A 62-year-old woman presents with a tender, irreducible swelling in the right groin below the inguinal ligament for 6 hours. On examination, the mass is firm, 2 cm, and tender. She reports nausea but no vomiting. Bowel sounds are present. What is the most appropriate next step in management?

## Clinical Assessment This patient presents with a **femoral hernia with signs of incarceration** (irreducibility, tenderness, short duration). Femoral hernias carry the highest risk of incarceration among all abdominal wall hernias due to the narrow femoral canal bounded by rigid anatomical structures (Cooper's ligament medially, inguinal ligament superiorly). **Key Point:** Femoral hernias account for only 3–5% of all groin hernias but have an incarceration rate of 20–40%, making them a surgical emergency when incarcerated. ## Why Urgent Surgery Is Correct 1. **Incarceration present**: Irreducibility + tenderness + short symptom duration = incarcerated hernia 2. **Risk of strangulation**: Femoral hernias have the highest strangulation risk; bowel viability is at risk 3. **No time for imaging**: Clinical diagnosis is sufficient; imaging delays definitive treatment 4. **Nausea (early sign of obstruction)**: Indicates bowel compromise is imminent **High-Yield:** In an incarcerated femoral hernia, the priority is **urgent surgical exploration**—not imaging, not observation, not attempted reduction. Delay risks bowel necrosis and peritonitis. ## Surgical Approach Femoral hernia repair requires: - **McVay repair** (Cooper's ligament repair) — most common - **Lichtenstein tension-free mesh** — if no bowel resection needed - **Assess bowel viability** intraoperatively; resect if non-viable **Clinical Pearl:** Femoral hernias often present late because the swelling is small and easily missed; by the time they present, incarceration is already present in ~20% of cases. [cite:Sabiston Textbook of Surgery Ch 43]