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What is a femoral hernia?

A femoral hernia is relatively uncommon cause of a lump and occasionally pain in the groin. It is much more common in women than in men.

How does a hernia occur?

Hernias can occur from a defect at birth or from gradual weakening of the tissue. The abdominal wall muscles surround the stomach, intestines, and other organs. There is an opening in the groin on each side called the femoral canal. This opening is beside the large (femoral) vein draining blood from the leg. The space of the femoral canal allows the vein to expand to drain the blood from the leg when you are exercising or walking. The canal is larger in women than in men. Coughing, straining and pregnancy can cause weak spots in the femoral canal. This can result in the contents of the abdomen being pushed through the abdominal wall. When fat or bowel protrudes into this canal, it produces a lump called a hernia.

What might you notice?

At the start of your trouble you may have noticed a sudden pain in the groin. This is followed by a swelling, either immediately or a few weeks later. Sometimes this swelling may slide back on lying down, or may be pushed back. The hernia is called reducible when this happens, but if it cannot be pushed back it is irreducible.

How is the diagnosis made?

A diagnosis is usually by examination by a doctor. Sometimes the diagnosis may require special x-rays and /or scans (herniogram, ultrasound, CT or MRI).

Are there any alternatives to surgery?

Femoral hernias often become irreducible and present as a lump in the groin. A hernia will not go away without an operation. Surgery is, therefore, usually recommended, as it is the only dependable way to cure the condition.

What may happen if you decide not to have the operation?

A hernia is not dangerous in itself. However, very occasionally they can be dangerous when the intestines or other structures within the abdomen get trapped and have their blood supply cut off. This can cause a serious complication (strangulated hernia) which, if left untreated , will need a bigger and more risky operation to correct. If a femoral hernia left untreated, it is likely to get larger and to become irreducible. If the hernia becomes irreducible, it cannot be pushed back. It may become painful, tender and may be associated with redness of the overlying skin. Blockage of the bowel may result; this leads to bowel obstruction which causes vomiting and abdominal pain ( strangulated hernia). In this case you must seek medical help immediately. To prevent this happening it is usually recommended that most femoral hernias are surgically repaired.

What does the operation involve?

Femoral hernias can be repaired using the laparoscopic (‘keyhole’) technique or by an open cut in the groin.

Laparoscopic repair (Keyhole) is a relatively new technique although many thousands of patients have had a laparoscopic repair already. The operation will be carried out under a general anaesthetic. The hernia is pulled back through the gap in the muscles into its proper place inside the abdomen by a special instrument. A mesh is inserted over the gap in order to reinforce the wall of the abdomen. The mesh is simply placed over the hole or weakness (a bit like repairing a puncture in a tyre). The mesh is left in the body and acts as a permanent barrier to prevent the hernia from recurring.

This mesh, although it remains forever, causes few, if any, problems. The mesh is stitched in placed and the skin then closed.

Occasionally, it may not prove possible to proceed with the laparoscopic method, in these circumstances an open procedure will be carried out.

What can I do to help make the operation a success?

Lifestyle changes

If you smoke, try to stop smoking now. There is strong evidence that stopping smoking several weeks or more before a general anaesthetic reduces your chances of getting complications.

If you are overweight, losing weight will reduce your chances of developing complications.

Medication

You should continue your medication unless you are instructed otherwise.

If you are on warfarin or aspirin, you will need to stop taking it before the operation. Make sure your surgeon is aware you are on these drugs and follow the advice about stopping it.

Preparing for your operation

Before your operation you will be sent to appointment for the Pre-admission Clinic. It is very important that you attend. If you do not it could result in your operation being delayed or even cancelled.

What arrangements do you need to make?

You must be collected by a responsible adult and escorted home in a car or taxi. Public transport is not recommended.

You must have a responsible adult at home with you for 24 hours after your surgery.

You must not drink alcohol, operate machinery or cycle for the first 24 hours.

What to bring to hospital with you

Any tablets/pills/medication that you are currently taking

A washbag and overnight clothes in case of an overnight stay

A contact number for your lift home

Complications of Laparoscopic Surgery

Damage to internal organs- when placing instruments into the abdomen. This is rare (Risk 1 in 2,000). The risk is higher in patients who have previously had surgery to the abdomen. If an injury does occur, open surgery may be needed, which involves a much bigger cut. About 1 in 3 of these injuries are not apparent until after surgery, so if you have pain, which does not improve the day after surgery, you must let your doctor know.

Surgical emphysema- (Crackling sensation in the skin due to trapped gas), which settles quickly and is not serious.

Specific complications of this operation

Pain – A local anaesthetic may not numb the area quite enough and you may feel some minor discomfort. Also, in rare cases, you may have an allergic reaction to the drug used in this type of anaesthesia.

Numbness – There’s a small chance (risk 1 in 10) of pain or numbness in the groin and thigh area, caused by the handing of a nerve during surgery, or by the pressure on the nerves by scar tissue that forms during healing. This nearly always settles in a few weeks.

Wound Problems – The development of a lump under the wound after surgery. This is caused by a collection of blood or fluid and normally settles. If it is annoying, it can be removed by sucking up a needle.

Testicular swelling –The testicle may also swell after the surgery and be uncomfortable. This should settle but may take a few weeks to do so.

In men, if the artery in the inguinal canal is damaged, it could stop the testicle from producing semen, and/or it could leave a bruise on the scrotum.

A vas deferens may also be damaged. This could make a man sterile only if the other vas deferens were also hurt.

Bladder problems – Difficulty in passing urine which may need a catheter for a day or two (risk 1 in 100). Even if this doesn’t happen, the flow of water can take a week or so to return to normal.

Injury to structures within the hernia which come from the abdomen. This is rare but may need further surgery. If you have any severe abdominal pain or any other concerns, contact the healthcare team after the operation.

Recurrence of the hernia may occur. This may need a further operation.

These complications, like those of any operation, can result in permanent damage or death, but this is extremely rare.

Conversion from Keyhole to Open surgery – In a small number of cases, it is not possible to repair a hernia using the keyhole technique and a conventional incision may be necessary. Should this happen it will mean staying in hospital for 2-5 days and you may be off work up to 6 weeks.

What to expect afterwards

At home

Wound :- You should keep the wound dry for 5 days after surgery, although you may have a shower the day after your operation. You can protect it with a waterproof plaster or plastic film for bathing. There are often no stitches to remove. Ask if you are in doubt. Expect some numbness beneath the scar-this may persist for some weeks but sensation usually returns in time. Bruising around the wound or tracking down into the scrotum is common-this looks dramatic but is harmless and will settle without special treatment in a week or two.

You may have small plasters over your wounds. You may have a bath or a shower when you get home. The wounds may itch, but do not be tempted to touch or pick them. You can replace the plasters at home if you wish, although they should be removed at one week. There may be lot of bruising around the wounds and groin area, this is quite normal and usually disappears after 2 weeks.

The wound can bleed/ seep a little; particularly the umbilical wound. However, the bleeding is never serious and the dressings can be changed if this occurs. Occasionally the navel gets infected and continues to seep sticky fluid. Daily baths are recommended and unless the wound is bright red, antibiotics are not usually necessary.

A high fibre diet is recommended (plenty of fruit, vegetables and wholegrain cereals). This will help to avoid constipation which can cause straining of the wound and discomfort.

Pain Relief

Local anaesthetic is usually injected into the wound to minimize pain immediately after surgery; this lasts for 4-6 hours. You should take painkillers to take home and should take these regularly for the first few days. As the discomfort subsides you will need less pain relief but you may not be fully comfortable for 2-3 weeks. It can be helped by wearing close-fitting underwear.

Return to normal activities

When you go home, the simplest advice is “if it hurts, don’t do it, but if it doesn’t that’s ok”. Many patients simply move around the house for the first day or two but that is not essential. You may, therefore, return to normal activities when you feel comfortable to do so, usually after about one week. You do not need to avoid lifting but you may find it uncomfortable if you left heavy weights within the first two to four weeks.

What to watch out for after treatment?

There will be some discomfort and tenderness where the keyhole incision was made. If the wounds become reddened, painful or throbbing or a firm swelling appears then make an appointment to see your doctor to have the wound(s) checked. It is important that you try to walk normally from the first possible opportunity, and overcome the stoop, which comes rather naturally from having had an operation in that region of your body. Simple pain killing tablets will relieve most of the discomfort. It is usually advisable not to put excessive stress on the operated area for 2-3 weeks after the operation.

Work: If your work is sedentary and does not involve heavy lifting or strenuous exercise, then a return to work could be as soon as 5-14 days. If it does involve heavy lifting or strenuous exercise, then it is safer to wait for a further 2-3 weeks.

Driving

You are not insured to drive (depending on the local laws) unless you are confident that you can brake in an emergency and turn to look backwards for reversing without fear of pain in the wound. It is wise not to drive for 2-4 weeks, once you can get in and out of the bath unaided.

Exercise

It is safe to perform light duties immediately after the operation, but sensible to avoid heavy work for 2-3 weeks. By 3 weeks you should be able to do any activity you wish. Plenty of activity will aid healing and your recovery. You may resume sexual activity as soon as you are comfortable.

Summary

Hernias are a common condition best treated by surgery. If left untreated, they can occasionally cause serious complications. Surgery is very safe and effective. However, risks and complications can occur. You need to know about them to help you make an informed decision about surgery. Knowing about them will also help with early detection and treatment.