Surgical Repair is Recommended for Asymptomatic Femoral Hernias
All femoral hernias, even when small and asymptomatic, should undergo elective surgical repair with mesh to prevent life-threatening complications of incarceration and strangulation. 1, 2
Rationale for Early Elective Repair
Femoral hernias carry an exceptionally high risk of complications that directly impact mortality:
Femoral hernias have a 36-41% emergency surgery rate compared to only 4.9% for inguinal hernias, indicating their propensity for acute complications even when initially asymptomatic 3, 2
Emergency femoral hernia repair carries a 10-fold increased mortality risk compared to elective repair, which has mortality rates no higher than the general population 2
Femoral hernia is an independent risk factor for bowel resection (OR = 8.31, P < 0.001), with 22.7% of emergency cases requiring bowel resection versus only 5.4% of emergency inguinal repairs 1, 2
Delayed treatment beyond 24 hours significantly increases mortality rates, particularly in elderly patients 1, 4
Recommended Surgical Approach
Open mesh repair is the preferred technique for elective femoral hernias:
Mesh repair is strongly recommended over tissue repair to reduce recurrence rates 1
Open preperitoneal mesh techniques result in significantly fewer re-operations than suture repairs (hazard ratio 0.28,95% CI 0.12-0.65) 2
The mesh plug technique via low inguinal approach has demonstrated excellent outcomes with minimal recurrence, shortened hospital stays, and low complication rates in elective cases 5, 6
For clean surgical fields without intestinal complications, synthetic mesh is recommended 1
Why Observation is Inappropriate
Observation (Answer A) is contraindicated because:
The unpredictable nature of femoral hernia progression means asymptomatic hernias can rapidly develop strangulation 3, 2
Early elective surgery reduces overall morbidity and mortality compared to waiting for complications to develop 3
Women have a 40.6% risk of requiring emergency surgery if femoral hernias are managed expectantly 2
Common Pitfalls to Avoid
Do not delay repair based on lack of symptoms - the absence of symptoms does not predict safety, as femoral hernias have inherently high complication rates 2
Do not confuse femoral hernia management with other hernia types - unlike some inguinal hernias where observation may be acceptable in certain populations, femoral hernias require repair due to their narrow, rigid neck and high strangulation risk 3, 2
Do not use simple tissue repair - mesh reinforcement is essential to prevent recurrence 1, 2
Answer: B. Open mesh repair is the most appropriate management for this asymptomatic small femoral hernia.