A protrusion of abdominal contents through a weakened area of abdominal wall is called a hernia. A femoral hernia refers to a loop of bowel bulging through a specific opening, the femoral canal.
Incidence, types and causes
Hernias are very common, and their repair is the commonest surgical procedure done.
Femoral hernia is one of four types of hernia, accounting for less than 10 percent of all. Although women are five times less likely than men to develop a hernia, femoral hernias are four times more common in women than in men, especially in the elderly. Femoral hernias have the highest risk of complications.
The basic cause of all hernias is a weakness of the abdominal wall, allowing abdominal contents to bulge outwards. This weakness may be inherent in the tissues, for instance where there is abnormal collagen, or may be acquired, through such as smoking, chronic steroid use or previous surgery.
Hernias may have varying contents, like loops of bowel, omentum or even parts of abdominal organs. They may also become complicated by incarceration, when the contents can no longer be pushed back into the abdomen, or strangulation, when the incarcerated contents are so compromised by swelling that they become non-viable. In these cases, trapped bowel may become gangrenous if not treated soon enough.
Symptoms, complications and diagnosis
Hernias may have no symptoms at all, and are often only noticed as a bulge near the groin. The commonest symptom is a feeling of heaviness or dull discomfort, made worse by straining, lifting or coughing, and often worse towards evening or after long periods of standing. Symptoms are usually found when complications arise, which occurs in 40 percent of femoral hernias.
Examination reveals a mass near the groin – femoral hernias are found lower down than the others, and more towards the midline. The mass may be tender, and a distinct impulse may be felt when the patient coughs or strains. Bowel sounds may be heard with a stethoscope, and it may be possible to gently push the hernia contents back into the abdomen where they belong. Generally, hernias are best demonstrated with the patient standing.
Complications can arise if the abdominal contents in the hernial bulge become stuck, and cannot fall back into the abdomen. If not treated, swelling begins, and can become severe enough to cut off the blood supply to whatever is in the hernia. In this way, a trapped loop of bowel may die, causing bowel obstruction and gangrene. This is usually associated with symptoms such as increased pain, signs of peritonism, fever and vomiting, and constitutes a surgical emergency.
Diagnosis is usually clinical, but an abdominal X-ray or ultrasound can be helpful. In theory, femoral hernia in males can be confused with a hydrocoele, testicular torsion, varicocoele or epididymal cysts.
The only successful treatment is surgery, which is usually quick and uncomplicated. There are a number of slightly different techniques, but all involve releasing the contents of the hernial sac, returning them to the abdominal cavity, and closing the defect which gave rise to the hernia. Closing the sac may be by stitches only, with the addition of a plug, or by stitching in place a mesh to cover the opening on the inside of the abdomen. In cases of strangulation, resection of dead bowel may be necessary, which increases the scope of the procedure, and may call for a modified technique. All forms of surgery aim to avoid tissue damage, which can lead to recurrence.
Conventional surgery may be done under local, epidural or local anaesthetic. Laparoscopic surgery is also possible, but the procedure may then take longer, and some series show a higher recurrence rate.
Patients usually do very well, being discharged from hospital the day after surgery. Advice in resuming normal activities is tailored to the individual patient.
(Dr A G Hall)