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Case 31: A lump in the groin

An otherwise fit and well 75 year old woman presents with 6 hours of pain and a lump in the right groin.

1. What is the likely diagnosis?

An incarcerated femoral hernia.
The contents of the sac are assumed to be strangulated until proven otherwise when a person presents with an acute, painful incarcerated hernia regardless of its location. The presence of a small bowel obstruction suggests a loop of small bowel is involved however an abscence of bowel symptoms does not exclude bowel involvement.
It is possible that this is an inguinal hernia however it appears to be arising below and lateral to the pubic tubercle.

2. How would you manage this problem?

Initial management includes thorough history and examination. The patient requires fluid resuscitation and analgesia then ugent operative exploration and repair. A plain abdominal xray may confirm small bowel obstruction however it does not significantly alter the mangement based on the clinical situation. A urinary catheter should be inserted to guide fluid resuscitation and decompress the bladder away from the operative field.

3. What operative approach would you use?

An acute strangulated femoral hernia should be approached with the probability of requiring bowel resection. Therefore a modified McEvedy approach above the inguinal ligament is preferred to give adequate exposure and allow access to the peritoneal cavity.