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| {{Femoral hernia}} | | {{Femoral hernia}} |
| {{CMG}} {{AE}} {{MKA}} | | {{CMG}} {{AE}} {{YH}} |
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| ==Overview== | | ==Overview== |
| Femoral hernia is the protrusion or bulge below the [[inguinal ligament]], through the [[femoral canal]], in the upper [[thigh]]. The rigid [[anatomy]] of the [[femoral canal]] predisposes these [[hernias]] to incarceration or [[strangulation]], thus more than 44% of the cases of femoral hernia present in an acute setting with incarceration. Certain [[connective tissue diseases]] predispose the patients to developing femoral hernia. Femoral hernia is classified based on its [[anatomical]] relations on presentation. Most cases of femoral hernia present in females and the most common cause is an enlarged [[femoral ring]]. The female to male ratio is approximately 5 to 1. Femoral hernia must be differentiated from other diseases that cause [[swelling]] in the [[groin]] area. The diagnostic study of choice for femoral hernia is [[ultrasound]], however in emergent cases that are difficult to diagnose [[CT scan]] is used to confirm the diagnosis. [[Surgery]] is the mainstay of treatment for femoral hernia. Immediate surgical intervention is needed in cases of incarceration or [[strangulation]].
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| ==Historical Perspective==
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| [[Hernia]] means a protrusion, [[hernias]] have been present in humans since the beginning of time, and the first interventions can be dated as early as the fifteenth century in ancient Egypt. However interventions had always been reserved for very large protrusions or painful [[Incarcerated hernia|incarcerated]] [[Hernia|hernias]].
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| ==Classification==
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| Femoral hernia may be occasionally classified into several subtypes based on anatomical relation.
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| ==Pathophysiology==
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| A femoral hernia is the protrusion of the [[hernia]] sac through the [[femoral ring]] in to the [[femoral canal]]. The [[anatomy]] of the [[femoral canal]] is such that the neck is made up of rigid structures that predispose herniated [[bowel]] to [[strangulation]] and incarceration. The [[hernia]] sac contains [[small bowel]] which can predispose to [[intestinal obstruction]]. Some [[connective tissue diseases]] predispose the patient to developing [[femoral hernia]]. [[Malignancy]] is very rarely associated with femoral hernias, thus [[histopathological]] analysis is done routinely following a repair but shows [[Incarcerated hernia|incarcerated]] [[bowel]] on most occasions.
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| ==Causes==
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| The most common cause of femoral hernia is an enlarged [[femoral ring]]. Less common causes of femoral hernia include increased intra-abdominal pressure and [[pregnancy]].
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| ==Differentiating {{PAGENAME}} from other diseases==
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| Femoral hernia must be differentiated from other [[diseases]] that cause [[swelling]] in the [[groin area]], such as [[inguinal hernia]], [[femoral artery]] [[aneurysm]], [[saphenous vein]] varicosity, [[lymphadenopathy]] and [[lipoma]].
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| ==Epidemiology and Demographics==
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| The [[prevalence]] of femoral hernia is estimated to be 2% - 8% of all [[groin]] [[Hernia|hernias]]. The [[incidence]] of femoral hernia increases with [[age]], individuals commonly affected are between 40 -70 years of [[age]]. [[Females]] are more commonly affected than [[males]].
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| ==Risk Factors==
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| Common risk factors in the development of femoral hernia include female gender, increasing age and a history of recurrent [[Hernia|hernias]].
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| ==Screening==
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| There is insufficient evidence to recommend routine screening for femoral hernia.
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| ==Natural History, Complications, and Prognosis==
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| If left untreated, 44%-86% of patients with femoral hernia may progress to develop [[strangulation]] or incarceration.
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| ==Diagnosis==
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| ===Diagnostic study of choice===
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| [[Ultrasound]] is the diagnostic study of choice for diagnosing femoral hernia as it has low cost, widespread availability and low risk of [[radiation exposure]]. If it is an emergent case with signs of incarceration that is difficult to diagnose based on [[clinical examination]], an abdominal [[CT scan]] must be performed to confirm the diagnosis.
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| ===History and Symptoms===
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| The majority of patients with femoral hernia are [[asymptomatic]]. Most common symptom is [[swelling]] below the [[inguinal ligament]]. Emergent cases may present with signs of incarceration; [[abdominal pain]], [[nausea]], [[vomiting]].
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| ===Physical Examination===
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| Patients with femoral hernia usually appear normal. Physical examination of patients with femoral hernia is usually remarkable for [[swelling]] or [[lump]] below the [[inguinal ligament]]. It is a difficult diagnosis and maybe impossible to differentiate from [[inguinal hernia]]. If incarceration is present, the [[swelling]] or [[lump]] maybe [[Tenderness|tender]].
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| ===Laboratory Findings===
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| There are no diagnostic laboratory findings associated with femoral hernia.
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| ===Imaging Findings===
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| ====X-ray====
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| There are no x-ray findings associated with femoral hernia. However, an x-ray [[KUB]] may be helpful in the diagnosis of complications of femoral hernia, which include incarceration.
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| ====CT scan====
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| Although the diagnostic study of choice for femoral hernia is ultrasound, abdominal [[CT scan]] may be helpful in the diagnosis of femoral hernia. Findings on CT scan suggestive of femoral hernia include [[bowel]] dilation, mesangial thickening and [[bowel]] [[strangulation]]. Due to the radiation exposure and high cost it is not used a s first line diagnostic tool. In emergent cases that are difficult to diagnose, abdominal [[CT scan]] can be used as a first line diagnostic tool.
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| ====MRI====
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| The diagnostic study of choice for femoral hernia is [[ultrasonography]], but abdominal [[MRI]] may be helpful in the diagnosis of femoral hernia. It provides the best anatomic detail, helps differentiate [[inguinal hernia]] from femoral hernia and has a [[sensitivity]] and [[specificity]] greater than 95%. Due to the high cost and lack of uniform availability it is not used as the diagnostic study of choice.
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| ====Ultrasound====
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| [[Ultrasound]] may be helpful in the diagnosis of femoral hernia. Findings on an [[ultrasound]] suggestive of femoral hernia include thickening and [[edema]] of the [[intestinal wall]], slightly [[echogenic]], long strip shaped [[omentum]] in the [[hernia]] sac.
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| ==Treatment==
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| ===Medical Therapy===
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| The definitive [[therapy]] for femoral hernia is [[surgery]]. Medical [[therapy]] is given to patients in preparation for [[surgery]] and postoperatively to prevent complications. Patients with pre and post operative [[pain]] should be treated with [[Non-steroidal anti-inflammatory drug|NSAID]] as a baseline [[analgesia]]. Patients with [[Strangulated hernia|strangulated]] femoral hernia should be given broad spectrum [[antibiotics]] that cover both [[Aerobic bacteria|aerobic]] and [[Anaerobic bacteria|anaerobic]] gram negative organisms.
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| ===Surgery===
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| [[Surgery]] is the mainstay of treatment for femoral hernia. Immediate surgical intervention is indicated in cases of incarceration or [[strangulation]]. The two popular surgical techniques are McVay repair and Lichenstein mesh repair. There is increased [[morbidity]] and [[mortality]] with surgical intervention in cases of [[strangulation]] or incarceration but it is still indicated. McVay repair is recommended in cases of intestinal incarceration as there is increased risk of [[infection]] following mesh repair in such cases.
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| ===Prevention===
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| ====Primary prevention====
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| Effective measures for the [[primary prevention]] of femoral hernia include optimal weight management, avoidance of [[rapid weight loss]], use of good body mechanics while lifting heavy objects.
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| ====Secondary prevention====
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| Effective measures for the [[secondary prevention]] of femoral hernia include avoiding activities that increase intra-abdominal pressure, preventing [[constipation|constipation and]] usage of monofilament stainless steel wire for [[suturing|suturing after surgical repair]].
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| ==References==
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| {{reflist|2}}
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| [[Category:Surgery]]
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| [[Category:Gastroenterology]]
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| [[Category:Up-To-Date]]
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| [[Category:Emergency medicine]]
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| {{WS}}
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| {{WH}}
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