[24] Femoral Hernia Flashcards
What is a femoral hernia?
When abdominal viscera or omentum passes through the femoral ring and into the potential space of the femoral canal
What % of abdominal hernias are femoral hernias?
5%
Who are femoral hernias more common in?
Females (3:1)
Why are femoral hernias more common in females?
It is secondary to the wider anatomy of the female bony pelvis
Can femoral herniation occur in a child?
It is very rare
What is the femoral canal?
An anatomical compartment
Where is the femoral canal located?
In the anterior thigh
What does the femoral canal contain?
Lymphatic vessels
Lymph nodes
Some loose connective tissue
What makes up the superior border of the femoral canal?
The femoral ring
What is the femoral ring covered by?
The femoral septum (a connective tissue layer)
Why are femoral hernias very prone to complications requiring urgent surgical interventions?
Due to the rigidity of the borders of the femoral ring, especially the concave margin of the lacunar ligament
What are the main risk factors for developing a femoral hernia?
Female gender
Increasing age
Pregnancy
Increased intra-abdominal pressure
Give two examples of causes of increased intra-abdominal pressure leading to a femoral hernia?
Heavy lifting
Chronic constipation
How will femoral hernias commonly present?
As a lump in the groin
What % of femoral hernia cases present as an emergency?
Around 30%
Why is it important to identify the exact location of the lump in the groin?
In order to decide what type of hernia is present
Where in the groin is a femoral hernia lump found?
Infero-lateral to the pubic tubercle, and medial to the femoral pulse
Where in the groin is an inguinal hernia lump found?
Superomedial to the pubic tubercle
When is a femoral hernia often misdiagnosed as an inguinal hernia?
If it migrates superiorly to the inguinal ligament
Is a femoral hernia likely to be reducible?
No, due to the tightness of the femoral ring
What are the differential diagnoses for a lump in the groin?
Low presentation of an inguinal hernia Femoral canal lipoma Femoral lymph noed Saphena varix Femoral artery aneurysm Athletic Pubalgia
What are the features of a saphena varix?
Disappears when lying flat
Palpable thrill when coughing
Presence of varicose veins elsewhere
What is athletic pubalgia?
A small tear in the rectus sheath, through which impingement of the abdominal wall musculature occurs
Who is athletic pubalgia common in?
Young athletes
Which patients with femoral hernias require surgical intervention?
All patients will eventually need surgical intervention
What is the result of all patients with a femoral hernia eventually needing surgical intervention?
Routine pre-operative investigations should be performed if possible
How is a diagnosis of femoral hernia usually made?
Clinical
What is the gold standard of diagnosis for a femoral hernia?
Ultrasound scan
How accurate are ultrasound scans in identifying the specific type of hernia?
96%
What is the limitation of ultrasound scans in identifying hernias?
Operator dependant
What should be done if there is significant doubt in the diagnosis of femoral hernia, or evidence of complications?
The lump should be surgically explored
Why should all femoral hernias be surgically managed?
Due to the increased risk of strangulation
What does surgical intervention for femora hernias involve?
Reduction of the hernia, then surgical narrowing of the femoral ring with the use of interrupted sutures
What care should be taken during surgical narrowing of the femoral ring?
To avoid narrowing the femoral vein in the process
What surgical approaches can be taken for the management of a femoral hernia?
Low approach
High approach
How is a low approach to femoral hernia repair done?
The incision is made below the inguinal ligament
What is the advantage of a low approach in femoral hernia repair?
It doesn’t interfere with inguinal structures
What is the disadvantage of a low approach in femoral hernia repair?
It results in limited space for the removal or any compromised small bowel
How is a high approach to femoral hernia repair done?
The incision is made above the inguinal ligament, via the posterior wall of the inguinal canal
Where is a high approach to femoral hernia repair the preferred intervention?
In an emergency intervention
Why is a high approach to femoral hernia repair preferred in an emergency intervention?
Due to the easy access to the compromised small bowel
What is the main limitation of a high approach to femoral hernia repair?
The need to repair the inguinal canal on closure, thus providing a new area of weakness and potential secondary herniation
What are the serious complications of a hernia that require urgent intervention?
Incarceration
Obstruction
Strangulation
What is meant by an incarcerated hernia?
The contents of the hernia are unable to return to their original cavity
What happens in obstruction caused by a hernia?
The bowel lumen becomes obstructed, leading to the clinical features of bowel obstruction
What is a strangulated hernia?
Compression of the hernia compromises the blood supply, leading to the bowel becoming ischaemic
How will a hernia that has become strangulated present?
As a irreducible and tender, tense lump, with the pain often being out of proportion to clinical signs
This may be accompanied with clinical features of obstruction
Why is a strangulated hernia a surgical emergency?
Due to the time-dependant risk of bowel infarction
How is a diagnosis of strangulated hernia made?
Typically a clinical one
Due to the time critical nature of the condition, further imaging will rarely be requested
What does the specific management for strangulated hernias depend on?
The type of hernia involved
How does the mortality from a strangulated hernia differ from elective hernia repairs?
It is much higher
What is the risk of strangulation of femoral hernias?
The risk increases with time following diagnosis - after 3 months, the risk is 22%, and reaches 45% after 21 months
What other risks are increased in strangulated femoral hernia repair compared to elective repair?
Bowel resection
Wound infection
Cardiorespiratory complications
