Obstructed Femoral Hernia

Prof. T.K. Partha Sarathy

A 65 year old elderly obese somewhat non-communicative lady was admitted to a

private nursing home with a history of fever, nausea, vomiting and not feeling well. She has had symptoms like this occasionally in the past but got better in a day or two. But this time after 2 days she is still not feeling well and because of vomiting

she refuses any oral intake. The family practitioner who examined the patient found that she was edentulous; head, neck ears and eyes were unremarkable except for early cataract in both the eyes. Examination of the breast and axillae were normal. Except for tachycardia (heart rate 102) her heart was clinically normal and breath sounds were normal. There were no rales or rhonchi heard anywhere. The abdomen was somewhat distended. There was no guarding or rigidity. There was no local tenderness. Bowel sounds were high-pitched. Rectal examination revealed an empty rectum and no blood was seen on the examination glove. Pelvic examination did not reveal any tubo-ovarian mass and the uterus was normal sized. The distal pulses in both extremities were equal and normal. Gross neurological examination was unremarkable.

Because of the presence of signs of minimal dehydration the patient was started on I.V. fluids. As no definite evidence of infection or sepsis was identified, antibiotic therapy was not considered. Patient continued to get worse and did not show any improvement. Although she was stable, because of the presence of abdominal distension a surgical consultation was obtained on the same evening of admission. The surgeon examined the patient and she pretty much agreed with the findings of the family practitioner. However the presence of abdominal distention, high-pitched bowel sounds and an empty rectum in a patient who has been vomiting, raised the possibility of "acute intestinal obstruction" in her mind. There was no evidence of any previous abdominal surgery to consider intra peritoneal adhesions causing intestinal obstruction, which is one of the common causes.

Flat and upright abdominal x-rays were performed which did not reveal any free air under the diaphragm. However the pattern of bowel gas was indicative of small bowel obstruction. With the suspicion of intestinal obstruction strengthened by the x-rays, the surgeon examined the patient once again to see if there was any evidence of any obstructed hernia, which can go unnoticed in an obese patient like her. There was no evidence of any umbilical hernia; both the inguinal regions appeared normal. But on careful palpation of the femoral areas below mid inguinal point the surgeon felt rather soft, prominent non-reducible lump on the right side somewhat like a large lymphnode deeper to the subcutaneous tissue. The left side was normal. The possibility of an obstructed femoral hernia could not be ruled out. The more the surgeon palpated the lump in the right femoral triangle the more she was convinced that patient had a femoral hernia probably obstructed or strangulated. A few additional tests were done like Ultrasound of the abdomen serum electrolytes, ECG, Chest x-ray etc., and they were all unremarkable, except for a slight elevation of the WBC count to 11,000 and a BUN of 38 with a normal creatinine.

The possibility of right femoral hernia with evidence of intestinal obstruction and possible strangulation of intestine within the hernial sac was at that point the working diagnosis. The surgeon discussed this diagnostic possibility with the relatives and strongly advised emergency surgery.

In preparation for surgery she started to hydrate the patient and shortly there after the patient was taken to surgery and under general anesthesia the right inguino femoral region was explored and the hernia, which was obstructed, was identified. When the sac was opened the intestine was found to be congested but not yet gangrenous. Once obstruction was relieved and a warm Lap-pad was applied over the intestine, the intestine appeared viable and there was no evidence of strangulation. That part of the intestine was reduced back into the peritoneal cavity and repair of the femoral hernia was performed using Mc Vay Cooper-ligament repair technique. Post operatively patient was kept NPO for a day, after which she was started on fluids. She was able to tolerate diet well and on the 5th postoperative day she was discharged with the operative site healing well and in good condition.