Femoral hernias: Clinical sciences

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Introduction0:00–1:26

A femoral hernia is the protrusion of abdominal contents, such as preperitoneal fat, omentum, or bowel, through a defect in the lower abdominal wall, which passes through the femoral canal and eventually exits through the femoral ring.
Anatomically, the boundaries of the femoral ring include the lacunar ligament medially, the femoral vein laterally, the pectineal ligament posteriorly, and the inguinal ligament anteriorly.
A femoral hernia usually occurs just inferior to the inguinal ligament and lateral to the pubic tubercle. Some risk factors can increase the chance of developing a femoral hernia.
For example, biological females are more likely to develop femoral hernias due to a larger distance between the pubic tubercle and internal ring, as well as a wider rectus abdominis muscle.
Other risk factors in both males and females include age-related atrophy of the pectineus muscle, as well as widening of the femoral ring either due to injury or age.
Femoral hernias can present in four ways: asymptomatic, symptomatic, incarcerated, or strangulated. Keep in mind that femoral hernias are more likely to incarcerate and strangulate than other types of hernias, such as inguinal hernias, so they might need immediate attention.

Unstable patient1:26–1:46

Alright, you should first perform an ABCDE assessment to determine if the patient is stable or unstable. If the patient is unstable, stabilize their airway, breathing, and circulation.
This means that you might need to intubate the patient, establish IV access, and administer fluids before continuing with your assessment.

Stable patient: Asymptomatic femoral hernia1:46–2:46

Now that unstable patients are stabilized, let’s go back to the ABCDE assessment and talk about stable patients. If the patient is stable, your first step will be to obtain a focused history and physical examination.
There are a few findings you might see here. First, some patients will present with asymptomatic hernias.
In this case, they don’t have any symptoms. However, physical examination reveals a small bulge in the groin area inferior to the inguinal ligament.
The bulge can be easily reduced. In this case, you are dealing with an asymptomatic femoral hernia.
Even though your patient is currently asymptomatic, femoral hernias have a high chance of incarceration and strangulation and they should be repaired as soon as possible.
So, you should call the surgical team for an elective repair. In the meantime, advise your patient on seeking immediate medical care if they develop sudden, severe pain in the groin.
Alright, let’s move on to stable patients who present with symptomatic hernias. In a patient with a symptomatic hernia, the history typically reveals heaviness and dull, achy pain in the groin.

Symptomatic femoral hernia2:46–3:35

Additionally, biologically female patients might report vague pelvic discomfort. Generally, the pain improves with rest and is worse after strenuous activity or at the end of the day.
When it comes to the physical exam, it might reveal a bulge inferior to the inguinal ligament that is easily reducible. If so, you can make a diagnosis of a symptomatic femoral hernia.
Just as in an asymptomatic femoral hernia, your patient should be scheduled for an elective surgical repair. Again, don’t forget to counsel your patient on seeking immediate care if they develop sudden, severe groin pain.

Incarcerated femoral hernia3:35–4:39

Okay, let’s move on to the more serious type called the incarcerated femoral hernia. Incarcerated femoral hernias usually present with more constant heaviness, pressure, and pain in the groin.
Patients might also report changes in bowel habits, such as constipation. On physical exam, you may see a bulge inferior to the inguinal ligament; however, unlike asymptomatic or symptomatic femoral hernias, the bulge will not be easily reducible.
This is an incarcerated femoral hernia. Here’s a clinical pearl!
To try to reduce an incarcerated hernia, you should place the patient in the Trendelenburg position. You can apply ice to the hernia, while gently pulling the hernia sac and pressing the base of the hernia.
This may help reduce swelling and allow the hernia to reduce. Now, even if you manage to reduce the hernia, the risk of strangulation is high.
So, once you have made the diagnosis, you should obtain a surgical consultation for an urgent repair. Lastly, let’s talk about the most severe type of femoral hernia called a strangulated hernia.

Strangulated femoral hernia4:39–6:02

In strangulated hernias, the blood supply to the contents of the hernia become obstructed, leading to ischemia. In a patient with a strangulated femoral hernia, the history may reveal fever and constant, severe pain in the groin that becomes progressively worse.
There might also be signs of bowel obstruction, including abdominal pain, nausea, and vomiting, as well as the absence of flatus and bowel movements.
On the other hand, physical exam typically reveals a bulge in the groin that is located inferior to the inguinal ligament.
The skin may appear erythematous, and can be warm to the touch, and very tender to palpation. In this case, you are dealing with a strangulated femoral hernia.
An important thing to note is that you should not attempt to reduce the contents back into the abdominal cavity, since the hernia sac may contain a necrotic bowel segment.
Alright, once you have made the diagnosis of strangulated femoral hernia, start the patient on IV fluids, as well as broad-spectrum IV antibiotics.
If your patient is vomiting due to a bowel obstruction, you should place a nasogastric tube. After you initiate these measures, call the surgical team for an emergent repair.
Alright, as a quick recap… Femoral hernias might present as stable or unstable. In unstable patients, stabilize the airway, breathing, and circulation before doing further workup.

Review6:02–6:52

If the patient is stable, they might have either an asymptomatic, symptomatic, incarcerated, or strangulated femoral hernia.
Asymptomatic and symptomatic femoral hernias require elective surgical repair due to a high risk of incarceration and strangulation.
On the other hand, incarcerated femoral hernias need urgent surgical treatment. Finally, if the hernia is strangulated, do not attempt to reduce it!
Start the patient on IV fluids and broad-spectrum antibiotics, and possibly place a nasogastric tube. Once you’ve done this, call the surgical team for an
Femoral hernias: Video, Causes, and Symptoms | Osmosis