Femoral Hernia
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Femoral hernias are
hernia A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal Devel ...
s which occur just below the
inguinal ligament The inguinal ligament (), also known as Poupart's ligament or groin ligament, is a band running from the pubic tubercle to the anterior superior iliac spine. It forms the base of the inguinal canal through which an indirect inguinal hernia may ...
, when abdominal contents pass through a naturally occurring weakness in the
abdominal wall In anatomy, the abdominal wall represents the boundaries of the abdominal cavity. The abdominal wall is split into the anterolateral and posterior walls. There is a common set of layers covering and forming all the walls: the deepest being the vi ...
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 develop in women due to the increased width of the female
pelvis The pelvis (: pelves or pelvises) is the lower part of an Anatomy, anatomical Trunk (anatomy), trunk, between the human abdomen, abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also c ...
. 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.


Definitions

A hernia is caused by the protrusion of a
viscus In a multicellular organism, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to a ...
(in the case of groin hernias, an intra-abdominal organ) through a weakness in the
abdominal wall In anatomy, the abdominal wall represents the boundaries of the abdominal cavity. The abdominal wall is split into the anterolateral and posterior walls. There is a common set of layers covering and forming all the walls: the deepest being the vi ...
. This weakness may be inherent, as in the case of inguinal, femoral and
umbilical hernia An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards—the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. ...
s. On the other hand, the weakness may be caused by previous surgical incision through the muscles and fascia in the area; this is termed an
incisional hernia An incisional hernia is a type of hernia caused by an incompletely-healed surgical wound. Since median incisions in the abdomen are frequent for abdominal exploratory surgery, ventral incisional hernias are often also classified as ventral herni ...
. A femoral hernia may be either reducible or irreducible, and each type can also present as obstructed and/or strangulated. A reducible femoral hernia occurs when a femoral hernia can be pushed back into the abdominal cavity, either spontaneously or with manipulation. However, it is more likely to occur spontaneously. This is the most common type of femoral hernia and is usually painless. An irreducible femoral hernia occurs when a femoral hernia cannot be completely reduced, typically due to adhesions between the hernia and the hernial sac. This can cause pain and a feeling of illness. An obstructed femoral hernia occurs when a part of the intestine involved in the hernia becomes twisted, kinked, or constricted, causing an intestinal obstruction. A strangulated femoral hernia occurs when a constriction of the hernia limits or completely obstructs blood supply to part of the bowel involved in the hernia. Strangulation can occur in all hernias, but is more common in femoral and inguinal hernias due to their narrow "weaknesses" in the abdominal wall.
Nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...
, vomiting, and severe abdominal pain are characteristics of a strangulated hernia. This is a medical emergency, as the loss of blood supply to the bowel can result in
necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...
(tissue death) followed by gangrene (tissue decay). This is a life-threatening condition requiring immediate surgery. 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 bstructedhernia that is irreducible but not strangulated. Thus, an irreducible, obstructed hernia can also be called an incarcerated one." "Incarcerated hernia is a hernia that cannot be reduced. These may lead to bowel obstruction but are not associated with vascular compromise." A hernia can be described as reducible if the contents within the sac can be pushed back through the defect into the peritoneal cavity, whereas with an incarcerated hernia, the contents are stuck in the hernia sac. However, the term ''incarcerated'' seems to always imply that the femoral hernia is at least irreducible.


Signs and symptoms

Femoral hernias typically present as a groin lump or bulge, which may differ in size during the day, based on internal pressure variations of the intestine. This lump is typically retort shaped. The bulge or lump is typically smaller or may disappear completely in the 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 cough impulse is often absent and is not 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 The inguinal ligament (), also known as Poupart's ligament or groin ligament, is a band running from the pubic tubercle to the anterior superior iliac spine. It forms the base of the inguinal canal through which an indirect inguinal hernia may ...
) whereas an inguinal hernia starts above this line. Nonetheless, it is often impossible to distinguish the two preoperatively.


Anatomy

The femoral canal is located below the inguinal ligament on the lateral aspect of the pubic tubercle. It is bounded by the
inguinal ligament The inguinal ligament (), also known as Poupart's ligament or groin ligament, is a band running from the pubic tubercle to the anterior superior iliac spine. It forms the base of the inguinal canal through which an indirect inguinal hernia may ...
anteriorly, pectineal ligament posteriorly, lacunar ligament medially, and the
femoral vein In the human body, the femoral vein is the vein that accompanies the femoral artery in the femoral sheath. It is a deep vein that begins at the adductor hiatus (an opening in the adductor magnus muscle) as the continuation of the popliteal v ...
laterally. It normally contains a few lymphatics, loose areolar tissue, and occasionally a lymph node called
Cloquet's node Inguinal lymph nodes are lymph nodes in the groin. They are situated in the femoral triangle of the inguinal region. They are subdivided into two groups: the superficial inguinal lymph nodes and deep inguinal lymph nodes. Superficial inguinal ...
. 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.


Diagnosis

The diagnosis is largely a clinical one, generally done by
physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...
of the groin. However, in obese patients, imaging in the form of
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
, CT, or
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...
may aid in the diagnosis. For example, 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 inguinal hernia or groin hernia is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absen ...
, an enlarged femoral
lymph node A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that includ ...
,
aneurysm An aneurysm is an outward :wikt:bulge, bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also b ...
of the femoral artery, dilation of the saphenous vein, athletic pubalgia, and an abscess of the psoas.


Classification

Several subtypes of femoral hernia have been described.


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

Some surgeons choose to perform "key-hole" or laparoscopic surgery (also called minimally invasive surgery) rather than conventional "open" surgery. With minimally invasive surgery, one or more small incisions are made that allow the surgeon to use a surgical camera and small tools to repair the hernia. Either open or minimally invasive surgery may be performed under general or regional anesthesia, 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 visualization of the 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 The inguinal ligament (), also known as Poupart's ligament or groin ligament, is a band running from the pubic tubercle to the anterior superior iliac spine. It forms the base of the inguinal canal through which an indirect inguinal hernia may ...
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 In the human body, the femoral vein is the vein that accompanies the femoral artery in the femoral sheath. It is a deep vein that begins at the adductor hiatus (an opening in the adductor magnus muscle) as the continuation of the popliteal v ...
.


Postoperative outcome

Patients undergoing elective surgical repair do very well and may be able to go home the same day. However, emergency repair carries a greater morbidity and mortality rate and this is directly proportional to the degree of bowel compromise.


Epidemiology

Femoral hernias are more common in multiparous females, which results from elevated intra-abdominal pressure that dilates the femoral vein and in turn stretches femoral ring. Such constant pressure causes preperitoneal fat to insinuate in the femoral ring, a consequence of which is development of a femoral peritoneal sac.


References


External links


Surgery Encyclopaedia
{{DEFAULTSORT:Femoral Hernia Hernias