About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Protrusion through the femoral canal — below and lateral to the pubic tubercle (vs inguinal = above and medial)
- Femoral hernias are less common than inguinal but have a MUCH higher strangulation risk (~22–45%)
- More common in WOMEN (but inguinal hernias are still the commonest groin hernia in both sexes)
- ALL femoral hernias should be repaired (even if asymptomatic) due to high strangulation risk
- Borders of the femoral canal: inguinal ligament (anterior), pectineal ligament (posterior), lacunar ligament (medial), femoral vein (lateral)
Overview
A femoral hernia protrudes through the femoral canal, which lies medial to the femoral vein within the femoral sheath. The femoral canal is a narrow rigid space bounded by the inguinal ligament anteriorly, the pectineal ligament posteriorly, the lacunar ligament medially, and the femoral vein laterally. The rigidity of these boundaries means that herniated contents are at high risk of becoming irreducible and strangulated. Contents are usually omentum or small bowel. Richter's hernia (partial circumference of bowel wall incarcerated) is particularly associated with femoral hernias.
Epidemiology
Femoral hernias account for approximately 5% of all abdominal wall hernias but ~40% of emergency hernia repairs (reflecting their high strangulation rate). They are more common in women than men (4:1), particularly multiparous and elderly women, but inguinal hernias remain the commonest groin hernia even in women. Risk of strangulation is 22–45%, compared to <5% for inguinal hernias. This high complication rate justifies repair of all femoral hernias regardless of symptoms.
Clinical Features
Symptoms
Small groin lump below the inguinal ligament (may be intermittent or persistent)
Often asymptomatic or mild groin discomfort
First presentation may be as bowel obstruction (SBO) — especially in elderly women
Signs
Lump below and lateral to pubic tubercle (key differentiator from inguinal hernia)
Small, firm, often non-reducible
Absent cough impulse (if incarcerated)
Tender, irreducible with overlying erythema (strangulation)
Investigations
First-line
Clinical diagnosisBased on position relative to pubic tubercle and inguinal ligament
USS groinIf diagnostic uncertainty — differentiate from inguinal hernia, lymphadenopathy, saphena varix, lipoma
Second-line
CT abdomen/pelvisIf presenting with bowel obstruction — identifies incarcerated femoral hernia as the cause
Management
European Hernia Society Guidelines1
Elective repair (ALL femoral hernias)
- ALL femoral hernias should be repaired due to high strangulation risk — even asymptomatic ones
- Open approaches: low (Lockwood), high (Lotheissen), or McEvedy (preferred for emergency — better bowel access)
- Laparoscopic: TEP or TAPP (particularly for bilateral or recurrent hernias)
- Mesh plug or mesh repair
2
Emergency (strangulated)
- Immediate surgical exploration via McEvedy approach (allows bowel assessment and resection if needed)
- Assess bowel viability — resect if gangrenous
- Do NOT attempt forceful reduction — strangulated bowel may perforate into abdomen
Complications
- Strangulation: 22–45% risk — much higher than inguinal hernias. Surgical emergency
- Richter's hernia: Only part of the bowel wall is incarcerated — bowel obstruction may NOT be present initially but wall necrosis and perforation can still occur
- Bowel obstruction: SBO from incarcerated bowel loop
UKMLA Exam Tips
- 1Elderly woman with unexplained SBO → check FEMORAL hernial orifices (commonly missed diagnosis)
- 2Femoral = below and lateral to pubic tubercle. Inguinal = above and medial to pubic tubercle
- 3ALL femoral hernias should be repaired (even asymptomatic) — due to high strangulation risk (22–45%)
- 4Richter hernia: partial bowel wall incarceration → can strangulate WITHOUT causing bowel obstruction — dangerous because diagnosis is delayed
- 5Femoral canal boundaries: inguinal ligament (A), pectineal ligament (P), lacunar ligament (M), femoral vein (L) — "ILFV"
practicetest your knowledge on femoral herniaApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
open q-bank