Jeffrey A. Blatnik and Michael J. Rosen

Introduction

A femoral hernia is a type of groin hernia in which the hernia sac is located below the inguinal ligament. It can often be difficult to differentiate between femoral and inguinal hernias clinically, and thus the surgeon sometimes cannot distinguish between them preoperatively. Femoral hernias are much more common in women than in men (4 : 1) but are still less common than other types of inguinal hernias; they constitute only one third of all groin hernias in women and about 2% in men. Compared with inguinal hernias, femoral hernias are much more likely to become incarcerated or strangulated because of its anatomic location and rigid boundaries. For this reason, elective repair of femoral hernias is highly recommended to avoid the complications associated with incarceration or strangulation.

Anatomy

By definition, the femoral hernia protrudes through the femoral canal, bordered by the inguinal ligament superiorly, the femoral vein laterally, and the pubic ramus inferomedially (Fig. 30-1, A). This space is tight and cannot expand, which leads to the high risk of incarceration and strangulation.

Clinical Presentation

The femoral hernia often is seen as an asymptomatic bulge inferior to the inguinal ligament, and as it enlarges, the sac can extend onto the thigh (Fig. 30-1, B). The hernia may or may not be reducible, and patients often report a sensation of fullness. Patients who have incarceration or strangulation often report significant pain, and they may also have evidence of a small bowel obstruction.

Imaging

Additional imaging is not required but can provide useful information, especially when the diagnosis is unclear. Ultrasound or computed tomography (CT) scans can help differentiate between a femoral hernia, inguinal hernia, and inguinal lymphadenopathy (Fig. 30-1, C).

Open Surgical Repair

If a patient has signs of incarceration or strangulation, urgent repair is warranted. If the diagnosis of a femoral hernia is confirmed preoperatively, the incision can be placed below the inguinal ligament on the upper thigh. If the etiology of the hernia is uncertain, a standard inguinal hernia incision can be made, with plans to divide the transversalis fascia to expose the femoral space. The dissection can be completed from above the inguinal ligament or below (Fig. 30-2).

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