Key Facts

Femoral hernias are less common than inguinal hernias but carry a much higher risk of strangulation. All femoral hernias should be repaired without delay.

Epidemiology

Femoral hernias account for ~5% of all groin hernias. More common in women (F:M ~4:1), elderly, multiparous women. However, inguinal hernias remain the commonest groin hernia in both sexes.

Aetiology

• Weakness at the femoral ring — below the inguinal ligament, medial to the femoral vein
• Risk factors: Female sex, multiparity, increased intra-abdominal pressure, previous inguinal hernia repair

Pathophysiology

• Abdominal contents (usually omentum or bowel) protrude through the femoral ring into the femoral canal
• Narrow, rigid boundaries of femoral canal (lacunar ligament medially) → high risk of incarceration and strangulation
• Richter's hernia: Only the antimesenteric border of bowel herniates → can strangulate and perforate without causing classic bowel obstruction

Typical Presentation

• Small, firm lump in the groin — below and lateral to the pubic tubercle
• May be difficult to detect clinically, especially in obese patients
• Often presents as an emergency with incarceration or strangulation

Examination

• Lump in femoral triangle below the inguinal ligament
• Non-reducible in many cases
• No cough impulse (if incarcerated)
• Distinguish from inguinal hernia by relationship to pubic tubercle

Red Flags

• Tender, irreducible femoral hernia — strangulation until proven otherwise
• Signs of bowel obstruction — colicky pain, vomiting, constipation
• Overlying skin changes (erythema, warmth) — bowel necrosis
• Richter's hernia — may present with localised peritonitis without frank obstruction

Bedside

• Clinical examination: Position relative to pubic tubercle is key
• Examine patient standing and lying

Bloods

• FBC, CRP, U&Es, lactate: If strangulation/obstruction suspected
• G&S: Pre-operative

Imaging

• CT abdomen/pelvis: If diagnostic uncertainty or suspected complication (obstruction, strangulation)
• Ultrasound: May identify hernia contents and vascularity

Surgical (All Femoral Hernias Should Be Repaired)

Elective:

• Low (Lockwood/crural) approach: Below inguinal ligament; simple, can be done under local
• High (McEvedy/preperitoneal) approach: Preferred for emergency; better access for bowel assessment and resection
• Laparoscopic (TEP/TAPP): Can be performed; offers advantage of bilateral repair
• Mesh repair where feasible (reduces recurrence)

Emergency:

• Strangulated femoral hernia = emergency surgery
• McEvedy approach preferred — allows assessment of bowel viability and resection if needed
• Do NOT attempt blind reduction — necrotic bowel may be returned to abdomen
• IV fluids, NG tube if obstructed, IV antibiotics (co-amoxiclav 1.2g)

Referral Criteria

• All femoral hernias — urgent surgical referral for repair (even if asymptomatic due to high strangulation risk)
• Suspected strangulation — emergency surgery

• Strangulation rate: ~30% — significantly higher than inguinal hernias (~1-3%)
• Emergency repair mortality: ~5-10% (much higher than elective <1%)
• Recurrence: ~2-5% after mesh repair
• Bowel resection required: In ~30-40% of emergency femoral hernia repairs
• Outcomes significantly better with elective repair → all femoral hernias should be repaired promptly

Inguinal vs Femoral Hernia