What is Femoral Hernia?
Femoral hernias are not as common as inguinal hernias, which develop in the groin area. Identifying a femoral hernia is a crucial part of examining and evaluating a patient who has an abnormal bulge in the groin area. This is because the approach and urgency of repair for a femoral hernia could be different from the usual type of hernia known as inguinal hernia.
A hernia is what we call it when an organ or tissue pushes through an opening in the walls that usually contain it. Hernias might happen in different parts of the abdominal wall, but they are most often found in the groin area. Hernias can emerge where the outer layer of the abdominal wall, made of tissues known as aponeurosis and fascia, is not protected by striated muscle, which is muscle that you can control voluntarily. Because of this, the peritoneal membrane, which lines the inside of the abdomen, or the hernia sac, which contains the tissue or organ that has pushed through, might be forced out of the hernia’s opening or neck.
What Causes Femoral Hernia?
A femoral hernia happens in a part of the body known as the femoral canal. This area has several important landmarks around it – the inguinal ligament is at the top, Cooper’s ligament is at the bottom, the femoral vein is on the side, and where the iliopubic tract and Cooper’s ligament (also known as the lacunar ligament) meet is in the middle.
A femoral hernia is usually noticeable because of a noticeable lump under the inguinal ligament (a band of tissue in the lower abdomen).
One big complication of a femoral hernia is strangulation, which happens when part of your intestine gets trapped in a way that cuts off its blood supply. What makes femoral hernias dangerous is that they have a high risk of leading to strangulation, with about 15 to 20 out of every 100 cases leading to this problem.
Risk Factors and Frequency for Femoral Hernia
During a person’s lifetime, the chances of experiencing a groin hernia are between 27% and 43% for men and 3% to 6% for women. Of all groin hernias, femoral hernias are less common, making up about 3%. Even though inguinal hernias are the most common type for both genders, femoral hernias occur 10 times more often in females than in males. In fact, they are quite rare in men. However, when diagnosed with a femoral hernia, a man is 50% likely to also have or develop an inguinal hernia, compared to a 10% likelihood for women. As one gets older, the risk of complications such as incarceration or strangulation from a femoral hernia increases. Both femoral and inguinal hernias tend to occur more frequently on the right side. This asymmetry may be due to a delay in fetal development on the right side. The position of a part of the large intestine, the sigmoid colon, can prevent a femoral hernia from occurring on the left side.
Signs and Symptoms of Femoral Hernia
A femoral hernia is often discovered during a routine check-up, and it’s possible that a third of patients may not have any symptoms when this hernia is diagnosed. Usually, a small bump is observed below the groin ligament. In some instances, this bump may move upward, mimicking a more commonly seen inguinal hernia. It’s common to find herniated preperitoneal fat within the hernia sac, which can be reduced with direct pressure or manipulation.
When the contents of a hernia can’t be pushed back into place, this is referred to as incarceration. Strangulation, or blood supply cut-off to the contents of a hernia, frequently happens with femoral hernias. This mostly occurs with hernias that have a small opening, causing blood flow to be blocked. This can lead to swelling of the hernia sac and contents, resulting in a painful, hard lump.
If a portion of the intestines is inside the hernia sac, symptoms of obstruction may be present. These could include:
- Nausea or vomiting
- Bloating
- Abdominal pain
- A decrease in bowel function, such as an absence of passing gas or having bowel movements
Patients may also feel abnormal sensations, such as tingling, due to the hernia compressing nearby sensory nerves.
Testing for Femoral Hernia
If you notice a swelling or experience pain in your groin area, it might be a sign of a condition known as femoral hernia. To confirm this, your doctor will carry out a physical examination. This examination may involve you lying down flat (supine position) and also standing up if possible. The doctor will look out for any unevenness, protrusions or lumps in your groin area.
The doctor will carry out a physical exam called palpation by placing their fingertip along the inner lining of the scrotal wall to check the “inguinal canal” and “inguinal floor” – these are areas in the groin where hernias frequently occur.
Your doctor might also ask you to perform a “Valsalva maneuver”. This is a technique where you’ll be asked to try and exhale while keeping your mouth and nose closed, which can make a hernia more noticeable. It is typically easy to identify a femoral hernia as they present as a protrusion below the inguinal ligament, which is a band of strong fibrous tissue in the lower abdomen. If the hernia isn’t causing pain or other complications, the doctor might try to gently push it back into place. However, this should be avoided if there is pain or signs of “strangulation” – this means the hernia is cutting off blood supply – or obstruction – this means the hernia is blocking the intestines.
Aside from the physical examination, additional tests like ultrasound or CT (computed tomography) scans can be used to further confirm the presence of a hernia. These imaging tests are particularly helpful in delivering precise results, even for patients who are extremely overweight in whom a physical exam might be less effective. A CT scan is particularly useful if the patient shows symptoms of incarceration or strangulation- conditions that need urgent attention because they indicate that a part of the intestine is trapped in the hernia. It’s worth noting that a laparoscopy – a procedure where a small camera is inserted into the abdomen – isn’t usually used to diagnose this condition.
Treatment Options for Femoral Hernia
Femoral hernias, which occur when tissue pushes through a weak spot in your abdominal wall, require surgery for a complete cure. Doctors usually advise this procedure as soon as the hernia is detected due to the higher risk of additional complications, such as incarceration (when hernia contents get stuck) or strangulation (when blood supply to hernia contents is cut off) when compared to an inguinal hernia, which is a more common type of hernia.
If the blood supply to the hernia gets blocked, this becomes a medical emergency and needs immediate surgical intervention. Femoral hernias can be repaired through multiple methods – a standard approach through the groin, an open approach accessing the area behind the abdominal cavity, or a minimally invasive method involving small cuts and instruments (laparoscopic or robot-assisted surgery).
No matter which approach is used, the hernia repair procedure typically involves separating and moving back the protruding tissue (the hernia sac) and closing the weak spot from which the hernia came. This can be done by directly stitching up the weak spot or using a mesh patch for reinforcement.
In cases where the hernia may contain trapped or compromised tissue, the hernia sac can be opened to assess the health of the tissue inside. Sometimes, a ligament (the lacunar ligament) may need to be cut to help move back the tissue and hernia sac. It’s important to note that if the tissue is compromised, or if there’s a risk of contamination like an accidental bowel opening, placing a mesh may be avoided due to increased risk of infection. While uncommon, mesh infections can be serious, difficult to manage, and may require removing the mesh.
Many ways to repair a femoral hernia exist, meaning there’s isn’t a universal “best method” for repairs. The chosen repair method might vary based on cultural differences among surgeons, differing healthcare payment systems, and the resources and logistical capabilities available.
What else can Femoral Hernia be?
When someone has a lump in the groin area, it’s not immediately clear what’s causing it. The doctor would have to think about a number of different possible explanations. These could include:
- A hernia in the groin (femoral or inguinal)
- A buildup of fluid around the testes (hydrocele) or in the veins of the testes (varicocele)
- Swollen lymph nodes (lymphadenopathy)
- A fatty lump under the skin (lipoma)
- A fluid-filled skin sac (cyst)
- A pocket of pus (abscess)
- A lump formed by coagulated blood (hematoma)
- Narrowing or bulging of an artery in the groin (femoral artery pseudoaneurysm or aneurysm)
Doctors can help narrow down these possibilities by inspecting the patient’s groin and looking for any unevenness between the two sides. They also must check the patient’s genital area, legs, and stomach. While it’s more expensive, getting an ultrasound or CT scan can also be very useful in identifying the cause of the lump.
What to expect with Femoral Hernia
Generally, the treatment for a femoral hernia – a type of groin hernia – is very successful. On average, the chances of experiencing another groin hernia (recurrence) after treatment range between 5% to 10%. If suitable, methods that do not involve placing stress on the tissues (tension-free techniques) and those that use a special material called mesh for reinforcement, can cut down the chance of the hernia coming back on the same side by around 60% compared to methods that do not use mesh or that only involve stitching.
Possible Complications When Diagnosed with Femoral Hernia
Certain factors can increase the chances of a hernia coming back after being treated. These include smoking, being overweight, high pressure in the abdomen, concurrent infections, disorders affecting connective tissues, having diabetes, and poor nutrition. Most of the time, if a hernia is going to come back, it will do so within two years of being treated.
Before you have hernia surgery, your doctor should talk to you about the potential benefits and risks involved. One possible problem that can arise is chronic pain, which can affect up to 15% of patients after hernia surgery. This persistent pain can interfere with normal activities in some people.[7]
However, this pain can often be managed without further surgery by using medications like pain-killers or anti-inflammatory drugs. Other problems that could occur after hernia surgery include not being able to urinate normally, infection at the surgery site, fluid-filled lumps (called seromas), or inflammation of the testicles (called orchitis).[8]
Potential Risks and Complications:
- Chronic pain following hernia repair
- Inability to urinate normally
- Infection at the surgical site
- Fluid-filled lumps (Seromas)
- Inflammation of the testicles (Orchitis)
Recovery from Femoral Hernia
People who have a femoral hernia, which is a type of hernia in the upper thigh, typically have it repaired in an elective, non-emergency surgical procedure. In most cases, these surgeries are performed at an outpatient facility, meaning the patient can go home the same day. The surgery may be done under general anesthesia (puts you into a deep sleep) or regional anesthesia (numbs a large area of your body).
Prior to surgery, it’s advised that patients avoid any heavy lifting or strenuous activity, and there could be some restrictions on physical activity post-surgery, especially in the early part of the healing process. The exact timeline for returning to normal activities greatly depends on the individual patient and the surgeon’s judgment.
Length of stay in the hospital tends to be longer if the hernia repair is done as an emergency procedure.
Preventing Femoral Hernia
If a doctor discovers a femoral hernia during a physical examination, they will inform the patient about this condition. It’s crucial that patients know what to look out for – signs of ‘incarceration’, ‘strangulation’, and ‘obstruction’. These terms refer to situations where the hernia has become trapped (incarcerated), the blood flow to the hernia is cut off (strangulated), or the intestines are blocked (obstructed). These are serious complications which need immediate medical attention or even surgery.
If surgery is required to treat the femoral hernia, the doctor will explain to the patient all about the procedure, including what will be done during the operation, potential risks involved, and also the possibility that future surgeries may be needed. This ensures the patient is fully aware about the treatment plan and what to expect.