General Surgery · Year 3 · from General Surgery

Case 2: Femoral Hernia with Bowel Obstruction

Patient Demographics

  • Age: 74 years
  • Sex: Female
  • Occupation: Retired school teacher

Chief Complaint

"I've had vomiting and haven't been able to have a bowel movement for 2 days."

History of Present Illness

The patient presents with a 2-day history of progressive abdominal distension, nausea, and vomiting. The vomiting has become bilious and more frequent over the past 24 hours. She reports crampy abdominal pain and has not passed flatus or stool in 48 hours. She mentions having noticed a small lump in her right groin for "a few months" but did not think it was significant. She has never had abdominal surgery.

Past Medical History

  • Hypertension
  • Osteoporosis
  • Osteoarthritis
  • No prior abdominal surgery

Medications

  • Amlodipine 5 mg daily
  • Alendronate 70 mg weekly
  • Acetaminophen as needed

Physical Examination

  • Vitals: BP 138/82 mmHg, HR 92 bpm, RR 20/min, Temp 37.4°C, SpO2 97% on room air
  • General: Thin elderly female appearing uncomfortable
  • Abdomen:
  • Inspection: Distended
  • Auscultation: High-pitched bowel sounds with rushes
  • Palpation: Diffuse tenderness, no peritoneal signs
  • Groin examination:
  • Right: 2 cm firm, tender mass located inferior and lateral to the pubic tubercle (below the inguinal ligament)
  • Non-reducible
  • Left: No hernia

Laboratory Results

  • WBC: 11,200/μL
  • Hemoglobin: 13.2 g/dL
  • Creatinine: 1.4 mg/dL
  • Potassium: 3.4 mEq/L
  • Lactate: 2.4 mmol/L

Imaging

Abdominal X-ray:

  • Multiple dilated loops of small bowel
  • Air-fluid levels
  • Paucity of gas in the colon

CT Abdomen/Pelvis:

  • Small bowel obstruction with transition point at a right femoral hernia
  • Herniated loop of small bowel through the femoral canal
  • Proximal small bowel dilation to 4.5 cm
  • Decompressed distal small bowel
  • No evidence of bowel wall ischemia or perforation

Diagnosis

Right femoral hernia with small bowel obstruction (Richter's hernia physiology)

Management

  1. Nasogastric tube for decompression
  2. IV fluid resuscitation
  3. Electrolyte correction
  4. Urgent surgical repair

Operative Approach

Given her body habitus and the need to assess bowel viability, a combined approach was used:

  1. Infrainguinal (Lockwood) approach for access to femoral canal
  2. Counterincision if needed for bowel assessment

Operative Findings

  • Right femoral hernia containing a loop of ileum
  • Hernia ring very tight (femoral canal narrowing)
  • Bowel initially appeared ischemic but recovered after release
  • McVay repair performed (Cooper's ligament repair)
  • Mesh not used due to potentially compromised bowel

Postoperative Course

  • NGT removed POD 1
  • Diet advanced POD 2
  • Bowel function returned POD 3
  • Discharged POD 4

Teaching Points

  1. Femoral hernias are more common in women and elderly patients
  2. Femoral hernias have the highest rate of incarceration/strangulation (15-20%)
  3. Located below inguinal ligament, medial to femoral vein
  4. Richter's hernia: partial circumference of bowel incarcerated (can have strangulation without obstruction)
  5. All femoral hernias should be repaired when diagnosed due to high complication rate

Clinical Image

Image Description: Anatomical diagram showing the location of femoral hernias relative to inguinal hernias. Femoral hernias protrude through the femoral canal below the inguinal ligament, medial to the femoral vein, while inguinal hernias occur above the inguinal ligament.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Hernias

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