Hernias are very common conditions encountered in general surgery; however, not all hernias carry the same risks, nor do they present in the same way. Femoral hernias are less common than other hernias, such as inguinal or umbilical hernias, and they are usually more dangerous. Femoral hernias have a subtle presentation and possess a tendency to develop severe complications, making it necessary for both patients and clinicians to recognize them early.
In this article, we explore what a femoral hernia is, how it differs from other hernia types, its symptoms, diagnostic methods, and the treatment strategies recommended by current surgical best practices.
A femoral hernia occurs when abdominal contents, such as a preperitoneal fat pad or a loop of intestine, bulge through a weakness in the femoral canal (a small passage located just below the inguinal ligament). The femoral canal lies between the femoral vein and the lacunar ligament, with lymphatic vessels present in it. The femoral canal is narrow and inflexible; thus, any tissue that enters this tightly constrained area can quickly get stuck or trapped.
Femoral hernias are rare and account for about 2%–5% of all abdominal wall hernias. However, they possess a high risk of complications, such as incarceration (trapped tissue can be manually pushed back) and strangulation (compromised blood supply), that can rapidly progress to perforation or bowel ischemia. Therefore, it is important that femoral hernias are recognized early, and prompt management is initiated.
It is crucial to differentiate femoral hernias from other types of hernias, particularly inguinal hernias, for correct diagnosis and treatment. Although femoral hernias share some common pathophysiological features, for example, protrusion through a weakened area, they differ in their location, demographic distribution, risk profile, and clinical presentation.
Femoral hernias appear below the inguinal ligament through the femoral canal, whereas inguinal hernias lie above the inguinal ligament. This distinction is crucial, but it can be difficult to distinguish in people with obesity or large hernias.
Femoral hernias lie deep and are difficult to palpate, whereas inguinal hernias appear above the inguinal ligament. Femoral hernias are commonly found in the groin area, whereas umbilical hernias occur at the belly button, and incisional hernias occur via a prior surgical incision and can appear anywhere along the abdominal wall.
Femoral hernias are commonly found in women (risk increases with age), and inguinal hernias are common in men. Femoral hernias are usually asymptomatic until complications, such as strangulation or incarceration, arise. Inguinal hernias present with a visible protrusion and groin discomfort.
Among all hernias, femoral hernias have the highest risk of strangulation, with studies showing up to 40% risk of strangulation within two years of diagnosis, and it can occur even when the symptoms are mild, or the hernia is small. In contrast, inguinal hernias possess a much lower short-term risk and can sometimes be safely managed with watchful waiting.
As the femoral canal is not flexible, the tissue can get compressed once it protrudes through. As the blood flow is reduced, it can lead to ischemia, necrosis, and potentially perforation (a hole in the wall of a hollow organ due to tissue death due to oxygen deprivation), requiring immediate surgery.
Femoral hernias can be particularly challenging to diagnose because many patients exhibit vague symptoms. Their occurrence deep below the inguinal ligament means a bulge may not be noticeable until complications develop.
Early symptoms may include a subtle protrusion in the upper thigh or groin area, just below the inguinal ligament. The bulge may become visible while coughing, standing or straining. Pain is located in the upper thigh or groin area, with the pain exacerbated while standing, lifting, or straining. Patients may experience lower abdomen heaviness and pain during activity, but it subsides when lying down.
Symptoms of incarceration/strangulation require urgent care and may exhibit the following symptoms:
Strangulation can lead to bowel ischemia, followed by tissue death (necrosis), sepsis and eventually death, if not treated immediately.
Diagnosing femoral hernias early requires careful physical examination and appropriate imaging, especially due to their subtle presentation.
A clinician palpates the groin both above and below the inguinal ligament, which includes examination while standing and straining (Valsalva maneuver). In this method, the patient is asked to take a deep breath, hold it, and forcefully exhale while the mouth is closed, and the nose is pinched. This increases the intra-abdominal pressure, causing the hernia to bulge.
The groin and upper thigh should be palpated and inspected for bulges and asymmetry. The patient must be examined for symptoms, and if asymptomatic, a manual reduction can be attempted. Considering femoral hernias are located deep below the inguinal ligament, palpation may be difficult, particularly in patients with obesity or when a bulge is absent.
Ultrasound: This is usually the first imaging technique used because it is readily accessible and does not involve radiation. It demonstrates high sensitivity for identifying the hernia sac, signs of strangulation and incarceration and relationship to vascular structures.
Computed Tomography: This technique is useful for differentiating hernias from lymphadenopathy or soft-tissue masses. This method can reveal the hernial sac contents, presence of bowel obstruction, indication of strangulation (reduced blood flow and bowel wall thickening) and location of the hernia relative to the inguinal ligament.
Magnetic Resonance Imaging: It is rarely used but may be useful in ambiguous, complex or recurrent cases. It provides exceptional soft-tissue detail, but it is time-consuming and costly.
Accurate diagnosis of femoral hernia is crucial as misdiagnosis may increase the risk of strangulation due to delay in initiating the treatment.
The anatomy of the femoral canal increases the risk of incarceration and strangulation, even in patients with no symptoms. Thus, femoral hernias always require surgical repair
Planned surgery is recommended with the following surgical options.
This traditional technique is the standard for femoral hernia repair. It involves an incision made over the groin just below the inguinal ligament. The hernia sac is identified, the herniated tissue is pushed back into the abdomen and the femoral canal is closed with sutures or mesh. This method is considered safe and effective, and it permits direct access to the femoral canal.
Two commonly used laparoscopic approaches are as follows:
This laparoscopic method is performed without entering the peritoneal cavity. A small incision is made to insert a camera and surgical instruments into the preperitoneal space (area located between the abdominal lining and abdominal wall). Dissection is performed to create a working space, then the femoral hernia is located, reduced, and finally, it is covered with a mesh placed in the preperitoneal space, without entering the abdominal cavity. It has the advantages of reduced pre-operative pain and faster return to daily activities.
In this method, the gastrointestinal surgeon makes an incision into the peritoneum (the membrane that lines the abdomen) to gain entry into the pre-peritoneal space. The hernia sac is reduced, and a mesh is placed in the preperitoneal space to cover the defect and strengthen (reinforce) the area. The incision is closed with sutures.
Benefits of laparoscopic repair include smaller incisions, less postoperative pain, faster recovery times, the ability to examine both groins for hidden hernias and lower recurrence rates. This method is preferred in patients with bilateral groin hernias, women with complex inguinal anatomy, and recurrent hernias following previous open repair.
Another minimally invasive technique that is becoming increasingly adopted in clinical settings is robot-assisted hernia repair. This allows improved dexterity, finer dissection and 3D visualization and is useful in complex or recurrent groin hernias.
In a clinical setting where laparoscopy/robotics are not feasible, the traditional open mesh repair has been modified to what is called the femoral-extended Lichtenstein repair. This can repair inguinal hernias and suspected femoral hernias simultaneously. After initial mesh placement, which reinforces the inguinal floor, an additional flap is created from the mesh to cover the femoral canal. The femoral canal is accessed by opening the fascia transversalis (connective tissue lining the abdominal wall) and incising the lacunar ligament. The mesh is fixed to the Cooper’s ligament with sutures.
The traditional permanent synthetic mesh is increasingly being replaced by biologic or bioabsorbable meshes, which offer the benefits of integrating into native tissue, breaking down over time, and reducing foreign-body complications like mesh rejection or chronic inflammation.
Enhanced Recovery After Surgery (ERAS) protocols are being adopted to combine minimal invasive surgery, optimize pain management and promote early mobilization, reducing the length of hospital stay and enhancing recovery. Emerging technologies, such as the use of machine learning to aid in surgical decisions and mesh selection, are allowing more personalized treatment that is based on individual patient anatomy and risk profile.
Patients who opt for elective surgery have excellent outcomes. However, emergency femoral hernia repair due to strangulation has an increased risk of infection, bowel resection, and extended hospitalization. One can return to light activity in 1-2 weeks and resume daily activities in about 2 to 4 weeks. Heavy lifting and strenuous exercise can be started in about 4 to 6 weeks. Pain is mild to moderate and can be managed with analgesics. The recurrence rates are low with modern mesh techniques. Both laparoscopy and open-mesh repair have shown similar success rates when performed by experienced gastrointestinal surgeons.
Femoral hernias are uncommon but dangerous, with a high risk of incarceration and strangulation. They differ from other hernias in location, risk profile, and demographic patterns. Many patients exhibit minimal or vague symptoms, making diagnosis challenging. Surgery is recommended for all femoral hernias, regardless of symptoms. Innovations in treatment methods and mesh materials are showing promise in better long-term outcomes. Early detection and elective repair lead to far safer outcomes than emergency treatment.
Early recognition and timely surgical care are crucial in preventing the serious complications associated with femoral hernias. With accurate diagnosis, modern imaging, and advanced minimally invasive techniques, patients can expect safer procedures, faster recovery, and excellent long-term outcomes. Kauvery Hospital, with expert surgical teams and state-of-the-art facilities in Chennai, Hosur, Salem, Tirunelveli, and Trichy, is committed to delivering comprehensive, patient-focused hernia care you can trust.
What is a femoral hernia?
A femoral hernia occurs when abdominal tissue pushes through the femoral canal, located just below the inguinal ligament in the groin. It is less common than other hernias but carries a higher risk of serious complications.
How is a femoral hernia different from an inguinal hernia?
Femoral hernias appear below the inguinal ligament, while inguinal hernias occur above it. Femoral hernias are more common in women and have a higher risk of strangulation.
Who is at higher risk of developing femoral hernia?
Women, especially older women, are at higher risk. Other risk factors include pregnancy, chronic cough, constipation, obesity, and conditions that increase abdominal pressure.
What are the symptoms of femoral hernia?
Symptoms may include a small bulge in the upper thigh or groin, discomfort while standing or straining, and pain that improves when lying down. Some patients may have no symptoms initially.
Why are femoral hernias considered dangerous?
The femoral canal is narrow and rigid, making trapped tissue more likely. This increases the risk of strangulation, where blood supply to the intestine is cut off, requiring emergency surgery.
What are the warning signs of strangulation?
Severe groin pain, redness over the bulge, nausea, vomiting, fever, and symptoms of bowel obstruction require immediate medical attention.
How is a femoral hernia diagnosed?
Diagnosis involves physical examination and imaging such as ultrasound or CT scan to confirm the location and assess complications.
Does a femoral hernia always require surgery?
Yes. Surgical repair is recommended for all femoral hernias because of their high risk of incarceration and strangulation, even if symptoms are mild.
What surgical options are available for femoral hernia?
Options include open mesh repair, laparoscopic techniques such as TEP and TAPP, and in some cases robotic-assisted repair. The choice depends on patient factors and surgeon expertise.
What is recovery like after femoral hernia surgery?
Most patients return to light activities within 1–2 weeks and resume normal routines in 2–4 weeks. Heavy lifting should be avoided for about 4–6 weeks.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet, Radial Road & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and paediatric trauma care.
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