FEMORAL HERNIAGiven a patient with a groin mass, the resident can accurately differentiate the anatomic landmarks of a femoral hernia in contrast to those of an inguinal hernia.

When palpable on examination, present as bulges below the inguinal ligament. The bulge can be found just medial to the femoral pulse and frequently feels like a lipoma or lymph node. Inferior to the iliopubic tract, midway along the inguinal ligament, is the femoral sheath, containing the femoral artery and branch of the genitofemoral nerve, the femoral vein, and the femoral canal. The latter is a 1 to 2 cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis.

The femoral ring is bordered by: inferiorly- the superior pubic ramuslaterally- the femoral vein anteriorly and medially- the iliopubic tract (with its curved insertion onto the pubic ramus)

Femoral hernias are rare and typically seen in women, as their pelvis is broad and the femoral space is wider.

Given a patient with a femoral hernia, the resident can accurately describe the necessary steps in repair of this hernia:Femoral hernias in females can be approached using a groin incision with dissection beneath the inguinal ligament without opening the external oblique fascia. To facilitate reduction of the contents of the hernia, the femoral canal may need to be opened by dividing the inguinal ligament and/or lacunar ligament. The defect can be closed with sutures or with a mesh plug from below the inguinal ligament. Larger femoral hernias in females and femoral hernias in males are better repaired using a McVay Cooper ligament repair.

For the McVay repair, the conjoint tendon is sutured to Cooper's ligament, thus patching the femoral space as well . Then, at the level of the femoral vein, a transition suture is used to continue the approximation from the conjoint tendon to the inguinal ligament .

Question 1You are seeing a patient with an incarcerated femoral hernia. The skin over the hernia mass is warm and erythematous. The patient has a fever and an elevated white blood cell count. What is your plan for treatment?

-strangulated- No attempt should be made to reduce the hernia. Rapidresuscitation, NGT, and replacement of fluids and electrolytes. The patient should be given antibiotics. Once the patient is resuscitated,urgent surgery commences to expose the hernia, open the sac, and

assess the viability of the bowel. More bowel can be pulled into the hernia so that viable bowel can be transected and the gangrenous portion removed. An end-to-end anastomosis should be performed and the bowel then reduced into the abdominal cavity. The hernia is then repaired.- no mesh

Question 2What is the differential diagnosis for an infra-inguinal groin mass? What methods can you use to determine if a mass in the inguinal region is a femoral hernia?

-femoral hernia, femoral aneurysm, lipoma or lymph nodeUltrasound- tender. If inguinal lymph nodes are replaced by metastasis, a primary lesion should belooked for in the skin in any part of the lower limb. The perineum and anal canal should also be examined. Lymphadenopathy can also be caused by lymphoma, and groin nodes may bethe only site. Lymphadenopathy characteristically appears as a well-circumscribed mass below the inguinal ligament that one can get above with the examining hand. Lymph nodes are solid on ultrasonography, and for this reason, it may be difficult to differentiate nodes from a femoral hernia containing omentum.

Question 3A 50-year-old obese woman presents with a firm right groin mass and bilious vomiting. Her plain abdominal films show a small bowel obstruction. What will your approach be?

Obstruction: resuscitation followed by urgent surgery. At surgery, an approach directly over the hernia is used. In all patients, the entire gastrointestinal tract must be assessed to eliminate causes of obstruction other than the hernia itself. This is done before the hernia is repaired. The bowel, if viable, is reduced into the abdomen. In the case of a femoral hernia, the inguinal ligament can be split anteriorly and the hernia contents reduced into the abdomen. If the bowel is nonviable, then a bowelresection can be performed with anastomosis. The hernia is then repaired.

Question 4Describe the structures that lie anterior, posterior, medial, and lateral to a femoral hernia.

The femoral ring is bordered by: inferiorly- the superior pubic ramuslaterally- the femoral vein anteriorly and medially- the iliopubic tract (with its curved insertion onto the pubic ramus)