Incarcerated femoral hernia in men: Incidence, diagnosis, and surgical management

Dear Editor, A femoral hernia is an uncommon, acquired condition, which has been reported in less than 5% of all abdominal wall hernias, with a female to male predominance of 1.8:1. It is twice as common in parous as non-parous women. Approximately 60% of femoral hernias are found on the right, 30% on the left, and 10% bilaterally.[1] Diagnosing the nature of a lump in the groin is often difficult, especially in obese patients. Delay in diagnosis may occur, especially because a strangulated femoral hernia does not always typically present with abdominal or inguinal pain. There appear to be only few reports in the literature that specifically describe incarcerated femoral hernia in male population. While herniorrhaphy makes up majority of a community general surgeon's case load, femoral hernia in men may not be readily recognized, especially by the younger surgical providers. An 83-year-old man presented to the emergency department with 6-hour history of nausea, vomiting, and abdominal bloating. Medical and surgical histories were significant for bilateral open inguinal hernia repair 40 years earlier, prostate cancer, tobacco use, and a kidney mass. He was found to have moderately distended non-peritonitic abdomen with a right incarcerated inguinal hernia. Computed tomography (CT) of the abdomen demonstrated small bowel obstruction caused by a right inguinal hernia [Figures ​[Figures11 and ​and2].2]. Intraoperatively, he was found to have an incarcerated femoral hernia with normal-appearing inguinal canal structures. A single loop of contused but viable small bowel was released and reduced into the abdominal cavity. A polypropylene plug was used to obliterate the femoral defect. The patient made an uneventful recovery and was released on postoperative Day 4. Several cases of men with incarcerated femoral hernias have been reported [Table 1]. Figure 1 Axial view of the right incarcerated femoral hernia Figure 2 Coronal view of the bowel containing incarcerated femoral hernia (arrow) FA = Femoral Artery Table 1 Previously reported cases of men with incarcerated femoral hernias Hernia is caused by a mechanical disparity between visceral pressure and resistance of the abdominal wall musculature. The transversalis fascia, as other fascial tissue, derives its strength from collagen fibers that are continually being produced and reabsorbed. A disturbance in this balance results in attenuation of the fascia. Congenital connective tissue defects, such as in Marfan, Ehlers-Danlos, and Hunter-Hurler syndromes are predisposing factors for the formation of hernia. Cigarette smoking has been associated with development of inguinal hernia.[2] Differential diagnosis of femoral hernia includes pseudohernia, femoral artery pseudoaneurysm, saphenous vein varicosity, soft tissue masses, and lymphadenopathy. Current recommendations suggest that femoral hernias should be repaired unless specific contraindications are present. This recommendation is based on the experience that complications of incarceration, obstruction, and strangulation are greater threats than are the risks of operation. The operative mortality, especially in the elderly, is increased at least ninefold to tenfold when intestinal obstruction occurs.[3] Selection of the inguinal, infra-inguinal, or preperitoneal approach is determined by the presentation. Berliner et al.[2] recommended repair of a reducible femoral hernia by using the inguinal approach and of an irreducible femoral hernia by using the infra-inguinal approach. If incarceration or strangulation dictates the need for an emergent operation, the preperitoneal approach is the preferred method. This operation requires general or spinal anesthesia, which may result in a slightly higher risk of cardiopulmonary complications in elderly individuals. The affected area or disease can be reached rapidly with excellent visualization of the external iliac-femoral vein structure. A femoral hernial sac is then reduced by cephalad traction. If the hernia is incarcerated, the sac is released by carefully incising the insertion of the iliopubic tract into the Cooper's ligament at the medial margin of the femoral ring. The sac should be opened for inspection of its contents. The repair is initiated with high ligation of the sac. The anterior margin of the hernia defect is formed by the iliopubic tract, and the posteromedial margin is formed by the Cooper's ligament. Intestinal resection can be performed with good exposure, if necessary, and the external iliac vein can be easily identified and protected from injury during the repair. The hernioplasty is completed by suturing the iliopubic tract and the Cooper's ligament together, thereby obliterating the femoral canal medial to the femoral vein. Alternately, a synthetic plug can be used to eliminate the femoral canal. In this preperitoneal approach, an appropriate degree of closure of the canal medial to the femoral vein is more readily obtained. The aberrant obturator artery (corona mortis) crossing the Cooper's ligament is readily visible and should be protected when present. Laparoscopic management of femoral hernias using totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) have also been described.[4] An anatomic piece of synthetic polyester mesh is placed to cover the direct, indirect, and femoral spaces. Similar principles apply to the TAPP approach, except that the abdominal cavity is entered. Access and visualization of the abdominal cavity can be used to facilitate reduction of incarcerated intra-abdominal contents, in addition to its purposes for diagnosis of other visceral abnormalities.