Differential diagnosis of femoral hernia is a important question for medical

1. SMOLENSK STATE MEDICAL
UNIVERSITY
TOPIC: DIFFERENTIAL DIAGNOSIS OF FEMORAL
HERNIA
SUBMITTED BY: Penothil Bhadra Sudheer Dev
504

2. INTRODUCTION
• A hernia is an abnormal protrusion of an organ or tissue through an opening in the layer that
normally confines it.
• There are many varieties of hernia arising through areas of weakness in the abdominal wall.
• The common external hernia are: Inguinal , Femoral ,Umbilical , Incisional. Other rare :Epigastric,
Lumbar , Spigelian, Obturator , Gluteal.
• ETIOLOGY:
1. Weakness of the abdominal musculature can be either (a) congenital or (b) acquired.
2. Increased abdominal pressure: Whooping cough in children , Chronic cough in bronchitis,
tuberculosis , Bladder neck obstruction or urethral stricture, Enlarged prostate causing dysuria ,
Powerful muscular effort or straining during lifting heavy weight , Vomiting , Repeated pregnancy ,
Constipation.

4. FEMORAL HERNIA
• In this type of hernia abdominal
contents pass through the femoral
ring, traverses the femoral canal and
comes out through the saphenous
opening. Femoral hernia is most liable
to gel strangulated.

6. SURGICAL ANATOMY
Femoral canal is the innermost compartment of the 3 compartments of the femoral sheath. The
middle compartment of this sheath carries the femoral vein, while the outer compartment carries
the femoral artery.
 The femoral canal contains areolar tissue, fat, lymphatic vessels and the lymph node. It is closed
above by the femoral septum at the femoral ring. The femoral sheath is formed by two fascial layers.
Femoral canal is closed above by the femoral septum which is pierced by lymphatic vessels . The
femoral canal is closed downwards by the cribriform fascia which covers the saphenous opening. The
saphenous opening (or fossa ovalis) is an opening in the fascia lata situated and lateral to the pubic
tubercle.
 Femoral hernia comes out through the femoral ring, passes through the femoral canal and comes
out through the saphenous opening. After this it progresses upwards in the subcutaneous tissue of
the thigh and may even reach above the inguinal ligament.
 A fully distended femoral hernia assumes the shape of a retort with its bulbous extremity looking
upwards.

7. Coverings of the sac of the femoral hernia(From outside inwards ):
(i) The skin.
(ii) The superficial fascia.
(iii) The cribriform fascia.
(iv) The anterior layer of the femoral sheath.
(v) The fatty content of the femoral canal.
(vi) The femoral septum.
(vii) The peritoneum
Rare types of femoral hernia:
1. Prevascular hernia.
2. 2. Pectineal hernia
3. External femoral hernia.
4. Langier’s femoral hernia (Lacunar hernia)

8. SYMPTOMS
 Local symptoms:
(i) Pain
(ii) Swelling : It is usually a small globular swelling situated below and lateral to the pubic tubercle.
Such a swelling is more apparent on standing and on straining. It may disappear on lying down
 General symptoms:
If femoral hernia causes obstruction : abdominal colic, vomiting, abdominal distension and
constipation may be complained of. Femoral hernia is notorious due to its ability to strangulate quite
often. Even a part of the circumference of the bowel may be strangulated — Richter's hernia. In case
of strangulation patient suddenly gets pain at the local site which immediately spreads allover the
abdomen with vomiting.

10. 1.Local examination to differentiate from inguinal hernia from femoral hernia:
(a) Impulse on coughing by Zieman's technique the index finger is put over the deep
inguinal ring, the middle finger over the superficial inguinal ring and the ring
finger over the saphenous opening. The patient is asked to hold the nose and blow
or to cough. When impulse is felt on the index finger it is the indirect inguinal
hernia, when on the middle finger it is direct inguinal hernia and when on the
ring finger it is the femoral hernia.
(b) By invagination test one can detect that the inguinal canal is empty.
(c) Ring occlusion test : When the hernia is reduced, pressure is exerted over the
femoral canal and the patient is asked to cough, the hernia does not come out.
(d) Position : The neck of the hernial sac lies below the inguinal ligament and lateral
to the pubic tubercle, whereas an inguinal hernia is always above the inguinal
ligament and medial to the pubic tubercle.

11. 2. Lymphadenopathy or enlarged lymph node:
A search for a possible focus of infection should be made in the drainage area which
extends from the umbilicus down to the toes including the terminal portions of the anal
canal, urethra and vagina.
The gland of Cloquet lying within the femoral canal may be enlarged and simulates an
irreducible femoral hernia. If any focus cannot be found out or any cause of enlargement
of lymph nodes cannot be detected, the nature of the lump remains a matter of opinion
which is best settled urgently in the operation theatre.

12. 3. Saphena varix:
It is a saccular enlargement of the termination of the long saphenous vein. This
swelling usually disappears completely when the patient lies down. The so called
impulse on coughing is present in this condition as well, but it is actually a fluid thrill
and not an expansile impulse to the examining fingers.
4. Femoral aneurysm.— Expansile pulsation is the pathognomonic feature of this
condition.

13. 5.Psoas abscess: It is a reducible swelling and gives rise to impulse on coughing. It is a
painless swelling and if the pulsation of the femoral artery can be palpated it will be
appreciated that the swelling is lateral to the artery (femoral hernia which is medial
to the femoral artery). Sometimes there is an iliac part of the abscess which is
determined by cross-fluctuation. Examination of the back and corresponding iliac
fossa including X-rays clarifies the diagnosis.
6. Hydrocele of a femoral hernial sac: This is an extremely rare condition in which the
neck of the sac becomes plugged with omentum or by adhesions. The hydrocele of the
sac is thus produced by the secretion of the peritoneum.

14. 7. Undescended and ectopic testis:
An undescended testis is one which is arrested at
any point along its normal path of descent.
An ectopic testis is one which has deviated from its
usual path of descent. In both these conditions the
scrotum of the same side will be empty.
If the swelling is within the inguinal canal it is
probably an undescended testis. The testis is
recognized by its shape, feel and ‘testicular
sensation’.
Though the commonest position of ectopic testis is
at the superficial inguinal pouch, yet ectopic testis
may be found (i) at the root of the penis (pubic type),
(ii) at the perineum (perineal type) and (iii) rarely at
the upper and medial part of the femoral triangle
(femoral type).

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