A 62-year-old woman presents to the emergency department with acute onset severe groin pain and vomiting for 6 hours. On examination, she has a small, tender, irreducible lump below the inguinal ligament, medial to the femoral vessels. Her abdomen is distended with hyperactive bowel sounds. Plain radiograph shows dilated small bowel loops with air-fluid levels. What is the most likely diagnosis?

## Clinical Presentation **Key Point:** Femoral hernia presents as a small, tender, irreducible mass located **below the inguinal ligament and medial to the femoral vessels**, in the femoral canal. ## Anatomical Basis The femoral hernia emerges through the femoral ring (bounded by: - Medially: lacunar ligament - Laterally: femoral vein - Superiorly: inguinal ligament - Inferiorly: pectineal ligament) This anatomically narrow defect explains why femoral hernias have a **high risk of incarceration and strangulation** (up to 40%). ## Clinical Features of Femoral Hernia | Feature | Femoral Hernia | Inguinal Hernia | |---------|---|---| | **Location** | Below inguinal ligament, medial to femoral vessels | Above inguinal ligament | | **Incidence** | 3–5% of all hernias | 75–80% of all hernias | | **Gender predilection** | Female > Male (3:1) | Male > Female (9:1) | | **Risk of strangulation** | 40% (highest among all hernias) | 10% | | **Presentation** | Often acute with obstruction/strangulation | Often chronic, painless bulge | | **Palpable mass** | Small, firm, below ligament | Large, above ligament | ## Why This Patient Has Femoral Hernia **High-Yield:** Femoral hernias are more common in **multiparous women** (due to weakened pelvic floor) and elderly patients. The narrow femoral ring makes incarceration the **most common presentation** — patients often present acutely with small bowel obstruction rather than a chronic bulge. **Clinical Pearl:** A femoral hernia is often **misdiagnosed as an inguinal hernia** because the lump is small and the history is acute. The key discriminator is the **location below the inguinal ligament and medial to the femoral vessels**. ## Diagnosis & Management 1. **Clinical diagnosis** based on location and anatomy 2. **Imaging:** Ultrasound or CT to confirm (if diagnosis unclear) 3. **Management:** **Urgent surgical repair** — even asymptomatic femoral hernias warrant repair due to high strangulation risk 4. **Surgical approaches:** - Low approach (Lockwood) — direct access to femoral canal - High approach (McEvedy) — via lower rectus sheath - Laparoscopic/TEP — increasingly used **Warning:** Do NOT attempt manual reduction of an acutely tender, irreducible femoral hernia — risk of reducing strangulated bowel back into the abdomen ("reduction en masse"), masking perforation. ## Why Obstruction Occurred Here The narrow femoral ring (bounded by ligaments and vessels) acts like a **tight noose** around the hernia contents. Small bowel loops become trapped, leading to: - Incarceration → obstruction (as in this case) - Strangulation → ischemia, perforation, peritonitis (if not operated urgently)