A 58-year-old woman presents to the emergency department with acute onset severe right groin pain and vomiting for 6 hours. On examination, she has a tender, irreducible lump below the inguinal ligament, medial to the femoral vessels. Her abdomen is distended with hyperactive bowel sounds. CT abdomen shows small bowel loops herniating through the femoral canal with transition point and proximal bowel dilatation. What is the most appropriate immediate management?

Explanation

## Clinical Presentation & Diagnosis **Key Point:** Femoral hernias present with a lump below the inguinal ligament, lateral to the pubic tubercle and medial to the femoral vessels. They account for 3–5% of all groin hernias but have the highest incidence of incarceration (20–40%) and strangulation among all abdominal wall hernias. ## Why Emergency Surgery Is Mandatory **High-Yield:** The presence of: - Irreducibility - Acute onset pain - Vomiting and bowel obstruction signs (distension, hyperactive sounds, transition point on imaging) - Imaging evidence of hernia with bowel dilatation ...constitutes **strangulation** or **incarceration with obstruction**, which requires **emergency surgical exploration**. **Clinical Pearl:** Femoral hernias have the worst prognosis among groin hernias because: 1. The rigid femoral canal has no elasticity 2. The narrow neck predisposes to early vascular compromise 3. Delayed surgery increases morbidity and mortality from bowel necrosis ## Management Algorithm ```mermaid flowchart TD A[Femoral Hernia]:::outcome --> B{Irreducible + Acute pain?}:::decision B -->|Yes| C{Signs of obstruction/strangulation?}:::decision C -->|Yes| D[Emergency surgical exploration]:::action C -->|No| E[Urgent surgery within 24 hrs]:::action B -->|No| F[Elective repair]:::action D --> G[Assess bowel viability]:::action G --> H{Viable?}:::decision H -->|Yes| I[Repair hernia]:::action H -->|No| J[Resect + repair]:::action ``` **Tip:** Do NOT attempt manual reduction of an acutely painful, irreducible femoral hernia — risk of reducing strangulated bowel back into the abdomen ("reduction en masse"), masking peritonitis and delaying diagnosis. ## Surgical Approach - **Low approach (Lockwood):** Direct access below inguinal ligament; preferred for acute cases - **High approach (McEvedy):** Medial to rectus; allows better assessment of bowel viability - **Mesh repair:** Safe even in emergency setting if bowel is viable; reduces recurrence from 10–15% (primary repair) to <5% [cite:Sabiston Textbook of Surgery Ch 43]