All femoral hernias should be repaired unless contraindicated by the physical or medical condition of the patient. Incarceration with possible strangulation is a concern, as the femoral opening is small and its boundaries are unyielding. Ultrasound imaging studies may be useful when the diagnosis is difficult.
The preoperative preparation is determined by the general condition of the patient. Uncomplicated femoral hernias may be repaired in an ambulatory surgery setting. Incarcerated femoral hernias without gastrointestinal signs or symptoms should be repaired expeditiously, while symptomatic hernias are treated urgently. Strangulation requires hospitalization and resuscitation of the patient with nasogastric tube decompression, intravenous rehydration, and parenteral antibiotics. Any general medical conditions are evaluated and sufficient time is allowed for volume and electrolyte stabilization. Improved vital signs and a good urine output indicate readiness for surgery.
Deep sedation with infiltration of a local anesthetic as a field block may be used in elective cases, as can spinal or epidural anesthetic techniques. Patients with strangulation and obstruction should have general anesthesia with an endotracheal tube and cuff to lessen the threat of tracheal aspiration.
The patient is placed in a supine position with the knees slightly flexed by a pillow so as to lessen the tension in the groin.
The hair in the planned operative site is clipped and the skin prepared in the routine manner. Parenteral antibiotics appropriate for prophylaxis against the usual skin bacteria are given immediately prior to the start of the procedure and in sufficient time to reach therapeutic tissue levels.
It is important that the surgeon understand the regional anatomy of the femoral space. This opening is approximately 1 to 1½ cm in diameter and lies directly lateral to the pubic tubercle but inferior to the inguinal ligament (figure 1). The fascia overlying the pectineus muscle forms the posterior wall, whereas the lateral aspect is bounded by the slightly compressible femoral vein as it emerges under the inguinal ligament. Clinically, the femoral herniation presents as a mass that may be confused with superficial inguinal lymphadenopathy. In thin patients, the line of the inguinal ligament from the anterior superior spine to the pubic tubercle can be projected and the femoral herniation will clearly present below this, being immediately lateral to the pubic tubercle and medial to the pulsation of the femoral vessels. If the surgeon is certain of this diagnosis, which may be aided by the use of ultrasonography, then the lower limited oblique incision directly over the mass may be made (figure 2b). If the diagnosis is in doubt, the patient is obese, or the possibility of strangulation exists, then the upper incision (figure 2a) is ...