Femoral Hernia Repair

A femoral hernia protrudes through the femoral canal — a small triangular space inferior to the inguinal ligament, bounded by Cooper's ligament posteriorly, the iliopubic tract superiorly, the femoral vein laterally, and the lacunar ligament medially. The femoral canal is small, the borders are unyielding, and the hernia neck is narrow — which is exactly why femoral hernias have such a high rate of incarceration and strangulation. Approximately 40% of femoral hernias present as emergencies, compared to <5% of inguinal hernias.

Femoral hernias are more common in women than men (especially multiparous and elderly women), partly because of a wider pelvis and altered pelvic floor support after childbirth. Any unilateral groin mass in an elderly woman should raise femoral hernia high on the differential, even if classically inguinal hernia is more common overall.

All diagnosed femoral hernias should be repaired electively because of the high risk of incarceration. This is the most important teaching point — femoral hernias are not watchful-waiting candidates, regardless of size or symptoms. An incarcerated femoral hernia is a surgical emergency.

Workup of a groin mass includes physical examination (a femoral hernia lies inferior and lateral to the pubic tubercle; an inguinal hernia lies superior and medial), ultrasound or CT in unclear cases, and assessment of bowel viability if incarceration is suspected.

The McVay (Cooper's ligament) repair is the classic open approach and remains the procedure that examiners want you to describe. A standard groin incision exposes the inguinal canal. The transversalis fascia is opened to expose the preperitoneal space; the hernia sac is identified, reduced, and either inverted or excised after ligation. The repair approximates the conjoint tendon to Cooper's ligament medially and to the femoral sheath laterally, with a relaxing incision in the anterior rectus sheath to reduce tension. A transition stitch is placed at the medial edge of the femoral vein.

The mesh plug technique (sometimes called the Lichtenstein-derived plug or Bassini-type repair with plug) uses a preformed mesh plug placed in the femoral canal to occlude it, secured with absorbable sutures to Cooper's ligament and the iliopubic tract. The classic open Lichtenstein repair as performed for inguinal hernia does not address the femoral canal — for a femoral hernia specifically, the plug technique or the McVay is preferred.

The McEvedy approach (also called the high approach) uses a vertical incision over the femoral canal entering the preperitoneal space directly. Its advantage is excellent exposure of the femoral defect and the ability to evaluate small bowel through the same incision — making it the approach of choice for strangulated femoral hernias where bowel assessment is critical.

Both TAPP (transabdominal preperitoneal) and TEP (totally extraperitoneal) laparoscopic approaches handle femoral hernias well — and may have an advantage in identifying occult femoral hernias contralaterally. A large piece of mesh covers the entire myopectineal orifice (the area encompassing both the inguinal and femoral spaces), addressing all groin hernia variants simultaneously.

Laparoscopic repair is particularly attractive in women, in whom femoral hernias are more common, and in recurrent groin hernias where the previous open dissection has scarred the anterior anatomy.

Strangulated femoral hernia is a surgical emergency. Resuscitation, broad-spectrum antibiotics, and immediate operation are mandatory. The McEvedy preperitoneal approach is excellent for these cases because it permits assessment of the bowel without compromising the repair if bowel resection is needed.

If bowel is non-viable, resection with primary anastomosis is performed (or end stoma if the patient is unstable). Mesh placement in a contaminated field is controversial — many surgeons would defer mesh and perform a primary tissue repair in this setting, accepting a higher recurrence risk in exchange for lower infection risk. Biologic mesh is an alternative.

Operative complications include injury to the femoral vein (the most feared — direct compression and vascular consultation are immediate steps), bowel injury, hematoma, and chronic groin pain. Recurrence rates after femoral hernia repair are low (<5%) but rise significantly if the femoral canal is not specifically addressed — repairing an apparent inguinal hernia without recognizing a concurrent femoral hernia is a classic source of early recurrence.

Examiners frequently test the differential between inguinal and femoral hernia by physical examination, the management of strangulated femoral hernia, and the choice between McVay, plug, and laparoscopic repair. The McVay procedure is still examinable in detail despite its declining use in clinical practice.