Femoral Hernia Surgical Approach
For femoral hernias, laparoscopic preperitoneal mesh repair (TAPP or TEP) is the recommended approach when expertise is available, as it allows assessment of both sides, reduces chronic pain risk, and has lower wound infection rates compared to open repair. 1, 2
Primary Surgical Approach Selection
Laparoscopic Preperitoneal Repair (First-Line)
Laparoscopic TAPP or TEP should be the preferred technique for femoral hernias in women, offering the critical advantage of identifying occult contralateral hernias (present in 11.2-50% of cases) and avoiding the risk of missing a femoral hernia that can occur with anterior open approaches 1, 2
The laparoscopic approach demonstrates significantly lower wound infection rates (P<0.018) and comparable recurrence rates to open repair, with an in-hospital mortality of only 0.14% 3
TAPP allows inspection of the contralateral side after patient consent, which is particularly important given that femoral hernias are bilateral in a substantial proportion of cases 1
Open Mesh Repair (Alternative When Laparoscopy Unavailable)
When laparoscopic expertise is unavailable, open preperitoneal mesh repair via low inguinal approach is recommended over tissue repair alone 1, 4
Mesh repair demonstrates dramatically lower recurrence rates (1.9%) compared to non-mesh techniques (6.5%), with a risk ratio of 0.924 (95% CI: 0.857-0.996) 4
The low inguinal approach with mesh placement provides direct access to the femoral canal and allows proper mesh overlap of 1.5-2.5 cm beyond defect edges 3, 5
Emergency/Incarcerated Femoral Hernia Management
Initial Assessment and Approach
Femoral hernias carry higher risk of incarceration/strangulation than inguinal hernias, with female gender and femoral hernia type being specific risk factors for emergency presentation 1, 2
Emergency laparoscopy (diagnostic laparoscopy or TAPP) is preferred when bowel viability needs assessment, as it allows reduction of the hernia sac, evaluation of bowel vitality, and simultaneous repair 6
Mesh Use in Emergency Settings
Synthetic mesh can be safely used even in emergency settings with intestinal strangulation and/or bowel resection without gross enteric spillage (CDC Class II), with significantly lower recurrence rates than tissue repair 1, 7
For clean surgical fields (CDC Class I) with incarceration but no strangulation, prosthetic mesh repair is strongly recommended (Grade 1A) 1, 7
Only when bowel necrosis or peritonitis is present with small defects (<3 cm) should primary tissue repair be considered, or biological mesh if direct suture is not feasible 1
When to Choose Open Over Laparoscopic in Emergencies
Open preperitoneal approach is preferable when active strangulation with bowel compromise is suspected or bowel resection is anticipated 1, 7
Open repair allows use of local anesthesia in emergency settings without bowel gangrene, which may be advantageous in elderly or high-risk patients 1
Patients with multiple previous abdominal operations may not be suitable for laparoscopic approach due to adhesions 6
Critical Technical Considerations
Mesh Fixation
In TEP repair, mesh fixation is unnecessary in most cases 1
In both TEP and TAPP, mesh fixation is recommended for large medial hernias (M3) to reduce recurrence risk 1
Avoid tacker fixation alone near vital structures; use transfascial sutures instead 3
Specific Pitfalls for Femoral Hernias
Femoral hernias are easily missed with anterior open approaches - exploration via the transversalis fascia is mandatory if open repair is performed to avoid overlooking a femoral hernia 6
The majority of recurrences (60%) occur within the first postoperative year, suggesting technical factors are critical 8
Tissue repair alone results in unacceptably high recurrence rates (6.5% vs 1.9% with mesh) and should be avoided 4
Special Population: Women with Groin Hernias
Women with any groin hernia should undergo laparoscopic repair when expertise is available to decrease chronic pain risk and avoid missing a femoral hernia, which is more common in women (22% of groin hernias in women vs 1.1% in men) 2, 4
Femoral hernias represent a higher proportion of emergency groin hernia presentations in women, making accurate preoperative diagnosis critical 2, 6