A 62-year-old woman with a 2-month history of intermittent right groin pain is found on examination to have a small, tender, irreducible mass below the right inguinal ligament. She reports that the pain worsens with prolonged standing and straining. Ultrasound confirms a 1.5 cm hernia sac in the femoral canal. She denies current nausea or vomiting. What is the most appropriate management?

Explanation

## Clinical Context: Asymptomatic or Minimally Symptomatic Femoral Hernia **Key Point:** Unlike inguinal hernias, **femoral hernias should be repaired electively even when asymptomatic or minimally symptomatic** because of the inherently high risk of strangulation. **High-Yield:** The strangulation rate for femoral hernias is approximately **40%** over the lifetime of the patient if left unrepaired. This is substantially higher than for inguinal hernias (10%) and mandates a different management philosophy. ## Why Elective Repair Is Indicated | Hernia Type | Strangulation Risk | Management Philosophy | |---|---|---| | **Femoral** | ~40% lifetime | **Elective repair recommended even if asymptomatic** | | **Inguinal** | ~10% lifetime | Watchful waiting acceptable if asymptomatic | | **Umbilical** | Low | Repair if symptomatic or > 1.5 cm | **Clinical Pearl:** The narrow, rigid femoral ring acts as a "guillotine" around the hernia sac. Once incarcerated, the hernia is at extreme risk of strangulation because the constricting band cannot be overcome by manual reduction or conservative measures. The small size (1.5 cm) does not reduce risk; in fact, small femoral hernias are particularly prone to strangulation because they are easily overlooked and the narrow neck increases constriction. ## Why Other Options Are Incorrect **Watchful waiting** is inappropriate because femoral hernia has an unacceptably high strangulation rate. Unlike inguinal hernia, where watchful waiting is an evidence-based option for asymptomatic patients, femoral hernia mandates prophylactic repair. **Manual reduction** is contraindicated because: 1. The hernia is already irreducible (as stated in the stem) 2. Even if reduction were possible, it does not address the underlying defect 3. Reduction may mask strangulation and delay recognition of bowel necrosis 4. The narrow femoral ring will re-incarcerate the hernia immediately **CT angiography** is not indicated in this uncomplicated presentation. Imaging is needed only if vascular compromise is suspected (which is not the case here). ## Surgical Approach **High-Yield:** Three approaches are available: 1. **Lockwood approach** (infra-inguinal, low approach) - Direct access to femoral canal - Preferred for uncomplicated femoral hernia - Good visualization of contents 2. **McEvedy approach** (medial approach) - Allows assessment of bowel viability - Preferred if strangulation suspected 3. **Lichtenstein tension-free mesh repair** (via inguinal approach) - Can be used if inguinal hernia coexists - Less commonly used as sole approach for femoral hernia **Mnemonic:** **FH-URGENT** = **F**emoral hernia, **H**igh strangulation risk, **U**rgent elective repair, **R**igid femoral ring, **G**eneral anesthesia, **E**xplore bowel viability, **N**eed prophylactic surgery, **T**ension-free mesh preferred. [cite:Sabiston Textbook of Surgery 21e Ch 43]