Femoral hernia
Encyclopedia
A hernia is caused by the protrusion of a viscus
(in the case of groin hernias, an intraabdominal organ) through a weakness in the containing wall. This weakness may be inherent, as in the case of inguinal, femoral and umbilical hernias. On the other hand, the weakness may be caused by surgical incision through the muscles of the abdominal/thoracic wall. Hernias occurring through these are called incisional hernias.
Femoral hernias occur just below the inguinal ligament
, when abdominal contents pass through a naturally occurring weakness called the femoral canal
. Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, almost all of them develop in women because of the wider bone structure of the female pelvis. Femoral hernias are more common in adults than in children. Those that do occur in children are more likely to be associated with a connective tissue disorder or with conditions that increase intra-abdominal pressure. Seventy percent of pediatric cases of femoral hernias occur in infants under the age of one.
A reducible femoral hernia occurs when a femoral hernia can be pushed back into the abdomen, either spontaneously or with manipulation. This is the most common type of femoral hernia and is usually painless.
An irreducible femoral hernia occurs when a femoral hernia becomes stuck in the femoral canal. This can cause pain and a feeling of illness.
An obstructed femoral hernia occurs when a part of the intestine becomes intertwined with the hernia, causing an intestinal obstruction. The obstruction may grow and the hernia can become increasingly painful. Vomiting may also result.
A strangulated femoral hernia occurs when a femoral hernia blocks blood supply to part of the bowel - the loop of bowel loses its blood supply. Strangulation can happen in all hernias, but is more common in femoral and inguinal hernias due to their narrow "necks". Nausea, vomiting, and severe abdominal pain may occur with a strangulated hernia. This is a medical emergency. A strangulated intestine can result in necrosis
(tissue death) followed by gangrene
(tissue decay). This is a life-threatening condition requiring immediate surgery.
A femoral hernia may be either reducible or irreducible, and each type can also present as either (or both) obstructed or strangulated.
The term incarcerated femoral hernia is sometimes used, but may have different meanings to different authors and physicians. For example: "Sometimes the hernia can get stuck in the canal and is called an irreducible or incarcerated femoral hernia." "The term 'incarcerated' is sometimes used to describe an [obstructed] hernia that is irreducible but not strangulated. Thus, an irreducible, obstructed hernia can also be called an incarcerated one." "Incarcerated hernia: a hernia that cannot be reduced. May lead to bowel obstruction but is not associated with vascular compromise." However, the term "incarcerated" seems to always imply that the femoral hernia is at least irreducible.
is located below the inguinal ligament on the lateral aspect of the pubic tubercle
. It is bounded by the inguinal ligament
anteriorly, pectineal ligament
posteriorly, lacunar ligament
medially, and the femoral vein
laterally. It normally contains a few lymphatics, loose areolar tissue and occasionally a lymph node called Cloquet's node
. The function of this canal appears to be to allow the femoral vein to expand when necessary to accommodate increased venous return from the leg during periods of activity. Femoral herniae are more common in females than in males.
, has been described. This is a vermiform appendix
trapped within the hernial sac.
They may or may not be associated with pain. Often, they present with a varying degree of complication ranging from irreducibility through intestinal obstruction to frank gangrene of contained bowel. The incidence of strangulation in femoral hernias is high. A femoral hernia has often been found to be the cause of unexplained small bowel obstruction.
The obvious finding may be a lump in the groin. Cough impulse is often absent and should not be relied on solely when making a diagnosis of femoral hernia. The lump is more globular than the pear shaped lump of the inguinal hernia. The bulk of a femoral hernia lies below an imaginary line drawn between the anterior superior iliac spine
and the pubic tubercle
(which essentially represents the inguinal ligament
) whereas an inguinal hernia starts above this line. Nonetheless, it is often impossible to distinguish the two preoperatively.
of the groin. However, in obese patients, imaging in the form of ultrasonography, CT or MRI may aid in the diagnosis. An abdominal x-ray showing small bowel obstruction in a female patient with a painful groin lump needs no further investigation.
Several other conditions have a similar presentation and must be considered when forming the diagnosis: inguinal hernia
, an enlarged inguinal lymph node
, aneurysm
of the femoral artery, saphena varix
, and an abscess of the psoas.
Conventional open surgery requires an incision large enough for the surgeon's hands to enter the patient, although the surgeon may describe it as "microscopic" surgery (the surgeon wears or uses magnifying devices during the surgery).
Either open or minimally invasive surgery may be performed under general or regional anaesthesia, depending on the extent of the intervention needed. Three approaches have been described for open surgery.
The infra-inguinal approach is the preferred method for elective repair. The trans-inguinal approach involves dissecting through the inguinal canal and carries the risk of weakening the inguinal canal. McEvedy’s approach is preferred in the emergency setting when strangulation is suspected. This allows better access to and visualisation of bowel for possible resection. In any approach, care should be taken to avoid injury to the urinary bladder which is often a part of the medial part of the hernial sac.
Repair is either performed by suturing the inguinal ligament
to the pectineal ligament
using strong non-absorbable sutures or by placing a mesh plug in the femoral ring
. With either technique care should be taken to avoid any pressure on the femoral vein
.
Viscus
In anatomy, a viscus is an internal organ, and viscera is the plural form. The viscera, when removed from a butchered animal, are known collectively as offal...
(in the case of groin hernias, an intraabdominal organ) through a weakness in the containing wall. This weakness may be inherent, as in the case of inguinal, femoral and umbilical hernias. On the other hand, the weakness may be caused by surgical incision through the muscles of the abdominal/thoracic wall. Hernias occurring through these are called incisional hernias.
Femoral hernias occur just below the inguinal ligament
Inguinal ligament
The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine. Its anatomy is very important for operating on hernia patients.-Anatomy:...
, when abdominal contents pass through a naturally occurring weakness called the femoral canal
Femoral canal
The femoral sheath has three compartments. The lateral compartment contains the femoral artery, the intermediate compartment contains the femoral vein, and the medial and smallest compartment is called the femoral canal. The femoral canal contains efferent lymphatic vessels and a lymph node...
. Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, almost all of them develop in women because of the wider bone structure of the female pelvis. Femoral hernias are more common in adults than in children. Those that do occur in children are more likely to be associated with a connective tissue disorder or with conditions that increase intra-abdominal pressure. Seventy percent of pediatric cases of femoral hernias occur in infants under the age of one.
A reducible femoral hernia occurs when a femoral hernia can be pushed back into the abdomen, either spontaneously or with manipulation. This is the most common type of femoral hernia and is usually painless.
An irreducible femoral hernia occurs when a femoral hernia becomes stuck in the femoral canal. This can cause pain and a feeling of illness.
An obstructed femoral hernia occurs when a part of the intestine becomes intertwined with the hernia, causing an intestinal obstruction. The obstruction may grow and the hernia can become increasingly painful. Vomiting may also result.
A strangulated femoral hernia occurs when a femoral hernia blocks blood supply to part of the bowel - the loop of bowel loses its blood supply. Strangulation can happen in all hernias, but is more common in femoral and inguinal hernias due to their narrow "necks". Nausea, vomiting, and severe abdominal pain may occur with a strangulated hernia. This is a medical emergency. A strangulated intestine can result in necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
(tissue death) followed by gangrene
Gangrene
Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies . This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood...
(tissue decay). This is a life-threatening condition requiring immediate surgery.
A femoral hernia may be either reducible or irreducible, and each type can also present as either (or both) obstructed or strangulated.
The term incarcerated femoral hernia is sometimes used, but may have different meanings to different authors and physicians. For example: "Sometimes the hernia can get stuck in the canal and is called an irreducible or incarcerated femoral hernia." "The term 'incarcerated' is sometimes used to describe an [obstructed] hernia that is irreducible but not strangulated. Thus, an irreducible, obstructed hernia can also be called an incarcerated one." "Incarcerated hernia: a hernia that cannot be reduced. May lead to bowel obstruction but is not associated with vascular compromise." However, the term "incarcerated" seems to always imply that the femoral hernia is at least irreducible.
Anatomy
The femoral canalFemoral canal
The femoral sheath has three compartments. The lateral compartment contains the femoral artery, the intermediate compartment contains the femoral vein, and the medial and smallest compartment is called the femoral canal. The femoral canal contains efferent lymphatic vessels and a lymph node...
is located below the inguinal ligament on the lateral aspect of the pubic tubercle
Pubic tubercle
The pubic tubercle is a prominent forward-projecting tubercle on the upper border of the medial portion of the superior ramus of the pubis...
. It is bounded by the inguinal ligament
Inguinal ligament
The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine. Its anatomy is very important for operating on hernia patients.-Anatomy:...
anteriorly, pectineal ligament
Pectineal ligament
The pectineal ligament is an extension of the lacunar ligament that runs on the pectineal line of the pubic bone....
posteriorly, lacunar ligament
Lacunar ligament
The lacunar ligament is a ligament in the inguinal region that connects the inguinal ligament to the pectineal ligament near the point where they both insert on the pubic tubercle.-Anatomy:...
medially, and the femoral vein
Femoral vein
In the human body, the femoral vein is a blood vessel that accompanies the femoral artery in the femoral sheath. It begins at the adductor canal and is a continuation of the popliteal vein...
laterally. It normally contains a few lymphatics, loose areolar tissue and occasionally a lymph node called Cloquet's node
Cloquet's node
Cloquet's node is a lymph node found in the inguinal region.It is named for Jules Germain Cloquet.It can be considered the superiormost deep inguinal lymph nodes or inferiormost external iliac lymph nodes....
. The function of this canal appears to be to allow the femoral vein to expand when necessary to accommodate increased venous return from the leg during periods of activity. Femoral herniae are more common in females than in males.
Classification
One subtype, De Garengeot's herniaDe Garengeot's hernia
De Garengeot's hernia is a rare subtype of an incarcerated femoral hernia. This eponym may be used to describe the incarceration of the vermiform appendix within a femoral hernia....
, has been described. This is a vermiform appendix
Vermiform appendix
The appendix is a blind-ended tube connected to the cecum , from which it develops embryologically. The cecum is a pouchlike structure of the colon...
trapped within the hernial sac.
Signs and symptoms
They typically present when standing erect as a groin lump or bulge, which may differ in size during the day, based on internal pressure variations of the intestine. The bulge or lump typically is smaller or may not be visible in a prone position.They may or may not be associated with pain. Often, they present with a varying degree of complication ranging from irreducibility through intestinal obstruction to frank gangrene of contained bowel. The incidence of strangulation in femoral hernias is high. A femoral hernia has often been found to be the cause of unexplained small bowel obstruction.
The obvious finding may be a lump in the groin. Cough impulse is often absent and should not be relied on solely when making a diagnosis of femoral hernia. The lump is more globular than the pear shaped lump of the inguinal hernia. The bulk of a femoral hernia lies below an imaginary line drawn between the anterior superior iliac spine
Ilium (bone)
The ilium is the uppermost and largest bone of the pelvis, and appears in most vertebrates including mammals and birds, but not bony fish. All reptiles have an ilium except snakes, although some snake species have a tiny bone which is considered to be an ilium.The name comes from the Latin ,...
and the pubic tubercle
Ilium (bone)
The ilium is the uppermost and largest bone of the pelvis, and appears in most vertebrates including mammals and birds, but not bony fish. All reptiles have an ilium except snakes, although some snake species have a tiny bone which is considered to be an ilium.The name comes from the Latin ,...
(which essentially represents the inguinal ligament
Inguinal ligament
The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine. Its anatomy is very important for operating on hernia patients.-Anatomy:...
) whereas an inguinal hernia starts above this line. Nonetheless, it is often impossible to distinguish the two preoperatively.
Diagnosis
The diagnosis is largely a clinical one, generally done by physical examinationPhysical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
of the groin. However, in obese patients, imaging in the form of ultrasonography, CT or MRI may aid in the diagnosis. An abdominal x-ray showing small bowel obstruction in a female patient with a painful groin lump needs no further investigation.
Several other conditions have a similar presentation and must be considered when forming the diagnosis: inguinal hernia
Inguinal hernia
An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. They are very common , and their repair is one of the most frequently performed surgical operations....
, an enlarged inguinal lymph node
Lymph node
A lymph node is a small ball or an oval-shaped organ of the immune system, distributed widely throughout the body including the armpit and stomach/gut and linked by lymphatic vessels. Lymph nodes are garrisons of B, T, and other immune cells. Lymph nodes are found all through the body, and act as...
, aneurysm
Aneurysm
An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
of the femoral artery, saphena varix
Saphena varix
A saphena varix, or a saphenous varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin.-Clinical features:...
, and an abscess of the psoas.
Management
Femoral hernias, like most other hernias, usually need operative intervention. This should ideally be done as an elective (non-emergency) procedure. However, because of the high incidence of complications, femoral hernias often need emergency surgery.Surgery
Younger surgeons frequently use "key-hole" or laparoscopic surgery (also called minimally invasive surgery rather than "open" surgery. With key-hole surgery one or more small incisions are made that allow the surgeon to use a surgical camera and small tools to repair the hernia.Conventional open surgery requires an incision large enough for the surgeon's hands to enter the patient, although the surgeon may describe it as "microscopic" surgery (the surgeon wears or uses magnifying devices during the surgery).
Either open or minimally invasive surgery may be performed under general or regional anaesthesia, depending on the extent of the intervention needed. Three approaches have been described for open surgery.
- Lockwood’s infra-inguinal approach
- Lotheissen‘s trans-inguinal approach
- McEvedy’s high approach
The infra-inguinal approach is the preferred method for elective repair. The trans-inguinal approach involves dissecting through the inguinal canal and carries the risk of weakening the inguinal canal. McEvedy’s approach is preferred in the emergency setting when strangulation is suspected. This allows better access to and visualisation of bowel for possible resection. In any approach, care should be taken to avoid injury to the urinary bladder which is often a part of the medial part of the hernial sac.
Repair is either performed by suturing the inguinal ligament
Inguinal ligament
The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine. Its anatomy is very important for operating on hernia patients.-Anatomy:...
to the pectineal ligament
Pectineal ligament
The pectineal ligament is an extension of the lacunar ligament that runs on the pectineal line of the pubic bone....
using strong non-absorbable sutures or by placing a mesh plug in the femoral ring
Femoral ring
The femoral ring is the base of the femoral canal. It is directed upward and is oval in form, its long diameter being directed transversely and measuring about 1.25 cm.-Boundaries:The femoral ring is bounded as follows:...
. With either technique care should be taken to avoid any pressure on the femoral vein
Femoral vein
In the human body, the femoral vein is a blood vessel that accompanies the femoral artery in the femoral sheath. It begins at the adductor canal and is a continuation of the popliteal vein...
.