9.

Femoral Hernia

Daniel E. Swartz and Edward L. Felix

Introduction
The femoral hernia, despite accounting for less than 10% of adult
groin hernias, is associated with greater risk of incarceration, strangulation,
requiring emergency surgery, bowel resection, morbidity and mortality
than inguinal hernias. Because the anatomic location is so closely related
to the more common inguinal hernia, the diagnosis is often not made
until surgery.

Femoral Hernia Facts

Femoral hernias account for 2-8% of inguinal hernias encountered,
with an even higher incidence of up to 11% of hernias reported since
laparoscopy was first introduced (1).
Femoral hernias occur 2-5 times more often in women than men
(62.5% occur in women vs 25% of inguinal hernias) (2). Additionally,
they typically occur in older patients with a peak incidence in the sixth
decade, and concomitant inguinal hernias are found in up to 51% (3,4).
Approximately 27,000 femoral hernia repairs are performed per year in
U.S, and 36% of femoral hernias are repaired emergently compared to
5% of inguinal hernias (5). Emergent repair of femoral hernia is associated
with up to 30% morbidity, 10% mortality (6,7) and 23% require a bowel
resection (5). Once diagnosed, up to 22% of femoral hernias incarcerate
by 3 months and up to 45% by 21 months (8).

B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair, 103
DOI 10.1007/978-1-4614-4824-2_9,
© Springer Science+Business Media New York 2013
104 D.E. Swartz and E.L. Felix

Anatomic Definitions
The femoral canal is an elliptical cone located medial to the femoral
vein extending from the femoral ring superiomedially to the femoral
orifice inferolaterally that contains lymphatics, adipose tissue, and
commonly the lymph node of Cloquet. The femoral ring (the entrance to
the femoral canal) is lined by the iliopubic tract anterosuperiorly, by
Cooper’s ligament inferoposteriorly and by the femoral sheath laterally.
When a femoral hernia is present, an opening known as the femoral
orifice is created. The femoral orifice is bounded posteriorly by the
pectineal fascia, laterally by the femoral sheath, anteriorly by the superior
cornu of the fascia lata, and medially by the fan-shaped fibers of the
iliopubic tract. A femoral hernia is the result of a protrusion of
preperitoneal fat, bladder or peritoneal sac through the femoral ring. It
becomes clinically evident once the exit of the femoral canal, or the
femoral orifice, is breached. It is considered an acquired, not a congenital,
defect.

Diagnosis
The classic presentation of a femoral hernia is with a main complaint
of pain and/or a lump in groin (may be asymptomatic), with physical
findings revealing a mass and/or tenderness below inguinal ligament on
anteromedial thigh. The differential diagnosis includes inguinal hernia,
obturator hernia, lymphadenopathy, lipoma, and pseudohernia which is
defined as a nonpathogenic lymph node (Cloquet’s node) in extremely

Table 9.1 Distinguishing Inguinal From Femoral Hernia

Inguinal Hernia Femoral Hernia
Relation to Pubic Tubercle Inferolateral Superomedial (Nyhus)
Have patient cough while Hernia Appears Hernia Appears Below
examining medial end Above the the Inguinal
of inguinal ligament Inguinal Ligament Ligament (Nyhus)
Have patient cough while Hernia Appears Hernia Stays Reduced
palpating just lateral to (Hair)
the Adductor Longus
Tendon about one
fingerbreadth medial to
the femoral artery.
 9. Femoral Hernia 105

thin patients. An incarcerated groin hernia should raise the physician’s

suspicion that this might be a femoral hernia as a higher percentage of
femoral hernias incarcerate compared to inguinal or any other abdominal
wall hernia (9). Other imaging modalities like CT Scan, color Doppler
ultrasound, and contast herniography are used, but because the accuracy
of these tests are unknown, physicians should generally rely on the
physical exam as the primary diagnostic modality. Distinguishing
Between Inguinal and Femoral Hernia: see Table 9.1

Three Classic Anatomic Approaches To Treatment

Femoral Approach
The femoral approach was first described by Socin (1879) with a
high ligation of the hernia sac but was associated with a high recurrence
rate (10). Bassini (1885) added a femoral ring closure with suture after
the high sac ligation. Three decades later, Lichtenstein and Shore (1974)
recommended a tension-free repair with a polyproplylene plug sutured
into the femoral ring followed by placement of an additional mesh to
repair inguinal floor (11).
The femoral approach technique begins with an inguinal or subinguinal
incision (Fig. 9.1a), where the hernia sac is usually located inferior to
external oblique aponeurosis and the lacunar ligament may be divided in
cases of incarceration (but counter incision to expose inguinal floor may
be required). The hernia sac is dissected, opened for exploration and
the contents reduced into the abdominal cavity before the sac is ligated
(Fig. 9.1b). The canal is obliterated by suture or mesh plug that is rolled or
sutured to inguinal ligament, fascia lata and pectineal fascia (Fig. 9.1c).
The femoral approach generally should not be used in strangulated femoral
hernias although it requires the least dissection. One advantage of the
femoral approach is that it may be performed under local anesthesia, thus
making it a preferred approach for high-risk surgical patients.

Inguinal Approach
The inguinal approach was first described by Annandale (1876) and
is also associated with a high ligation of the sac (12). Ruggi then described
suturing Cooper’s Ligament to inguinal ligament (1892) after sac ligation.
Fig. 9.1 (a) Illustration of the skin incision for the femoral approach to repair of
a right femoral hernia. (b) Illustration of the exposure of a right femoral hernia
via the femoral approach. Note the location of the hernia medial to the femoral
vein. (c) Cylindrical mesh roll use to obliterate the femoral canal on a right-sided
femoral hernia repair using the femoral approach.
 9. Femoral Hernia 107

Moschowicz included the use of an inguinal floor repair (included

transverse aponeurotic arch) (13). Later, McVay and Anson’s (1942)
“Cooper’s ligament repair” (suturing Cooper’s ligament to transverse
aponeurotic arch) then became standard repair for femoral and direct
inguinal hernias (12). Three decades later, Lichtenstein and Shore (1974)
recommended a tension-free repair with a polyproplylene plug sutured
into the femoral ring and additional mesh to repair inguinal floor (11).
This approach provides excellent exposure of the femoral ring with an
opportunity to resect bowel if needed.
Femoral hernia repairs performed via an inguinal incision begin with
a traditional inguinal incision that permits routine opening of the inguinal
canal via the external oblique aponeurosis, followed by mobilization of
the cord with an examination to exclude or repair any concomitant
indirect inguinal hernias. Next the inguinal floor can be opened by
transecting the transveralis fascia. If incarceration is present, the lacunar
ligament and iliopubic tract can be divided at the medial edge of the
femoral ring. Incarceration mandates opening of the sac to examine the
contents for any evidence of ischemia or gangrene. High ligation of the
sac is performed and is then followed by a hernia repair, preferentially
with mesh. Suture repair may be selected if prosthetic mesh is
contraindicated (gross contamination, strangulation). The main principle
is to approximate the iliopubic tract and lacunar ligament to Cooper’s
ligament with nonabsorbable suture. The inguinal floor will also need to
be reconstructed with mesh (preferably) or, rarely, suture approximation
(Fig. 9.2).

Preperitoneal Approach
The preperitoneal repair through a low midline incision was also first
described by Annandale (1876). Here, the linea alba was opened with
blunt dissection of the peritoneum from the pelvis with again, a high
ligation of the sac. McEvedy then described a repair where Cooper’s
ligament is sutured to the conjoined tend on via an oblique incision over
the lateral rectus sheath (1950). An additional modification was described
by Nyhus who used a transverse incision to approximate Cooper’s
ligament to the iliopubic tract (1950) and later added polypropylene
mesh to buttress the repair. (14) Stoppa (1973) placed large sheet of
Dacron mesh over both of the groins (15), while Kugel used a ring-
supported mesh placed through a small incision (2003) (16).
108 D.E. Swartz and E.L. Felix

Fig. 9.2 Inguinal approach to the repair of a right femoral hernia. After an
exposing the inguinal canal, the inguinal floor is opened to access and repair a
femoral hernia.

The preperitoneal approach can also be accomplished by laparoscopy,

and the first laparoscopic transabdominal preperitoneal (TAPP) repair
was reported by Schultz (1990) (17), while the first laparoscopic totally
extraperitoneal (TEP) repair was reported soon afterward (18). The
laparoscopic TEP repair should intuitively be avoided in suspected
strangulation as the bowel needs a thorough assessment during the repair.
In contrast to laparoscopy, an open preperitoneal approach provides
excellent exposure of all potential groin hernia sites and easy access to
the intraperitoneal contents. The technique involves making a transverse
lower abdominal incision 3 cm cephalad to a routine inguinal incision.
The anterior rectus sheath is divided cephalad to the internal ring, and the
rectus abdominis is retracted medially. The femoral sac is then reduced
(if incarceration is present, the surgeon can incise the iliopubict tract
near the medial edge of the femoral ring). Small primary femoral hernias
can be suture repaired by approximating Cooper’s ligament to the
iliopubic tract or repaired with mesh. Primary and recurrent hernias
 9. Femoral Hernia 109

Fig. 9.3 Preperitoneal exposure of the right groin. The femoral hernia is located
posterior to the iliopubic tract and medial to the femoral vein. The indirect
inguinal hernia is located at the internal ring, while the direct hernia is located in
Hesselbach’s triangle medial to the epigastric vessels and anterior to the iliopubic
tract.

should be repaired with mesh with a 2 -3 cm overlap that also covers the
direct and indirect inguinal spaces. Preperitoneal structures and hernia
sites are demonstrated in Fig. 9.3.
The laparoscopic TAPP first requires placement of ports (Fig. 9.4a)
and establishment of pneumorperitoneum. Next, an intraperitoneal
dissection can then be performed by beginning to open the parietal
peritoneum 2 cm cephalad to the internal ring. Thorough dissection of
retroperitoneal structures is required, including dissection of the iliopubic
tract, symphisis pubis, and sometimes a partial bladder dissection into
the Space of Retzius, to create enough space for the inferior edge of the
mesh. All three potential groin hernia sites must be exposed (Fig. 9.3).
Examination for an inguinal canal lipoma must be included. During a
TAPP, the incarcerated sac is often reduced, if possible, however sac
division with proximal sac ligation is acceptable. If there are incarcerated
110 D.E. Swartz and E.L. Felix

Fig. 9.4 (a) Illustration of port placement for a laparoscopic transabdominal

preperitoneal (TAPP) groin hernia repair. (b) Illustration of port placement for a
laparoscopic totally extraperitoneal preperitoneal (TEP) groin hernia repair.

or strangulated contents in a tight femoral ring, to reduce the contents it

may be necessary to first divide Lacunar’s ligament for 1 – 2 cm heading
mediosuperiorly along the transversalis fascia in order to widen the
defect and to permit safe reduction of hernia contents. This can be done
with a hook cautery or with ultrasonic shears. Careful attention must
be made to identify the iliac vein lateral to the hernia and to avoid it’s
injury. If there are no veins running on the transversalis fascia, a hook
cautery can be used to do this maneuver, however ultrasonic shears may
also be employed to obtain simultaneous hemostasis if veins are present.
We recommend using bipolar cautery on a Maryland grasper to coagulate
all small veins in the region first, and then opening the fasica to reduce
the contents. The fascia does not have to be closed again at the end of
the case when doing this laparoscopically. Once the hernia contents are
reduced, the cord structures should be dissected from peritoneum as far
posteriorly as possible. Mesh is placed covering all three potential groin
hernia sites with overlap. Fixation to Cooper’s ligament may be used.
Reappoximation of the peritoneum must be performed.
 9. Femoral Hernia 111

The laparoscopic TEP technique also begins after port placement

(Fig. 9.4b) and subrectus preperitoneal dissection with a balloon. The
technique is identical to the TAPP repair without the need for peritoneum
reapproximation and fixation of mesh is not usually necessary. Technical
details are described in other chapters in this manual.

Surgical Caveats
Nonincarcerated, nonstrangulated femoral hernias may be repaired
using any of the described approaches. However, incarceration or
strangulation of femoral hernias is a relative contraindication to
laparoscopic TEP repairs unless the surgeon has tremendous
experience with laparoscopic techniques and can explore and assess
the bowel intraperitoneally during the case. Strangulation in a femoral
or inguinal hernia requiring bowel resection becomes a contraindication
to simultaneous permanent synthetic mesh placement. That being
said, it has been shown that Franklin et al. reported no recurrences or
mesh-related complications over 19 months in 58 patients with
strangulated groin hernias with gross contamination repaired with
biologic mesh (19).
We feel that despite having a hernia, in the setting of clean-
contaminated or contaminated fields, like a bowel strangulation with
gangrene during a femoral hernia case, the patient’s primary problem
becomes that infectious process. A more permanent solution to the hernia
defect can be staged at a later time. Attempts that risk a potential synthetic
mesh infection should generally be avoided, and absorbable mesh
products which are widely available may be more ideal in this situation.
Patients should be told to anticipate a hernia recurrence after the mesh is
resorbed, at which time an elective repair should be performed.
Most surgeons repair femoral hernias with polypropylene mesh
with or without fixation. Laparoscopic hernia repair is increasingly
popular since it combines the benefits of laparoscopy (less pain, early
return to activities, nonexistent mesh infection rate) and preperitoneal
approach (excellent exposure, access to viscera, assessment of all groin
hernias). Laparoscopic TEP approach avoids potential intraperitoneal
complications (both are equally acceptable). Laparoscopic TAPP pre-
ferred for incarceration or previous retroperitoneal pelvic surgery or
radiation because of the risk of tearing the peritoneum or incarcerated
viscera when performing balloon dissection.
112 D.E. Swartz and E.L. Felix

Results
Publications in the literature suggest a post-femoral hernia repair
recurrence rate incidence of up to 10%. The femoral approach with plug
has been reported to have a higher seroma and foreign body sensation
than suture repair. The femoral approach has been shown to miss
concomitant inguinal hernias (20). The laparoscopic repair is generally
associated with <1% recurrence rates.

Commentary
Femoral hernias occur much less commonly than inguinal hernias
(accounting for less than 8% of groin hernias) and are therefore often
misdiagnosed as inguinal hernias. This fact has several consequences.
First, the anterior approach to groin hernia repair can result in “missing”
a femoral hernia unless careful palpation through the inguinal floor is
undertaken. One study using a national database of almost 35,000
consecutive groin hernias performed over a three year period found that
the incidence of femoral hernias following inguinal hernia repair was 15
times the incidence of primary femoral hernias (21). A preperitoneal
approach, either laparoscopic or open, has the advantage of direct
visualization of femoral hernias as well as treatment of either femoral or
inguinal hernia includes the mesh coverage of the other.
The second consequence of misdiagnosed femoral hernias is that due
to their increased likelihood of incarceration with or without strangulation,
once diagnosed, a femoral hernia should be repaired. This is because one
in three femoral hernias will need to be repaired emergently (compared
to 5% of inguinal hernias). The risk of incarceration of a femoral hernia
once diagnosed is 22% at three months and 45% at 21 months (8). There
is a recent tendency toward watchful waiting in the treatment of small,
asymptomatic inguinal hernias but one must be certain that the hernia is
inguinal and not femoral because of the high incidence of incarceration
in femoral hernias (22, 23).
Which of the three approaches to use for femoral hernia repair largely
rests upon surgeon preference and experience. Several caveats, however,
exist as listed above which serve as relatively strong contraindications
for one or more approaches. Almost all surgeons now embrace a tension-
free hernioplasty using prosthetic mesh in all approaches. The only
contraindications to prosthetic mesh are gross contamination or bowel
 9. Femoral Hernia 113

resection and, although biologic mesh has been used in these situations,
there is not enough data at this time to recommend against primary suture
repair. In fact, small primary femoral hernias (without concomitant
inguinal hernia) in non-obese patients may be repaired with suture.
Polypropylene cylindrical plugs have been associated with a discomforting
foreign-body sensation and higher recurrence and seroma rates (20).
Incarcerated and strangulated femoral hernias should be approached
from either an inguinal or preperitoneal incision if open, or a TAPP repair
if laparoscopic. The femoral approach may make reduction difficult and
it will prevent adequate assessment of the bowel and resection if needed.
Laparoscopic TEP repair in the face of incarceration makes tearing the
peritoneum likely which requires conversion to a TAPP if resection of
the bowel is needed.
A common conundrum occurs if, upon laparoscopy, no hernia (as
evidenced as no peritoneal dimpling) is identified. The peritoneum
should be opened and a repair should be performed as planned.
Recurrences after failing to identify a retroperitoneal hernia are common.
We encourage a meticulous search for an inguinal or femoral lipoma, as
well as for other frequent etiologies of the clinical diagnosis of groin
hernias is encouraged (24).
At our center, we have repaired over 2000 groin hernias using a
laparoscopic approach. Unless a contraindication exists (obliteration of
the preperitoneal space from surgery or radiation or a risk of general
anesthesia), we routinely employ a laparoscopic approach as this
facilitates evaluation and treatment of all potential groin hernia sites
including the femoral hernia.

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