Femoral, Umbilical, and Para-Umbilical Hernia

FEMORAL HERNIA

Definition & Anatomy

Epidemiology

• Rare before age 20; peak incidence >50 years
• Commoner in women (2:1) — the female pelvis widens the femoral canal — but inguinal hernia is still the commonest groin hernia even in women
• Right side twice as common as left; 20% bilateral
• The rigid canal means strangulation is common (~50% present as emergencies)

Clinical Features & Diagnosis

• Swelling below and lateral to the pubic tubercle, below the inguinal ligament
• Often only 1–2 cm; easily mistaken for a lymph node
• Rapidly becomes irreducible; cough impulse may be absent due to tight neck
• In late stages, may reflect superiorly and mimic a direct inguinal hernia

Differential Diagnosis

1. Saphena varix — disappears on lying down; fluid thrill rather than expansile impulse; Schwartz's test positive
2. Enlarged inguinal lymph node (including Cloquet's node within the canal)
3. Psoas abscess — cold abscess from Pott's disease, tracks lateral to femoral vessels
4. Lipoma, femoral artery aneurysm

Treatment — Surgery is mandatory; treat with urgency

• In all approaches: sac opened, contents inspected/reduced, defect closed (sutures or mesh plug). The lacunar ligament may need incision to aid reduction — beware an abnormal obturator artery branch ("Crown of Death").
• Laparoscopic repair (TAPP/TEP) is appropriate in selected elective cases.

UMBILICAL HERNIA

Classification

1. Exomphalos (Omphalocele)

• Congenital: abdominal contents protrude into the umbilical cord, covered by a transparent diaphanous membrane (not skin)
• A neonatal surgical emergency

2. Congenital (Infantile) Umbilical Hernia

• Occurs through the centre of a congenitally weak umbilical scar
• Common in premature infants and Black infants (incidence up to 8× higher than in white infants); affects up to 10% of infants
• Appears weeks after birth; increases on crying — classic conical shape
• Wide neck → obstruction/strangulation extremely rare (<3 years)
• Content: usually small intestine (resonant on percussion)
• 90–95% resolve spontaneously by age 2–5 years as the umbilical scar thickens

• Conservative (reassurance) if <2 years and asymptomatic
• Surgical repair if persists beyond age 2: curved infra-umbilical incision, sac excised, defect closed with interrupted slowly absorbable sutures

3. Acquired (True) Umbilical Hernia in Adults

• Protrudes through the umbilical scar itself
• Rarer than para-umbilical hernia
• Causes: pregnancy, ascites, bowel distension, ovarian cyst, fibroid (any cause of raised intra-abdominal pressure)
• Always seek the underlying cause of raised IAP

4. Umbilical Hernia in Adults — Clinical Features (includes paraumbilical)

• Seen in overweight men (thinned midline raphe) or postpartum women
• Bulge typically slightly to one side, creating a crescent-shaped umbilicus
• Pain from tissue tension or intermittent bowel obstruction
• Large hernias: overlying skin becomes thin; ulceration possible; spontaneous rupture extremely rare
• Narrow neck relative to sac size → prone to become irreducible, obstructed, strangulated

• High strangulation risk → surgery advised when hernia contains bowel
• Small asymptomatic hernias may be observed but may enlarge
• Mayo repair ("waistcoat over trousers" overlap): transverse incision, sac opened/reduced, fascial edges overlapped with non-absorbable sutures — for defects ≤2 cm
• Mesh repair is recommended for all defects >2 cm and is now preferred even for smaller defects (lower recurrence)
• Open or laparoscopic approaches both acceptable
• Pregnancy: avoid repair before/during pregnancy; postpartum women should exercise and lose weight first

PARA-UMBILICAL HERNIA

Definition

Under current guidelines, any hernia in the immediate vicinity of the umbilicus is now termed "umbilical." The distinction "paraumbilical" remains clinically useful, however.

Who Gets It?

• Middle-aged to elderly patients
• Obese women predominantly affected
• Conditions thinning the linea alba: obesity, pregnancy, liver disease with ascites

Clinical Features

1. Develops in middle and old age
2. Obese women most commonly affected
3. Symptoms: pain and swelling — if very small, pain/discomfort may be the only complaint
4. Surface smooth, edge distinct (unless patient is very obese)
5. Contents:
   • Omentum → firm lump
   • Bowel → soft, resonant on percussion
6. Many are irreducible — contents adhere to sac, or neck becomes narrow; if reducible, the firm fibrous edge of the linea alba defect can be palpated
7. Intermittent abdominal pain common due to rigid, non-expanding defect; frank strangulation is less common but possible

Treatment

• Mayo repair for small defects (≤2 cm) — fascial overlap with non-absorbable sutures
• Mesh repair for larger defects and preferred overall given recurrence data
• Laparoscopic repair is an option

Key Comparison Summary