Femoral hernia are groin hernia which have a small opening and are prone to incarceration. If incarcerated, a femoral hernia may be difficult to differentiate from an inguinal hernia. Several operative approaches are used in femoral hernia. However, for the practitioner who is familiar with inguinal hernia repair, the groin approach is easiest. This approach is also helpful if the diagnosis is not certain and in the treatment of combined femoral and inguinal hernia.

Technique

1	In the groin approach for femoral hernia, make the same incision as for an inguinal hernia (Figures 8.1, 8.2, 8.3 on page 8–2). Retract the spermatic cord, taking care to protect the ileo-inguinal nerve (Figure 8.23).
Figure 8.23
2	The findings and the procedure will now differ from an inguinal hernia. In femoral hernia, the floor of the inguinal canal is intact. Using gentle blunt dissection, open the floor of the inguinal canal, enter the properitoneal space and reduce the femoral hernia (Figure 8.24).
Figure 8.24
3	After reduction, the sac can be managed with a purse-string suture and reduced (Figures 8.25, 8.26). If you are concerned that the sac contents are gangrenous, open the sac and inspect the contents. If the femoral hernia sac cannot be reduced, place an artery forceps at the neck of the sac and divide the overlying inguinal ligament. Take care to cut along the artery forceps to avoid injury to the femoral vessels (Figure 8.27). The sac will then reduce easily.
Figure 8.25
Figure 8.26
Figure 8.27
4	Repair the femoral hernia by attaching the conjoined tendon to the Cooper’s ligament, which is the periosteum of the pubic ramus medial to the femoral canal.
5	Close the femoral defect by inserting a transition stitch to include the conjoined tendon, Cooper’s ligament and the femoral sheath. Remember that the femoral vein is just under the femoral sheath (Figure 8.28). Figure 8.28 shows how the Cooper’s ligament repair and the transition suture are tied.
Figure 8.28
6	Lateral to the transition suture (untied sutures), reconstruct the inguinal canal by approximating the conjoined tendon to the remnant of the floor and the edge of the inguinal ligament. This type of repair results in excess tension unless a relaxing incision is made. Make an incision in the internal oblique aponeurosis just under the elevated external oblique (Figure 8.29). As in inguinal hernia repair, the internal ring should admit a finger (Figure 8.14). Close the external oblique and skin, as for an inguinal hernia (Figures 8.15, 8.16).
Figure 8.29

In addition to its use in femoral hernia, the Cooper’s ligament repair is also an excellent repair for direct inguinal hernia.