Femoral Hernia Causes and Treatment

Femoral Hernia

Describe anatomy, pathophysiology, required investigations for diagnosis of femoral hernia and the surgical techniques in management of femoral hernia.

• Herniation of intra-abdominal contents through the femoral canal is described as femoral hernia
• Women are more often involved, as compared to men with the ratio being 2:1, which is doubled in parous women.
• However, it should be remembered that in women, inguinal hernias are the most common type of hernia, followed by incisional hernia femoral hernia is the third most common type of hernia.

Femoral Hernia Anatomy

Femoral Hernia: Coverings

• Sac
• Fat and lymphoid tissue
• Transversalis fascia
• Cribriform fascia
• Superficial fascia
• Skin

Commonly the hernia is unilateral, with the right side being affected more often than the left side. It is bilateral in about 15–20% of the patients.

Anatomy of Femoral Canal and Femoral Ring

• The femoral canal extends from the femoral ring to the saphenous ring. It is 1½ inches below and lateral to the pubic tubercle. It is the innermost compartment of the femoral sheath.
• It is similar to a truncated cone which is narrow at the femoral ring.

Femoral Hernia Anatomy

Contents of the femoral canal are:

• Fat
• Fascia
• Lymphatics: Lymph node of Cloquet
• The femoral vein is in the middle compartment of the femoral sheath and the femoral artery is in the lateral compartment. The femoral nerve is outside the femoral sheath.
• Femoral sheath: Fascia transversalis is continued downwards behind the inguinal ligament as the anterior layer of the femoral sheath.
• Fascia iliaca continues behind the femoral vessels as the posterior layer of the femoral sheath.

Boundaries of Femoral Ring

• Anterior: Inguinal ligament.
• Posterior: Ligament of Cooper, iliopectineal ligament.
• Medial: Lacunar ligament (Gimbernat’s ligament).
• Lateral: Thin septum which separates the femoral canal from a femoral vein (silver fascia).

Causes for Femoral Hernia

1. Pregnancy: As the gravid uterus compresses the external iliac vein, the empty femoral sheath on the medial side allows the femoral vein to expand within the femoral sheath.
   • Thus, increased abdominal pressure due to repeated pregnancies is one of the chief factors responsible for femoral hernias. The maximum incidence is around 30–40 years of age.
2. Wide femoral canal: This is due to the narrow insertion of the iliopubic tract into the pectineal line of the pubis and may be responsible for a few cases of femoral hernia.

The course of the Hernial Sac

• As the hernia comes into the femoral canal, it is an oblong swelling due to the rigid femoral canal.
• When it comes out through the saphenous opening, it expands and becomes retort-shaped because Scarpa’s fascia is attached to the deep fascia of the thigh below the saphenous opening.

Clinical Features of Femoral Hernia

• Females between the ages of 20 and 40 years are commonly affected.
• Gaur sign: Dilatation of superficial epigastric/ circumflex iliac veins due to compression.
• The right side is more commonly affected because of the dominant nature of the right side of the body.
• To start with, there is a small swelling below the inguinal ligament, which goes unnoticed very often.
• Expansile impulse is often not present due to the narrow canal.
• Reducibility may be present.
• Typically, the swelling is below and lateral to the pubic tubercle (the inguinal hernia is above and medial to the pubic tubercle).
• Many (30–80%) present with strangulation.

Femoral Hernia Treatment

1. Low operation of Lockwood:

• The incision is placed directly over the swelling in the thigh. The sac is carefully dissected out without damaging the femoral vein.
• The sac is ligated at the neck, excised and the hernia is repaired—the inguinal ligament is sutured to Cooper’s ligament (iliopectineal ligament) thus obliterating the femoral ring. Nonabsorbable sutures such as proline or ethanol are ideal.
• A low approach is indicated in uncomplicated herniate is very difficult to manage a gangrenous loop of the bowel with this approach.

Surgery of Femoral Hernia

• Should be done as early as possible, once the diagnosis is made.
• For elective repair, a low (femoral) approach: Incision directly over the swelling is ideal. Injury to the abdominal obturator artery can occur in this route (found on the lateral side in 20% of cases).
• Transinguinal (Lothiessen): Can use it when there is gangrene. However, it may weaken the inguinal canal.
• Combined: A high approach is the choice for strangulated femoral hernias. Approximate inguinal ligament and pectineal ligament.

Abnormal obturator artery

• The normal obturator artery is a branch of the internal iliac artery. It gives a pubic branch that anastomoses with a pubic branch of the inferior epigastric artery.
• Occasionally, this anastomosis is large and the obturator artery then appears to be a branch of the inferior epigastri Usually it passes lateral to the femoral canal in contact with the femoral vein.
• Occasionally, the abnormal artery may lie along the medial margin of the femoral ring, i.e. along the free margin of the lacunar ligament.
• This artery is in danger during surgery for an obstructed femoral hernia.

2. Inguinal operation

• Through an inguinal incision, the inguinal canal is open transversalis fascia is inciseHernial sac is visualise.
• This is followed by the excision of the sac The high approach is preferred when there is a strangulated femoral herni.
• This offers a very good view of the abnormal obturator artery from above if it is present. Repair is done by suturing the conjoined tendon to iliopectineal line.

3. Combined approach: High operation of McEvedy: Inguinofemoral approach:

• A vertical incision is made over the swelling and extended above the inguinal ligament, and the sac can be dissected from both above and below (look for abnormal obturator artery—see below). This approach has the advantages of both operations mentioned above.

4. Henry’s approach: Lower midline for bilateral hernia.

Complications of Femoral Hernia

1. As the femoral ring and the neck of the sac are narrow, obstruction and strangulation are very common.
2. Richter’s hernia

• Commonly seen in femoral hernias and obturator hernias, which have narrow necks.
• This occurs when a portion of the circumference of the bowel is caught within the hernial sac and is constricted by the narrow ring.
• Signs and symptoms of intestinal obstruction are absent, even though it is an obstructed hernia because the lumen is not obstructed.
• The hernia is tense, tender, irreducible, and has no cough impulse.
• As the lumen is patent, there may be bloody diarrhea rather than constipation. Gangrene can occur soon.
• Treatment: A combined or inguinal approach to deal with gangrene.

Summary of Femoral Hernia

Rare Types of Femoral Hernia

1. Lacunar hernia (Laugier’s hernia): In this case, the hernia passes through a small defect in the lacunar ligament.
2. Prevascular hernia (Narath’s femoral hernia): In this case, the hernial sac is located behind the femoral.
3. Pectineal hernia: In this case, the hernia passes between the pectineus muscle and its fascia, behind the femoral vessels. It is also called Cloquet’s hernia.
4. 4. External femoral hernia: It is a hernia lateral to the femoral artery (Hesselbach’s hernia).

Femoral Hernia Pictures

Femoral Hernia

• Rarely occurs in males (5–10%)
• Commonly associated with Richter’s hernia
• Fatty female with small swelling under a big belly usually goes undetected.
• Dangerous because of early strangulation
• Cannot be controlled by a truss
• Surgical repair is a must for vessels and the inguinal ligament. It may be associated with congenital dislocation of the hip (Narath’s hernia).

Femoral Hernia Causes

Differential Diagnosis of Femoral Hernia

1. Inguinal hernia: An inguinal hernia is above and medial to pubic tubercle. The femoral hernia is below and lateral to the pubic tubercle.
2. Saphena varix: It is the dilated, saccular, upper end of the long saphenous vein with varicosity. It disappears on lying down because of gravity. The thrill may be felt by coughing.
3. Lipoma: Soft and lobular, slips under palpating fingers.
4. A femoral artery aneurysm is rare. It presents as a pulsatile swelling in the groin with a continuous murmur. Peripheral pulses are often weak.
5. Enlarged femoral lymph nodes are firm and raunchy and can be enlarged in lower limb infections, abrasions, wounds in the perineum, and also in carcinoma penis
6. Psoas bursa: Osteoarthritis of the hip can produce distension of the psoas bursa, which disappears on flexing the hip. Tuberculosis spine can present as iliopsoas abscess.
7. Psoas abscess: It is an iliopsoas abscess due to tuberculosis of the spine. There are two swellings, one above and one below the inguinal ligament. Cross fluctuation can be elicited between these two swellings. Tenderness over the spine and X-ray of the spine help in arriving at a diagnosis.

Femoral Hernia Causes