a mesh repair may be performed
- However, if there is contamination from gangrenous or perforated bowel, primary tissue repair is preferred
Postoperative Management
Postoperatively, patients typically require:
- 1-2 days of hospitalization
- Pain management with acetaminophen and NSAIDs (adding opioids if needed)
- Early ambulation
- Gradual return to normal activities over 4-6 weeks
According to the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias, emergent prosthetic repair with a synthetic mesh can be performed in patients with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage, and is associated with a significant lower risk of recurrence 1.
Key Considerations
- Early detection of complicated abdominal hernias is crucial to reduce mortality rates
- The elapsed time from onset to surgery is the most important prognostic factor
- Signs of systemic inflammatory response syndrome (SIRS) and contrast-enhanced CT findings can be predictive of bowel strangulation
- Lactate level and D-dimer assays can be useful predictors of non-viable bowel strangulation and intestinal ischemia, respectively 1.
Recommendations
- Surgical repair should be performed immediately in cases of suspected intestinal strangulation
- A multidisciplinary approach should be taken to manage patients with obstructed femoral hernias, involving surgeons, anesthesiologists, and other healthcare professionals
- Patients should be closely monitored postoperatively for signs of complications and receive prompt treatment if necessary.
From the Research
Surgical Repair for Femoral Hernia Obstructed
- The PerFix mesh plug technique is considered a suitable method for elective and non-infected cases of femoral hernia, resulting in reduced recurrence rates, shortened hospital stays, and low postoperative complications 2.
- In emergency situations, the McEvedy's approach may be superior to other approaches when entry into the peritoneum is anticipated, although it may be associated with longer operation times and hospital stays 3.
- Mesh repair probably reduces the risk of hernia recurrence compared to non-mesh repair, with one hernia recurrence prevented for every 46 mesh repairs 4.
- Laparoscopic totally extraperitoneal mesh repair is a suitable technique for repair of femoral hernia, including irreducible but not obstructed femoral hernias, with no postoperative complications or chronic pain reported in one study 5.
Comparison of Surgical Techniques
- A study comparing surgical outcomes of patients with femoral hernias using different techniques under emergency or elective conditions found no significant differences between the two groups according to hernia side 6.
- The choice of surgical technique may depend on the specific circumstances of the patient, with mesh repair being a common approach due to its benefits in reducing hernia recurrence and visceral or neurovascular injuries 4.