Femoral, Umbilical, and Paraumbilical Hernias

PART 1 — FEMORAL HERNIA

Definition

Femoral ring anatomy — S Das, Manual on Clinical Surgery

Right femoral hernia — laparoscopic view. Bailey & Love, 28th ed.

Etiology & Risk Factors

• Female sex — the female pelvis is wider, enlarging the femoral canal (femoral hernia is 2× more common in women; female:male ≈ 2:1). However, inguinal hernia remains the commonest groin hernia even in women.
• Age — rare before 20 years; incidence rises steadily and peaks over 50 years; elderly thin women are most commonly affected.
• Right side affected twice as frequently as the left; bilateral in 20% of cases.
• The rigid bony/ligamentous ring means this hernia strangulates very frequently.

Symptoms

• Swelling in the groin below and lateral to the pubic tubercle (symptoms are generally less pronounced than inguinal hernia)
• Pain and discomfort in the groin
• Symptoms of intestinal obstruction (colicky abdominal pain, vomiting, constipation) — because 50% present as an emergency with strangulation
• The hernia may be as small as 1–2 cm and easily missed

Diagnosis

• Swelling appears below and lateral to the pubic tubercle, below the inguinal ligament
• In late stages, the bulbous extremity may extend above the inguinal ligament, mimicking a direct inguinal hernia
• Cough impulse palpable at the saphenous opening (~4 cm below and lateral to the pubic tubercle)
• Invagination test: inguinal canal is empty — no hernia felt in the inguinal canal
• The hernia rapidly becomes irreducible and loses its cough impulse due to the tight neck

• Lies lateral to pubic tubercle and below inguinal ligament (inguinal hernia is medial and above)
• Pressure over the femoral canal/saphenous opening controls a femoral hernia; pressure over the deep inguinal ring stops indirect inguinal hernia

1. Saphena varix — disappears on lying down; fluid thrill (not expansile impulse); Schwartz's test positive
2. Enlarged inguinal lymph nodes (especially the node of Cloquet within the femoral canal)
3. Psoas abscess — cold abscess tracking from Pott's disease; lateral to femoral vessels
4. Femoral artery aneurysm — expansile pulsation
5. Psoas bursa — cystic, diminishes with hip flexion
6. Lipoma
7. Ruptured adductor longus with haematoma

• Routine elective cases: no specific investigations needed
• Uncertainty: ultrasound or CT scan
• Emergency (obstruction): plain abdominal X-ray (dilated bowel loops); CT to exclude malignancy and identify the hernia
• Any unexplained small bowel obstruction → careful examination for femoral hernia

Management

1. Low approach — Lockwood

• Simplest; suitable only when bowel resection is not anticipated
• Can be done under local anaesthesia
• Transverse incision over the hernia; sac contents reduced; sac reduced; inguinal ligament sutured to pectineal ligament
• Mesh plug may be placed for reinforcement
• Limitation: cannot perform bowel resection (anastomosis cannot be returned through the narrow canal)

2. Inguinal approach — Lotheissen

• Incision identical to Bassini/Lichtenstein; opens inguinal canal; mobilises spermatic cord; incises transversalis fascia into extraperitoneal space
• Hernia reduced by pulling from above and pushing from below; peritoneum can be opened if needed
• Defect closed with sutures, mesh plug, or flat mesh in preperitoneal plane
• Surgeon may also place inguinal mesh to protect against concomitant inguinal hernia

3. High (preperitoneal) approach — McEvedy / Nyhus modification

• Indicated when strangulation risk is high and bowel resection may be required
• Transverse incision just above the inguinal canal (Nyhus) → anterior rectus sheath incised → surgeon works in the preperitoneal space
• Bowel can be inspected, resected and anastomosed before being returned
• Can be extended for bilateral repair (Henry's approach)
• Requires regional or general anaesthesia

4. Laparoscopic approach (TEP or TAPP)

• Ideal for elective reducible femoral hernias
• Recommended in women because laparoscopy visualises all hernia orifices, removing diagnostic uncertainty and reducing early recurrence from misdiagnosis
• Increasing reports of TAPP in the emergency setting

PART 2 — UMBILICAL HERNIA

Definition & Classification

Umbilical Hernia in Children (Congenital)

Etiology / Risk Factors

• Failure of the umbilical ring to close normally after cord healing
• Occurs in up to 10% of infants; higher in premature babies
• Black infants affected up to 8× more than white infants
• Sexes equally affected

Symptoms

• Swelling at the umbilicus, prominent on crying
• Classic conical shape on straining
• Usually symptomless
• Obstruction/strangulation extremely uncommon under age 3

Diagnosis

• Clinical: bulge through the centre of the umbilical scar, everts the umbilicus
• Resonant to percussion (small bowel content)
• Easily reducible; spontaneously reduces when child lies down; definite impulse on crying
• Defect size: tip of little finger to 2–3 fingers' breadth

Management

• Conservative under age 2: parental reassurance; 95% resolve spontaneously (the umbilical scar thickens and contracts within 5 years)
• Surgery if persists beyond age 2:
  • Curved incision below umbilicus
  • Sac neck defined, opened, contents reduced
  • Sac closed and redundant sac excised
  • Defect closed with interrupted slowly absorbable sutures

Umbilical / Paraumbilical Hernia in Adults

Definition

Etiology & Risk Factors

• Obesity — most important risk factor
• Pregnancy and postpartum — stretching of the midline raphe
• Liver cirrhosis with ascites — raised intra-abdominal pressure + impaired tissue healing
• Other causes of raised intra-abdominal pressure: bowel distension, ovarian cyst, fibroid
• Paraumbilical hernia is the commonest acquired umbilical hernia; develops in middle and old age; obese women most commonly affected

Symptoms

• Pain (tissue tension or intermittent bowel obstruction symptoms) — main complaint
• Swelling at or adjacent to the umbilicus
• In small hernias, swelling may be imperceptible and pain/discomfort is the dominant complaint
• In large hernias: overlying skin becomes thin, may develop irritation and ulceration
• The hernia is firm when containing omentum; soft and resonant when containing bowel

Diagnosis

• Clinical:
  • Bulge typically slightly to one side of the umbilical depression, creating a crescent-shaped umbilicus
  • Smooth surface with distinct edge (unless patient is obese)
  • Paraumbilical hernia: firm fibrous edge of the linea alba defect palpable when hernia is reduced
  • Many paraumbilical hernias are irreducible (contents adherent to sac or narrow neck)
  • Women > men affected
• Complications: Because the neck is narrow relative to sac size, they are prone to incarceration, obstruction, and strangulation

Management

• Hernia containing bowel → surgery strongly advised (high strangulation risk)
• Small asymptomatic hernias may be observed but tend to enlarge
• Postpartum women: encourage weight loss and abdominal exercises first; avoid surgery before/during pregnancy

• Defects < 1 cm: simple suture repair, provided no tension
• Defects up to 2 cm — Mayo repair: transverse incision; sac dissected, opened, contents reduced; peritoneum closed; fascial edges closed in overlapping "waistcoat over trousers" fashion with non-absorbable sutures
• Defects > 2 cm: mesh repair is advised (current evidence recommends mesh even for smaller defects given high recurrence without it)

• Camera port + two lateral working ports
• Contents reduced by traction and external pressure
• Falciform ligament and median umbilical fold taken down for smooth surface
• Intraperitoneal mesh (non-adherent) introduced and fixed with staples/tacks/sutures
• Preferred in obese patients, those with rectus divarication, and multiple ventral defects
• Fewer wound complications but requires expensive tissue-separating mesh; potential for bowel adhesion/erosion

• Cirrhosis (Child's B/C): Very high surgical morbidity/mortality; requires hepatology input; fine continuous fascial sutures to minimise post-op ascites leak; mesh avoided in contaminated field
• Emergency (strangulation): Open surgery preferred; avoid mesh in established strangulation (infection risk); suture repair now with definitive mesh repair later

PART 3 — PARAUMBILICAL HERNIA (Summary)

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