Femoral Hernia Repair
What the Examiner Expects
Repair of a hernia through the femoral canal, located below the inguinal ligament medial to the femoral vein. The examiner expects you to know the femoral canal boundaries (inguinal ligament anteriorly, Cooper's ligament posteriorly, lacunar ligament medially, femoral vein laterally), that femoral hernias have a much higher risk of incarceration and strangulation than inguinal hernias due to the rigid boundaries of the canal, and that ALL femoral hernias should be repaired when diagnosed. The preperitoneal approach (laparoscopic TEP/TAPP or open preperitoneal) is preferred as it provides the best access to the femoral space for mesh placement.
Key Examiner Focus Points
- Hernia through the femoral canal (below the inguinal ligament, medial to the femoral vein)
- Higher incarceration/strangulation rate than inguinal hernias — always repair when diagnosed
- More common in women (but inguinal hernias are still more common overall in women)
- Preperitoneal approach (laparoscopic or open) is ideal for mesh placement
- Cooper's ligament (McVay) repair: open technique suturing to Cooper's ligament
Common Curveballs
Patient presents with a strangulated femoral hernia with a loop of ischemic small bowel
Emergent repair. Reduce the hernia, assess bowel viability. If the bowel is non-viable, resect and perform primary anastomosis. If there is contamination from perforated bowel, a non-mesh (McVay/Cooper's ligament) repair is preferred, or biologic mesh if reinforcement is needed. Synthetic mesh in a contaminated field has higher infection rates.
You mistake a femoral hernia for an inguinal hernia during open repair
If an inguinal approach was started and a femoral hernia is discovered, you can access the femoral canal through the inguinal floor by opening the transversalis fascia. Alternatively, a preperitoneal approach gives the best exposure. The key is recognizing that the defect is below the inguinal ligament.
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