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A 78-year-old woman presents with 12 hours of colicky central abdominal pain, bilious vomiting, and absolute constipation. There is a 2 cm tender, tense, irreducible lump below and lateral to the left pubic tubercle. No previous abdominal surgery. HR 110, BP 100/60, local guarding over the lump.
Questions
a) Diagnosis and why this hernia is particularly dangerous. (3 marks)
Strangulated left femoral hernia causing small-bowel obstruction with ischaemia risk.
The femoral canal is narrow and rigid (bounded by inguinal ligament, pectineal ligament, lacunar ligament, and femoral vein) → highest strangulation risk among common hernias (classically up to ~40% present complicated). Elderly women are the classic demographic; always examine hernial orifices in SBO.
b) Immediate management and why taxis is contraindicated. (4 marks)
NBM, IV crystalloid, nasogastric decompression, analgesia, bloods including lactate, IV antibiotics if compromise suspected (e.g. co-amoxiclav 1.2 g IV), urgent senior surgical review and emergency operation.
Do not attempt taxis when strangulation is likely — risk of reduction en masse (gangrenous loop reduced into the abdomen still strangulated within the sac neck) and missed dead bowel.
c) Anatomical landmarks: femoral vs inguinal; direct vs indirect inguinal. (4 marks)
- Inguinal hernia: lump above and medial to the pubic tubercle.
- Femoral hernia: lump below and lateral to the pubic tubercle.
- Indirect inguinal: through deep ring, lateral to inferior epigastric vessels; may enter scrotum.
- Direct inguinal: through Hesselbach's triangle, medial to inferior epigastrics; rarely scrotal.
d) Elective inguinal repair standard and emergency femoral approach principles. (4 marks)
Elective adult primary unilateral inguinal: Lichtenstein open tension-free mesh repair remains a guideline standard; laparoscopic TEP/TAPP preferred for bilateral or recurrent after anterior repair (HerniaSurge).
Emergency femoral with possible dead bowel: approaches include Lockwood, Lotheissen, and McEvedy (high) — McEvedy facilitates bowel inspection/resection; repair femoral canal (tissue or mesh depending on contamination); respect corona mortis risk when dividing lacunar ligament.