Strangulated Femoral Hernia

An elderly lady presented acutely with a 24 hour history of abdominal pain and vomiting together with a painful lump in the right groin. Last year I repaired a recurrent incisional hernia in the upper abdomen with mesh. She did not have any other hernias elsewhere at that time but she is on steroid long term. 

This time her CT scan confirmed the presence of a large femoral hernia containing small bowel loops and causing small  bowel obstruction. I took her to theatre for urgent repair. At surgery she had a loop of small bowel strangulated inside the femoral hernia. A segment of the small intestine stuck in the hernia had died and she had to have that segment resected and bowel joined back again.  

The hernia defect itself was of moderate size and I closed it with sutures only. 

After surgery she did well and was discharged home after 6 days. 

Discussion:

Although femoral hernias are less common than inguinal hernias, they are more prone to cause serious complications like bowel obstruction and strangulation. Once the bowel gets stuck in the hernia strangulation of the bowel can occur within about 6 hours. Urgent repair is needed before the loop of bowel dies inside the hernia (as in this patient). 

Most often the patient would be aware of the hernia before the bowel get stuck in it however, this is not the case here. This may be related to the long term use of steroids which are known to weaken tissue and cause hernias. Elective repair is better to prevent bowel strangulation, the repair can be done laparoscopically and mesh would be used. Laparoscopic repair is not an option if there is a chance of bowel strangulation.  I do not use mesh to repair hernias if I had to do bowel resection as the chance of mesh infection would be otherwise too high. So for femoral hernias operation is always needed even if not causing symptoms and the sooner the better.