A 62-year-old woman presents to the emergency department with a 6-hour history of severe right groin pain and vomiting. On examination, a tender, irreducible mass is palpable below the inguinal ligament, medial to the femoral vessels. Abdominal examination reveals mild distension and hyperactive bowel sounds. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient presents with **acute femoral hernia with signs of incarceration and possible strangulation** — severe pain, vomiting, irreducibility, and a palpable tender mass below the inguinal ligament in the femoral canal. ## Why Urgent Surgery Is Indicated **Key Point:** Femoral hernias carry the highest risk of strangulation among all abdominal wall hernias (up to 40% incidence), and once strangulation occurs, bowel necrosis develops rapidly. **High-Yield:** The clinical triad of **irreducibility + severe pain + vomiting** in a femoral hernia is a surgical emergency. Delay risks bowel perforation, peritonitis, and sepsis. ## Management Algorithm ```mermaid flowchart TD A[Femoral hernia presentation]:::outcome --> B{Acute, irreducible,<br/>severe pain?}:::decision B -->|Yes| C[Signs of incarceration/<br/>strangulation]:::urgent B -->|No| D[Elective repair<br/>within days]:::action C --> E[Urgent surgical exploration]:::action E --> F[McVay or Lockwood approach]:::action F --> G[Assess bowel viability]:::decision G -->|Viable| H[Repair hernia]:::action G -->|Necrotic| I[Resect + anastomosis]:::urgent ``` ## Surgical Approaches for Femoral Hernia | Approach | Access | Advantages | Indications | |----------|--------|------------|-------------| | **McVay (Cooper's ligament)** | Infra-inguinal | Direct visualization of femoral canal; low recurrence | Elective and emergency | | **Lockwood (high approach)** | Inguinal ligament division | Better for strangulated hernia; easier bowel assessment | Acute strangulation | | **Laparoscopic** | Transperitoneal/TEP | Minimal access; bilateral assessment possible | Elective only | **Clinical Pearl:** Femoral hernias are more common in women and elderly patients. The narrow femoral canal and rigid borders (inguinal ligament, lacunar ligament, femoral vein) make strangulation inevitable if not repaired urgently. **Key Point:** Do NOT attempt manual reduction in acute femoral hernia — risk of reducing gangrenous bowel back into the abdomen, causing peritonitis. ## Why Imaging Is Not First-Line Here While CT can confirm diagnosis, the clinical picture is already diagnostic (location below inguinal ligament, irreducibility, acute symptoms). **Imaging delays definitive treatment and risks bowel perforation.** In an emergency setting with clear clinical signs, proceed directly to the operating theatre.