Femoral Hernias: Analysis of Preoperative Risk

Factors and 30-Day Outcomes of Initial Groin

Hernias Using ACS-NSQIP
BARRET HALGAS, M.D.,* JENNIFER VIERA, M.D.,* JOSHUA DILDAY, D.O.,* JULIA BADER, PH.D.,*
DANIELLE HOLT, M.D.†

From the *William Beaumont Army Medical Center, El Paso, Texas; and †Walter Reed National Military
Medical Center, Bethesda, Maryland

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to
describe the natural history of femoral hernias by evaluating patient demographics, comorbid-
ities, operative details, 30-day mortality, and risk factors for postoperative complications com-
pared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral
hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American
College of Surgeon-National Surgical Quality Improvement Program’s database. Univariate
analysis was used to compare patient characteristics between femoral and inguinal hernias
and between reducible and nonreducible femoral hernias. Multivariable logistic regression
analyses were used to identify risk factors for 30-day postoperative complications after repair.
Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin
hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and
these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001),
exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%,
P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible
femoral hernias. There were significantly higher rates of unplanned return to the OR, post-
operative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral
hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias
present more commonly incarcerated in patients with significant comorbid diseases and are
associated with significantly increased rates of systemic, local, major, and minor complica-
tions, return to OR, and mortality. Careful consideration should be given for the evaluation of
intestinal viability in the acute setting.

F EMORAL HERNIAS ARE infrequently encountered,

representing between 2 and 8 per cent of all groin
hernias in adults. Although rare, they comprise nearly
30 per cent of groin hernias in the female population.1–4
By contrast, inguinal hernias are commonly seen
and classically present as a bulge above the inguinal
ligament. Femoral hernias typically extend below the
inguinal ligament and result from a protrusion of intra-
abdominal contents through the femoral ring.1, 2 They are
rarely found in children, which supports an acquired
etiology.1 More than half occur in the right groin for
unknown reasons.3, 5 Accurately diagnosing a femoral
Address correspondence and reprint requests to Barret Halgas,
M.D., Department of General Surgery, 5005 N Piedras Street, El
Paso, TX 79920. E-mail: barret.j.halgas.mil@mail.mil.
Disclaimer: The views expressed in this document are those of
the authors and do not reflect the official policy of William
Beaumont Army Medical Center, the Department of the Army, or
the United States Government.
hernia can be challenging and diagnosis is made only
after discovery in the operating room.4, 6 For all groin
hernias, morbidity and mortality increase in the setting of
incarceration and/or strangulation, and femoral hernias
are reported to have the highest rates of incarceration
and strangulation. Femoral hernias that have been de-
scribed containing the appendix are termed De Garengeot
hernias.
Multiple approaches for surgical repair of femoral
hernias have been described which emphasize re-
duction of the abdominal contents, ligation of the
hernia sac, and closure of the femoral defect.1 Despite
approximately 30,000 femoral hernia operations be-
ing performed annually in the United States,7 there
are no evidence-based guidelines regarding the op-
erative approach for repair. Several authors recom-
mend laparoscopic repair of initial groin hernias in
females in the nonemergent setting8; however, there
is little or no information available on the optimal

1455
1456 THE AMERICAN SURGEON
repair for an acutely incarcerated femoral hernia. We
performed a query of more than 188,000 patients with
initial groin hernias identified by the American Col-
lege of Surgeon-National Surgical Quality Improve-
ment Program’s (ACS-NSQIP) database, which is
the largest study of its kind to date. Our primary ob-
jective was to describe the natural history of femoral
hernias compared with inguinal hernias to assist in the
acute diagnosis and characterization of the patients
who present with these rare groin hernias. Our sec-
ondary objective was to evaluate risk factors for
postoperative complications to gain further insight
into the outcomes and associated surgical procedures
performed.
Methods
Data Collection
Local approval from the Institutional Review Board
was obtained before data collection and analysis. A
retrospective analysis of the ACS-NSQIP was used
for the purposes of this study. The ACS-NSQIP da-
tabase includes prospectively collected data from
more than 250 U.S. hospitals. The data is entered
by ACS-trained and certified clinical reviewers and
audited for accuracy. The ACS-NSQIP database ob-
tains data on more than 300 variables, including:
patient demographics, preoperative comorbidities,
laboratory values, intraoperative details, and 30-day
postoperative mortality and morbidity of patients
undergoing major surgery in academic and com-
munity hospitals. Each hospital collects data on
a random sample of patients undergoing a surgical
procedure under general or regional anesthesia. This
is usually performed by capturing the first 40 patients
from a rotating 8-day cycle. No more than 1600 pa-
tients are enrolled annually from each hospital. In
addition, certain procedures within each surgical
specialty are “targeted,” which aims for a 100 per
cent capture rate of certain procedures with higher
complication rates. ACS-NSQIP captures 30-day post-
operative occurrences in five categories: wound (super-
ficial, deep, organ-space surgical site infections, and
dehiscence), respiratory (pneumonia, unplanned in-
tubation, pulmonary embolism, and intubated >48
hours), urinary (progressive renal insufficiency, acute
renal failure requiring dialysis, and urinary tract in-
fection), central nervous system (cerebral vascular
accident, coma >24 hours, and peripheral nerve in-
jury), cardiac (cardiac arrest requiring CPR and
myocardial infarction), and other (postoperative
blood transfusions, deep venous thrombosis, sepsis/
septic shock, and graft/flap failure). This study uses
public use files including patients with inguinal or
femoral hernias between 2005 and 2015.
September 2018 Vol. 84
Cases were grouped into two cohorts, inguinal her-
nia and femoral hernia, based on CPT code. Only
initial inguinal hernia and femoral hernia cases were
included. Cases were queried to include open reducible
inguinal hernia (CPT 49505), open incarcerated in-
guinal hernia (CPT 49507), sliding inguinal hernia
(CPT 49525), laparoscopic inguinal hernia (CPT
49650), reducible femoral hernia (49550), and in-
carcerated femoral hernia (CPT 49553). Differences in
demographics, comorbidities, and associated pro-
cedures were compared between cohorts. All femoral
hernias were further divided into reducible femoral
hernias and incarcerated femoral hernias. Differences
in demographics, comorbidities, and associated pro-
cedures were compared between these cohorts as well.
Statistical Analysis
The statistical analysis was designed to determine
the difference in morbidity and mortality between in-
guinal hernia and femoral hernia cohorts and between
reducible femoral hernia and incarcerated femoral
hernia cohorts. The likelihood of developing an ACS-
NSQIP–defined postoperative occurrence for each
approach was also analyzed. Postoperative occurrences
were defined as major systemic (pulmonary embolism,
unplanned intubation, intubation >48 hours, sepsis/septic
shock, stroke/cerebrovascular accident, acute renal fail-
ure, myocardial infarction, cardiac arrest requiring CPR,
and coma), minor systemic (urinary tract infection, deep
venous thrombosis, pneumonia, and progressive renal
insufficiency), major local (deep/organ space SSI, pe-
ripheral nerve injury, and graft/prosthesis failure), and
minor local (superficial SSI and wound disruption). Pa-
tient characteristics were compared using the chi-square
test for binary and categorical variables and Student’s t
test for continuous variables. Univariate logistic re-
gression analysis was used to test the effect of individual
risk factors on 30-day overall complications after femoral
hernia repair. The initial risk factors included age, gender,
body mass index (BMI), functional status (dependent
versus independent), wound classification (all others
versus clean), American Society of Anesthesiologists
(ASA) classification (1 or 2 versus 3 or 4), recent weight
loss, smoking, regular alcohol use, diabetes, dyspnea,
chronic obstructive pulmonary disease, ascites, hyper-
tension, cardiac disease, bleeding disorder, wound in-
fection, sepsis within 48 hours before surgery, steroid use
for chronic condition, preoperative blood transfusion,
total number of comorbidities, operative time, and time
from operation to discharge. Factors with a P-value of
less than 0.2 in the initial univariate logistic regression
underwent subsequent multivariable logistic regression
analysis. Odds ratio, 95 per cent confidence intervals
were reported for significant factors with P-values of less
No. 9 FEMORAL HERNIAS: ANALYSIS OF RISKS AND OUTCOMES
than 0.05. There were 185, 3833, 801, 18, and three
missing entries for gender, BMI, functional status, ASA
classification, operative time, and time from operation to
discharge, respectively. All analyses were performed
using SAS (SAS Institute Inc., Cary, NC).
Results
Overall, 5360 femoral hernias and 183,173 inguinal
hernias were identified in the ACS-NSQIP database
between 2005 and 2015 (Table 1). Femoral hernias
accounted for 2.8 per cent of all initial groin hernias and
18.9 per cent of hernias in females. Of all initial en-
counters for femoral hernias, 75.8 per cent were female,
with an overall mean age of 63.9 years. Of all initial
encounters for inguinal hernias, only 9.5 per cent were
female with a mean age of 57.1 years. At the time of
initial presentation, 56.5 per cent of initial femoral
hernias were nonreducible. These patients were signif-
icantly older compared with patients with reducible
femoral hernias (67.4 vs 59.4 years, P < 0.0001).
Patients presenting with femoral hernias had statis-
tically higher rates of medical comorbidities to include
recent weight loss, dyspnea, COPD, ascites, congestive
heart failure, bleeding disorders, sepsis, and steroid
use. Patients with femoral hernias compared with in-
guinal hernias were more likely to be characterized as
ASA 3 or 4 (35.7% vs 25.2%, P < 0.0001), with 43.1
per cent of patients with incarcerated femoral hernias
being ASA 3 or 4. There was a significantly elevated
rate of sepsis within 48 hours before surgery in patients
with incarcerated femoral hernias compared with re-
ducible femoral hernias (10.4% vs 1.4%, P < 0.0001).
The sepsis variable includes systemic inflammatory
response syndrome (SIRS), sepsis, and septic shock
and is defined by either a positive blood culture or
suspected preoperative infection or bowel infarction.
This included ischemic/infarcted bowel, purulence at
the operative site, enteric contents in the operative site,
or positive intraoperative cultures.
Postoperative hospital stay was statistically longer
for femoral hernias compared with inguinal hernias
(1.7 vs 0.3 days, P < 0.0001) and for incarcerated
femoral hernias compared with reducible femoral hernias
(2.5 vs 0.6 days, P < 0.0001). Sepsis as a postoperative
occurrence that was identified as present at time of sur-
gery was significantly elevated in femoral hernias com-
pared with inguinal hernias (0.4% vs <0.1%, P < 0.001)
and was due entirely to incarcerated femoral hernias.
Patients with femoral hernias were more likely to have
other associated procedures compared with patients with
inguinal hernias to include excisional biopsy of superfi-
cial lymph nodes (1.2% vs 0.1%, P < 0.0001), explor-
atory laparotomy (1.6% vs 0.1%, P < 0.0001), exploratory
laparotomy with small bowel resection (3.4% vs 0.1%,
? Halgas et al. 1457
P < 0.0001), and diagnostic laparoscopy (1.4% vs
0.3%, P < 0.0001). The rates of small bowel resection
(5.7% vs 0.3%, P < 0.0001), exploratory laparot-
omy (2.5% vs 0.4%, P < 0.0001), and diagnostic lapa-
roscopy (2.0% vs 0.7%, P < 0.0001) were significantly
higher in the incarcerated femoral hernia group com-
pared with the reducible femoral hernia group (Table 2).
The incidence of major (2.8% vs 0.5%, P < 0.0001),
and minor (3.0% vs 0.7%, P < 0.0001) systemic
complications were statistically higher in the femoral
hernia group compared with the inguinal hernia group
(Table 3). The most common major systemic compli-
cation in femoral hernias compared with inguinal
hernias was postoperative sepsis (1.5% vs 0.2%, P <
0.0001). Major (0.6% vs 0.1%, P < 0.0001), and minor
(1.8% vs 0.4%, P < 0.0001) local complications were
significantly higher in the femoral hernia group com-
pared with the inguinal hernia group. Pneumonia was
the most common minor systemic complication in
femoral hernias compared with inguinal hernias (1.6%
vs 0.2%, P < 0.0001). Surgical site infection and
wound disruption accounted for most minor local
complications.
A significantly higher percentage of femoral hernias
compared with inguinal hernias had unplanned returns
to the OR (2.2% vs 0.7%, P < 0.0001) and incarcerated
femoral hernias compared with reducible femoral hernias
(3.1% vs 0.9%, P < 0.0001). Most patients who returned
to the ORrequired either intra-abdominal assessment of
bowel viability by laparotomy or laparoscopy or bowel
resection with either primary anastomosis or ostomy
(Table 4).
The 30-day mortality after repair was significantly
higher for femoral hernias compared with inguinal
hernias (1.2% vs 0.2%, P < 0.0001) and in the non-
reducible femoral hernia group compared with the
reducible femoral hernia group (1.9% vs 0.3%, P <
0.0001). Based on the multivariate logistic regression
results, six risk factors were statistically predictive of
overall 30-day complications for femoral hernias (Table 5).
Discussion
Based on our study, first-time femoral hernia pa-
tients statistically tend to be female, older, sicker, and
presenting with an incarcerated hernia. They will more
frequently require an emergency operation with higher
rates of bowel resection, postoperative complications,
and death.
Patients with femoral hernias have a higher in-
cidence of recent weight loss, dyspnea, COPD, as-
cites, and congestive heart failure. Dyspnea, COPD,
and ascites can lead to a state of elevated intra-
abdominal pressure and have been thought to ac-
celerate the progression of groin hernias, although
1458 THE AMERICAN SURGEON September 2018 Vol. 84

TABLE 1. Patient Demographics: Inguinal vs Femoral Groin Hernias and Reducible vs Nonreducible Femoral Hernias
Groin Hernias Femoral Hernias
Variables Inguinal Femoral P-Value Reducible Incarcerated P-Value
Demographics
Number, (%) 183,173 (97.2) 5360 (2.8) 2330 (43.5) 3030 (56.5)
Age, years, mean ± SD 57.1 ± 16.8 63.9 ± 17.2 <0.0001 59.4 ± 17.2 67.4 ± 16.4 <0.0001
Gender, N (%)
Male 165,615 (90.5) 1298 (24.2) <0.0001 576 (24.7) 722 (23.8) 0.447
Female 17,377 (9.5) 4058 (75.8) <0.0001 1752 (75.3) 2306 (76.2) 0.447
BMI, kg/m2 mean ± SD 26.7 ± 4.7 23.6 ± 4.7 <0.0001 23.8 ± 4.7 23.5 ± 4.7 0.0643
Functional status, N (%)
Independent 180,648 (99.0) 5124 (96.0) <0.0001 2292 (98.6) 2832 (94.0) <0.0001
Dependent 1746 (1.0) 214 (4.0) <0.0001 32 (1.4) 182 (6.0) <0.0001
ASA classifcation, N (%)
No/mild disturbance 136,648 (74.8) 3432 (64.3) <0.0001 1712 (74.1) 1720 (56.9) <0.0001
Severe disturbance/life threatening 46,012 (25.2) 1902 (35.7) <0.0001 600 (25.9) 1302 (43.1) <0.0001
Medical comorbidites, N (%)
Recent weight loss (>10%/six months) 627 (0.3) 68 (1.3) <0.0001 18 (0.8) 50 (1.7) 0.0044
Smoking 34,509 (18.8) 1043 (19.5) 0.2532 477 (20.5) 566 (18.7) 0.1004
Diabetes 12,935 (7.1) 243 (4.5) <0.0001 102 (4.4) 141 (4.7) 0.6304
Dyspnea 7028 (3.8) 336 (6.3) <0.0001 120 (5.2) 216 (7.1) 0.0031
COPD 5444 (3.0) 463 (8.6) <0.0001 155 (6.7) 308 (10.2) <0.0001
Ascites 497 (0.3) 43 (0.8) <0.0001 6 (0.3) 37 (1.2) <0.0001
Hypertension 67,156 (36.7) 2031 (37.9) 0.0657 742 (31.9) 1289 (42.5) <0.0001
Congestive heart failure 691 (0.4) 77 (1.4) <0.0001 14 (0.6) 63 (2.1) <0.000
Dialysis use/renal failure 1239 (0.7) 32 (0.6) 0.4838 8 (0.3) 24 (0.8) 0.0475
Bleeding disorder 4645 (2.5) 286 (5.3) <0.0001 63 (2.7) 223 (7.4) <0.0001
Systemic sepsis 1227 (0.7) 349 (6.5) <0.0001 33 (1.4) 316 (10.4) <0.0001
Steroid use for chronic condition 3008 (1.6) 150 (2.8) <0.0001 50 (2.2) 100 (3.3) 0.0111
SD, standard deviation.

TABLE 2. Operative Details and Associated Procedures: Inguinal vs Femoral Groin Hernias and Reducible vs Nonreducible
Femoral Hernias
Groin Hernias Femoral Hernias
Variables Inguinal Femoral P-Value Reducible Incarcerated P-Value
Operative details, N (%)
Operative time, minutes, mean ± SD 63.5 ± 35.7 56.3 ± 33.7 <0.0001 52.1 ± 30.6 59.6 ± 35.6 <0.0001
Operation to discharge time, days, mean ± SD 0.3 ± 2.1 1.7 ± 4.2 <0.0001 0.6 ± 3.4 2.5 ± 4.6 <0.0001
Postoperative sepsis PATOS 21 (<0.1) 12 (0.4) <0.0001 0 (0) 12 (0.7) 0.0021
Associated procedures, N (%)
Excisional biopsy of superficial lymph node 190 (0.1) 63 (1.2) <0.0001 41 (1.8) 22 (0.7) 0.0005
Exploratory laparotomy with resection 114 (0.1) 180 (3.4) <0.0001 8 (0.3) 172 (5.7) <0.0001
Exploratory laparotomy 231 (0.1) 86 (1.6) <0.0001 10 (0.4) 76 (2.5) <0.0001
Diagnostic laparoscopy 534 (0.3) 76 (1.4) <0.0001 16 (0.7) 60 (2.0) <0.0001
PATOS, present at time of surgery.

the evidence is weak.9, 10 As expected, patients with
at least three comorbidities were four times more
likely to undergo a complicated postoperative course.
The diagnosis of systemic sepsis before surgery was
significantly higher in the femoral hernia group, likely
reflecting the higher rates of incarceration and
strangulation.
Unlike inguinal hernias which are often repaired
early in an elective setting, femoral hernias more
commonly present acutely requiring emergent re-
pair. The femoral canal is a space created by the rigid
confluence of fascial and ligamentous structures
which explains the higher rate of incarceration
compared with other groin hernias.1 Prior studies
have suggested 35 to 40 per cent of femoral hernias
present incarcerated with or without strangulation.8
In our study, a much higher percentage (55%) of
femoral hernias were nonreducible on presentation
and 5 per cent progressed to strangulation requiring
a bowel resection. The actual number is possibly
closer to 8 per cent because patients that were coded
for exploratory laparotomy may have also un-
dergone a resection as well. Other studies have
found even higher rates of resection.8, 11, 12 An ac-
ceptable repair should provide adequate visualiza-
tion of the compromised segment of bowel and
No. 9 FEMORAL HERNIAS: ANALYSIS OF RISKS AND OUTCOMES ? Halgas et al. 1459

TABLE 3. Morbidity and Mortality: Inguinal vs Femoral Groin Hernias and Reducible vs Nonreducible Femoral Hernias
Groin Hernias Femoral Hernias
Inguinal N (%) Femoral N (%) P-Value Reducible N (%) Incarcerated N (%) P-Value
Overall complications 2698 (1.5) 333 (6.2) <0.0001 67 (2.9) 266 (8.8) <0.0001
Major systemic complications 924 (0.5) 149 (2.8) <0.0001 12 (0.5) 137 (4.5) <0.0001
Pulmonary embolism 108 (0.1) 15 (0.3) <0.0001 2 (0.1) 13 (0.4) 0.0597
Unplanned intubation 236 (0.1) 46 (0.8) <0.0001 4 (0.2) 42 (1.4) <0.0001
Ventilator >48 hours 166 (0.1) 35 (0.6) <0.0001 0 (0) 35 (1.2) <0.0001
Postoperative sepsis/septic 363 (0.2) 82 (1.5) <0.0001 5 (0.2) 77 (2.5) <0.0001
shock
Stroke/cerebrovascular 80 (0.1) 8 (0.2) <0.0001 1 (0.1) 7 (0.2) 0.2019
accident
Acute renal failure 92 (0.1) 8 (0.2) 0.0078 0 (0) 8 (0.3) 0.0131
Cardiac arrest requiring CPR 83 (0.1) 10 (0.2) <0.0001 1 (0.1) 9 (0.3) 0.0505
Myocardial infarction 145 (0.1) 11 (0.2) 0.0053 0 (0) 11 (0.4) 0.0036
Coma 5 (<0.1) 2 (0.1) <0.0001 0 (0) 2 (0.1) 0.5064
Minor systemic complications 1224 (0.7) 163 (3.0) <0.0001 31 (1.3) 132 (4.4) <0.0001
Urinary tract infection 631 (0.3) 64 (1.2) <0.0001 18 (0.8) 46 (1.5) 0.0127
Deep venous thrombosis 185 (0.1) 24 (0.5) <0.0001 3 (0.1) 21 (0.7) 0.0022
Pneumonia 386 (0.2) 86 (1.6) <0.0001 10 (0.4) 76 (2.5) <0.0001
Progressive renal insuffiiency 107 (0.1) 5 (0.1) 0.2539 0 (0) 5 (0.2) 0.0731
Major local complications 222 (0.1) 32 (0.6) <0.0001 6 (0.3) 26 (0.9) 0.0047
Deep wound infection/organ 206 (0.1) 30 (0.6) <0.0001 5 (0.2) 25 (0.8) 0.037
or space SSI
Peripheral nerve injury 11 (<0.1) 2 (0.1) 0.0536 1 (0.1) 1 (0.1) 0.8705
Minor local complications 776 (0.4) 95 (1.8) <0.0001 24 (1.0) 71 (2.3) 0.0003
Superficial wound infection 685 (0.4) 77 (1.4) <0.0001 21 (0.9) 56 (1.9) 0.0039
Wound disruption 96 (0.1) 21 (0.4) <0.0001 5 (0.2) 16 (0.5) 0.0686
Return to OR 1332 (0.7) 116 (2.2) <0.0001 21 (0.9) 95 (3.1) <0.0001
Major complications 1073 (0.6) 166 (3.1) <0.0001 17 (0.7) 149 (4.9) <0.0001
Minor complications 1976 (1.1) 248 (4.6) <0.0001 55 (2.4) 193 (6.4) <0.0001
Mortality 357 (0.2) 62 (1.2) <0.0001 6 (0.3) 56 (1.9) <0.0001

TABLE 4. Return to the OR after Initial Repair of Incarcerated Femoral Hernias

Type of Procedure Frequency, n (%) CPT Codes
Wound complications 7 (7.37) 10060, 10140, 11008, 26990
Intra-abdominal evaluation 15 (13.7) 49000, 49002, 49320, 49557
Bowel resection or ostomy 19 (20.0) 44005, 44120, 44125, 44144, 44202, 44615
Miscellaneous 9 (9.47) 27245, 27337, 27687, 35840, 36558, 47563, 49505, 49507, 51860
Missing information 45 (47.4)

TABLE 5. Significant Risk Factors for 30-Day Overall Complications for Femoral Hernias as Determined By Multivariable
Logistic Regression Analysis
Risk Factor OR (95% CI) P-Value
Age (continuous) 1.03 (1.02, 1.04) <0.0001
Wound classification: all others vs clean 1.83 (1.37, 2.44) <0.0001
Sepsis within 48 hours before surgery 2.19 (1.48, 3.23) <0.0001
Total number of comorbidities: 3 vs 0 co-morbidites 2.50 (1.20, 5.19) 0.016
Operative time (continuous) 1.007 (1.004, 1.010) <0.0001
Time from operation to discharge (continuous) 1.07 (1.00, 1.15) 0.05

closure of the defect. Preperitoneal mesh repair, ei-
ther laparoscopic or open, has been shown to have
lower recurrence rates compared with open suture repair
in the elective setting,13 but equivalent results in the acute
setting.8 It is also well known that laparoscopic hernior-
rhaphy results in less postoperative pain, quicker return to
normal activities, and detection of synchronous groin
hernias.12, 14 For incarcerated or strangulated femoral
hernias, most surgeons are opting for an open suture re-
pair, followed by a Lichtenstein mesh repair, followed by
a laparoscopic mesh repair.8, 11 Aside from anecdotal
evidence, there are no superiority studies evaluating these
approaches. A limitation of using CPT codes is that we
could not determine how many femoral hernias were
approached laparoscopically or used mesh. The cases
that were coded as a concurrent diagnostic laparoscopy
1460 THE AMERICAN SURGEON
could have been truly diagnostic or possibly a laparo-
scopic repair as well.
We found statistically higher rates of both major and
minor complications after femoral hernia repairs. As
previously noted, these patients tend to be older with
multiple comorbidities. The high incidence of pneu-
monia and need for long-term ventilation after surgery
could demonstrate a general lack of physiological re-
serve in this patient population. Compared with in-
guinal hernias, the incidence of deep wound infections,
superficial wound infections, and wound disruption is
significantly higher after femoral hernia repairs. One
explanation could be the higher rate of associated is-
chemia which can create an infectious environment.
Another reason could be the type of repair that was
performed, although emerging data suggest that syn-
thetic mesh products are safe even in the setting of
bowel resection. These results are controversial at best.15–19
The increased rate of both postoperative local and
systemic complications suggests that the ideal repair
is one that quickly provides closure while allowing
for a visual assessment of bowel viability. A primary
tissue repair is an excellent alternative in this situa-
tion. Unfortunately, there is minimal exposure to
groin tissue repairs during surgical training. Femoral
hernias are relatively rare and when preoperatively
diagnosed are often approached laparoscopically.
From 2000 to 2011 there was a 10 per cent decrease in
open inguinal/femoral hernia operations performed
by residents in the United States.20, 21 In a survey of
graduating chief residents, only 24 per cent felt
comfortable independently performing a McVay
(Cooper’s ligament) repair.22 Our data found that 0.7
per cent of nonreducible femoral hernias also had
a diagnosis of sepsis at time of surgery; however, 2.5
per cent were diagnosed with postoperative sepsis
within 30 days of the index operation. One explana-
tion is that missed intestinal ischemia was instead
captured as postoperative systemic organ failure.
There were also statistically more reoperations after
incarcerated femoral hernia repairs compared with no
reoperations after reducible femoral hernia repairs.
Return to OR for incarcerated femoral hernias was
primarily performed for intra-abdominal assessment
with or without subsequent bowel resection or ostomy
creation. As such, surgeons should consider alternate
means for assessing bowel viability when repairing
an acute femoral hernia because more than 5 per cent
will require a bowel resection. We found a nearly 2
per cent mortality for nonreducible femoral hernias
which is significantly higher than the 0.2 per cent
seen in inguinal hernias. Surgeons must be aware of
the nearly 10-fold increase in mortality associated
with incarcerated femoral hernias for appropriate
patient counseling.
September 2018 Vol. 84
A major limitation to this study is that CPT codes do
not differentiate the type of repair performed by the
operating surgeon; therefore, we cannot draw conclu-
sions about the superiority of one technique over an-
other. In addition, the study was a retrospective analysis
and cannot be used to infer causal relationships. The
strength of this study is its large sample size and high
quality data from participating institutions in North
America. To our knowledge, this is the largest retro-
spective evaluation of femoral hernia characteristics
reported. Given the rare presentation of femoral hernias,
multicenter data would be required to determine the
optimal surgical approach to mitigate complications.
Conclusion
In the end, not all groin hernias are created equally.
Femoral hernias most often present in older and
sicker patients with the majority being incarcerated.
Almost half of these patients will present as an ASA 3
or 4, prompting collaboration with anesthesia to
create an appropriate plan. Patients with incarcerated
femoral hernias are statistically more likely to un-
dergo laparotomy with bowel resection, exploratory
laparotomy, or laparoscopy, with more than 10 per
cent requiring a secondary concurrent procedure. We
identified a greater than 10 per cent incidence in pre-
operative sepsis in the 48 hours before surgery in pa-
tients with incarcerated femoral hernias which could be
secondary to bacterial translocation as a result of bowel
ischemia. Patients with acutely incarcerated femoral
hernias should undergo a careful evaluation of bowel
viability. Although our data do not support a single repair
option, mesh products should be cautiously considered
and weighed against the risk of wound complications and
postoperative sepsis. Overall, femoral hernia patients
have almost a 2 per cent mortality, which should be used
to better counsel patients and their families. Given the
paucity of data regarding femoral hernias and their rel-
atively rare presentation, further multicenter studies
would be required for determining the optimal surgical
approach in the acute setting.
REFERENCES
1. Hachisuka T. Femoral hernia repair. Surg Clin 2003;83:
1189–205.
2. Glassow F. The surgical repair of inguinal and femoral her-
nias. Can Med Assoc J 1973;108:308.
3. Dabbas N, Adams K, Pearson K, et al. Frequency of ab-
dominal wall hernias: is classical teaching out of date? JRSM Short
Rep 2011;2:5.
4. Alimoglu O, Kaya B, Okan I, et al. Femoral hernia: a review
of 83 cases. Hernia 2006;10:70–3.
5. Sandblom G, Haapaniemi S, Nilsson E. Femoral hernias:
a register analysis of 588 repairs. Hernia 1999;3:131–4.
No. 9 FEMORAL HERNIAS: ANALYSIS OF RISKS AND OUTCOMES
6. Naude GP, Ocon S, Bongard F. Femoral hernia: the dire
consequences of a missed diagnosis. Am J Emerg Med 1997;15:
680–2.
7. Rutkow IM. Demographic and socioeconomic aspects of
hernia repair in the United States in 2003. Surg Clin North Am
2003;83:1045–51.
8. Dahlstrand U, Wollert S, Nordin P, et al. Emergency femoral
hernia repair: a study based on a national register. Ann Surg 2009;
249:672–6.
9. Carbonell JF, Sanchez JL, Peris RT, et al. Risk factors asso-
ciated with inguinal hernias: a case control study. Eur J Surg 1993;
159:481–6.
10. Lau H, Fang C, Yuen WK, et al. Risk factors for inguinal
hernia in adult males: a case-control study. Surgery 2007;141:
262–6.
11. Nilsson H, Stylianidis G, Haapamäki M, et al. Mortality
after groin hernia surgery. Ann Surg 2007;245:656–60.
12. Fitzgibbons RJ Jr, Forse RA. Clinical practice. Groin her-
nias in adults. N Engl J Med 2015;372:756–63.
13. Koch A, Edwards A, Haapaniemi S, et al. Prospective
evaluation of 6895 groin hernia repairs in women. Br J Surg 2005;
92:1553–8.
14. Putnis S, Wong A, Berney C. Synchronous femoral hernias
diagnosed during endoscopic inguinal hernia repair. Surg Endosc
2011;25:3752–4.
? Halgas et al. 1461
15. Pans A, Desaive C, Jacquet N. Use of a preperitoneal
prosthesis for strangulated groin hernia. Br J Surg 1997;84:310–2.
16. Atila K, Guler S, Inal A, et al. Prosthetic repair of acutely
incarcerated groin hernias: a prospective clinical observational
cohort study. Langenbecks Arch Surg 2010;395:563–8.
17. Bessa SS, Katri KM, Abdel-Salam WN, et al. Early results
from the use of the Lichtenstein repair in the management of
strangulated groin hernia. Hernia 2007;11:239–42.
18. Mauch J, Helbling C, Schlumpf R. Incarcerated and stran-
gulated hernias—surgical approach and management. Swiss Surg
1999;6:28–31.
19. Nieuwenhuizen J, Van Ramshorst GH, Ten Brinke JG, et al.
The use of mesh in acute hernia: frequency and outcome in 99
cases. Hernia 2011;15:297–300.
20. McCoy AC, Gasevic E, Szlabick RE, et al. Are open ab-
dominal procedures a thing of the past? An analysis of graduating
general surgery residents’ case logs from 2000 to 2011. J Surg
Educ 2013;70:683–9.
21. Carson JS, Smith L, Are M, et al. National trends in mini-
mally invasive and open operative experience of graduating gen-
eral surgery residents: implications for surgical skills curricula
development? Am J Surg 2011;202:720–6.
22. Gillman LM, Vergis A. General surgery graduates may be ill
prepared to enter rural or community surgical practice. Am J Surg
2013;205:752–7.
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.