Strangulated Femoral Hernia: *A Review of 170 Cases

FRANK A. ROGERS, M.D.

From the College of Medical Evangelists, Los Angeles County General Hospital, California

A STUDY of a relatively large group ofcases of strangulated femoral hernia wasundertaken in order to point out factorswhich most influenced the mortality and toevaluate methods of surgical treatment. Re-cently femoral hernias have attracted lessattention in the literature than in earlieryears. The relative high mortality associatedwith the acutely incarcerated femoral herniasuggests that a reappraisal of the recogni-tion and treatment of this type of herniawill be of value. An analysis of 170 casestreated over a 15-year period on the Col-lege of Medical Evangelists surgical serv-ice at the Los Angeles County Hospital ispresented.Anatomic Features: A femoral hernia is

more likely to undergo acute incarcerationand subsequent strangulation than anyother common hernia. Strangulation mayoccur at any time and constitutes an urgentsurgical emergency. It is estimated thatstrangulation occurs in approximately 10per cent of all femoral hernias..5 31 Acuteincarceration occurs more frequently in thistype of hernia because the small femoralring through which the herniation occursis more rigid and because herniation throughthe defect occurs in a more vertical ordownward direction. It is this latter factor,uniquely characteristic of the femoral canalhernia, which contributes to the difficultyin reducing it. Once entrapped, the contentsof the sac are inhibited in returning to theabdomen by the well defined and narrowedmargins of the hernia defect. When inter-

' Submitted for puiblication Mlarch 3, 1958.Presented before the Souithern California Chap-

ter of the American College of Surgeons, PalmSprings, California, January 18, 1958.

ference with circulation occurs the stran-gulation affects the contents of the sac andthe tissues which make up the sac-theparietal peritoneum, properitoneal tissueand transversalis fascia.The femoral ring is bounded laterally by

the femoral vein, anteriorly by the inguinalligament, medially by the lacunar or Gim-bernat's ligament and posteriorly by thesuperior ramus of the pubic bone coveredby Cooper's ligament. It is through this nar-rowly confined space that all femoral her-niae must emerge, except the very rarelateral femoral hernia which occurs lateralto the neural bundle.Sex Incidence: During the period 1941

to 1955 there were 1,427 femoral herniasadmitted to the two medical school servicesof Los Angeles County General Hospital(University of Southern California and Col-lege of Medical Evangelists). Of this num-ber, 323 cases or 23.6 per cent were treatedwith acutely incarcerated, irreducible fem-oral herniae. These were approximatelyequally divided between the two medicalschool services.The sex incidence of all studies on all

femoral hernia favors the female. When agroup of 1,716 cases from the literature 8, 9,11, 20, 26 31, 32 are averaged, the sex inci-dence is exactly two to one. In the 1,427County cases including acute and chronichernias, the ratio was slightly less than 2: 1.In the present study of 170 acutely in-carcerated hernias 68 per cent were femalesand 32 per cent males. There were twiceas many males treated in the first half ofthis period of the stuLdy as in the latter half.Out of the total hospital admissions foracute femoral herniation there were 14

9

Annals of SurgeryJanuary 1959

Negro females and two Negro males. ThusNegroes made up 5 per cent of the totalpatients in this study. Shelby recorded a 2.3per cent incidence of Negro patients.34Since the average hospital Negro censusduring these years averaged 22 per cent,it appears that femoral hernias may occurwith relative less frequency in the Negrorace.Predominance of Side of Herniation:

As in the case of inguinal hernias, femoralhernias occur on the right side twice asfrequently as on the left.8 9, 10. 16, 17 27, 31, 34This is difficult to explain but is probablypartially accounted for by the predom-inance of right handedness and increasedstrain on the right side of the body. Oc-cuirrence of bilateral femoral herniation isnot uncommon and ranges from 4 to 9 percent.25' 35 The occurrence of bilateral stran-gulated femoral hernias is a rarely recordedevent.l8Age: The distribution by age is shown in

Table 17. Previous studies have shown thata maximum number of patients with fem-oral hernias are in their fourth, fifth andsixth decades. 8 11 14, 20, 2; :. 32, :10 In the90 cases studied by McClure and Fallis, over75 per cent were between 30 and 60 yearsof age. In 139 cases reported bv Koontz, 84per cent were betxveen 30 and 70. As isuisual for any group of cases reported fromthe Los Angeles General Hospital the aver-age age of the patients is a great deal higherthan most similar reported series. Only 25per cent of this group were between 30 and60 years of age, while 71 per cent were inthe seventh, eighth and ninth decades. Be-cause age is always a factor affecting resultsof surgical treatment, the advanced age ofthis group is significant. There are several

TABLE 1. Duration of Hernia Pr-ior to Incarceration

0-1 v'ear 281-3 vears 133 5 vears 1 05- IOvears 17

Over 10 years 30

TABLE 2

Signs

Tenderness over hernia 75Abdominal distention 55Visible peristalsis 6Blood in stool 2Melena 2

reports of strangulated hernias in infants.29, 1 "2, 33, 37 Strangulation of a femoral her-

nia, however, may occur at any age. Theyoungest recorded case was that of a fiveweek infant male reported by Underhill.Pfeiffer and Sain record the case of a monthold female with an incarcerated right tubeand ovary. A five-month-old female withstrangulated ectopic endometrial tissue was

included in the series by Jarboe and Pratt.Two patients in this series were in the tenthdecade and both were treated successfully.

Past History; Signs and Symptoms:In the majority of instances the patientswere aware of their hernia. A history ofknown herniation was given by 105 patientsin this series. Of this group eight had hadprevious incarcerations. The diagnosis was

made for the first time in 61 patients or 40per cent of the group. There were 12 deathsamong those who knew of their hernias.Most of these deaths could have been pre-

vented by elective repair of the hernia. Inthe series reported by Jarboe and Pratt 65per cent of the patients were aware of theexistence of their hernia prior to the timeof the acute episode. Pfeiffer and Sain re-

ported an incidence of 82 per cent in theirgroup of acute and chronic hernias. Stran-gulation occurred without knowledge ofprevious hernia in 16 per cent of Peden'scases. Strong emphasis should be placedhere since the elective repair of femoralhernias ca rries an exceedingly small risk,whereas the imort-ality from suirgical treat-ment of straingulated femor al her-nia re-

imains hiigl. Table 1 inidicates that a large

ntumber of actute incarcerations occturredwithin one vear after the hernia first made

10 ROGERS

STRANGULATED FENIORAL HERNIA

its appearance. Twenty-eight, or about 30per cent, fall under this category, while an-other 30 per cent had the hernia over tenyears before trouble ensued. In anotherlarge series :-" the average known durationof the hernia was 12 years. The duration ofthe hernia appears to be unrelated to thesac contents or to the subsequent results oftreatment.

Clinical Signs and Symptoms: Althoughthe purpose of this paper is not to presentclinical behavior of these cases, Tables 2

and 3 indicate the relative frequency ofcertain signs and subjective symptoms as-

sociated with the acutely incarcerated or

strangulated femoral herniae. Jarboe andPratt( 1949) have presented a detailedstudy of clinical manifestations associatedwith the acutely incarcerated femoral her-nia, and there are other excellent reviews.1.-,9, 1, 2. s In general the acutely stran-

gulated hernia containing small bowel pro-duces more pronounced symptoms indica-tive of mechanical intestinal obstruction.When structures other than small intestineare incarcerated and subsequently stran-gulated, the symptoms and signs are oftenless dramatic. The usual history is that ofa sudden onset of pain frequently notedin the region of a previously reducible her-nia which has become firm and irreducible.The abdominal pain is poorly localized atfirst and later becomes cramping in natuLre.The onset of incarceration is associatedwith increased exertion in approximatelyone-third of the cases.5' 26, 28 However,many cases occur with no unusual effort.The majority of patients reached the hos-

pital soon after the onset of symptoms. The

TABLE 3

Symptoms

Nausea- v-omi1iting- 126Natiseat onlv 13

(rampllip g painl(Constant p;ain 32(Constipation 53Diarrhea 7

TABLE 4. Dutration of Acutte Symptoms

Cases Mlortalitv

0-24 hours 6224-48 hours 16 5%;2-3 days 313-4 days 17 13%c

Over 5 days 39 23("

duration of acute symptoms prior to reach-ing medical care is summarized in Table 4.The mortality increased as the period ofdelay lengthened. In this summary patientswith only omentum strangulated are in-cluded, a fact which keeps these mortalitystatistics from being higher.Vomiting occurs early and is a prominent

symptom. A mass in the femoral region isthe most important single physical finding.Many times the mass is completely over-looked and in other instances its significanceis often misinterpreted. Acute strangulationof a femoral hernia is a common cause ofacute intestinal obstruction among patientsmore than 50 years of age. If the diagnosisis thought of and properly examined for,the condition is uisuially not difficult todiagnose.The classical symptoms of intestinal ob-

striuction are usually present in cases ofstrangulated femoral hernia. When intes-tinal colic associated with vomiting sug-gests a diagnosis of probable acute intes-tinal obstruction hernial orifices should becarefully examined for the presence of amass. With care, a differential diagnosisbetween a femoral hernia and an incarcer-ated inguinal hernia can be made. The fem-oral hernia is palpable below and lateral tothe pubic spine, while the inguinal herniais found to lie superiorly and medially tothe puibic spine. Frequently the femoralhernia milass protrutides forNward and tipwardto paritly obscure the iinguinial ligamilenlt.

Effect of Delayed Diagnosis: The cor-Irect (liagnosis was ad(le in 80 per cenit ofcases preoperatively in this gr-ouip (Table5). This percentage of correct diagnosis is

\ olume 149Number I 11

12 ROGERS

higher than that found in other series.5 7'15 31 The diagnosis was made in another 31cases, or 19 per cent of the total series, atsurgery. Two cases died undiagnosed, rep-resenting 1 per cent of the group. The mor-tality was 11.4 per cent among those diag-nosed preoperatively and 13 per cent in thegroup where the diagnosis was made atsurgery. Where the proper diagnosis ofthese patients was made either in the gen-eral admitting room or by the initial ad-mitting ward, the over-all mortality wasextremely low (10%). As indicated inTable 5, this information was obtainable in138 instances. When the patients had beenadmitted to hospital services other thangeneral surgery and the proper diagnosiswas delayed until made by surgical con-sultation, the mortality reached 50 per cent.The incidence of gangrene rises sharply asthe delay in diagnosis increases. Delay inreaching surgery for any reason greatly in-creases the number of deaths.A sharp increase in the mortality was

noted when the proper diagnosis was de-layed for more than 24 hours. The correctdiagnosis was made in 145 cases in lessthan 24 hours (Table 6). Of these, 128were diagnosed in the emergency room oron their arrival to the primary admittingward. Seventeen others were either initiallydirected to medical wards or were alreadyin the hospital on services other than gen-eral surgery when their acute incarcerationsoccurred, but were also diagnosed correctlyin 24 hours or less. Only 12 deaths occurredamong the patients diagnosed in less than

TABLE 5. The Effect of Delayed Diagnosis

Per CentCases Mortality

Preoperatively 132 (80%) 11.4At operation 31 (19%) 13.0At autopsy 2 ( 1%) 100.0

Hospital AdmittingRoom or Ward 128 10.0

Consultant 10 50.0

Annals of SurgeryJanuary 1959

TABLE 6. Diagnosis by Time Intervals

Cases Deaths Mortality

0-24 hours 145 12 8.3%24-36 hours 5 236-48 hours 2 2 470%48-72 hours 3 2 47.0

Over 72 hours 7 2

24 hours (8.3%o). Among 17 other patientswhere diagnosis was delayed over 24 hoursthere were eight deaths (47%o ). Early diag-nosis of this type of hernia appears to bethe most important single factor in affectinggood results. The correct diagnosis wasmade in a higher percentage of cases whenthe patients knew of their hernia prior tothe acute incident. It was delayed whenthere was lack of tenderness in the herniaor the hernia was not visible or palpable.

Effect of Electrolyte Imbalance: Al-though the treatment for incarcerated orstrangulated femoral herniae is early sur-gery, many of the patients reached the hos-pital in various stages of shock. Others hadsuffered a good deal of fluid and electrolyteloss and required some delay in treatrnentwhile partial replacement therapy could becarried out. Table 7 summarizes the num-ber of patients who had significant preop-erative electrolyte disturbances to give ab-normal NPN, serum chloride and carbon di-oxide readings. Such abnormalities werenoted in 53.5 per cent of all patients. Amongmales the mortality was 35 per cent, whilefemales exhibiting comparable abnormalelectrolyte imbalance had only a 22 percent mortality.

Operative Approach and Repair: Thebasic repairs for femoral hernia have tradi-tionally been done either from above orbelow the inguinal ligament. More than 60operative technics have been described anda good deal of discussion has taken placein the literature regarding the preferredsurgical approach for the acutely incarcer-ated femoral hernia. In general, proponentsof an inguinal approach outnumber those

Volume 149 STRANGULATEDNumber 1

who favor the femoral approach. The ear-liest operative attempts, however, dealt di-rectly with the hernia sac from below theligament. Bassini (1894) originated the op-eration from below using the pectineusfascia, falciform process and Poupart's liga-ment to close the femoral opening witheither a pursestring or mattress suture. Asimilar operative technic was described byCushing in 1888.The inguinal approach was used by An-

nandale (1876). This was a simple pro-

cedure which plugged the femoral canal bysuturing the sac into it. Ruggi (1892) firstsutured the inguinal ligament to Cooper's

ligament. Moschowitz popularized thistechnic in the United States and added an

inguinal hernioplasty to the procedure toprevent an inguinal herniation. Suturingof the conjoined tendon to Cooper's liga-ment was described by Lotheissen (1898).This method has also received approval byMcVay and Anson. These latter two authorscriticized the Ruggi-Moschowitz procedurein that the suturing of Poupart's ligamentto Cooper's transposed tissue planes andopposed one yielding structure to an un-

yielding structure.The abdominal approach was first used

by Tait (1883) while operating for an

ovarian tumor. According to Koontz, H. A.Kelly used this method at Johns Hopkinsand was followed by other gynecologists.In the early days Kelly plugged the open-

ing in the femoral canal with a glass marbleand closed peritoneum over it.The suprapubic extra-peritoneal approach

(Cheatle-Henry) 4 12 is particularly deserv-ing of attention and has found favor amongthe residents at the Los Angeles CountyGeneral Hospital, where it was first used

TABLE 7. Electrolyte Imbalance and Mortality

MalesFemales

2863

35%22%

91 of 170 - 53.5%with electrolyte abnormalities

FEMORAL HERNIA 13TABLE 8. Surgical Approach

(168 cases)

Cases Deaths

Femoral 10 0Inguinal 112 14Retro pubic (1949) 29 4Right rectus 10 0Other 7 2

and popularized by Mikkelsen. As indi-cated in Table 8 the retropubic approachhas only been used ince 1949. In 1954 Mik-kelsen and Berne reported briefly on 214patients with femoral hernias treated overa four year period at the Los AngelesCounty Hospital. The Cheatle-Henry extra-peritoneal or retropubic approach was usedon 113 of these. Experience with this tech-nic has shown it to be superior to othermethods of approach to femoral hernia be-cause of the unusually good exposure of thefemoral canal from above. It allows an ex-cellent repair of the femoral defect and isfar more advantageous in dealing with gan-grenous bowel than any of the inguinal orfemoral approaches. This approach also al-lows exposure of the opposite femoral ringwhere a femoral defect exists in approxi-mately 20 per cent of patients 25 (Fig. 1a, b, c).An adequate approach is of primary im-

portance in dealing with strangulated in-testine. In addition the approach shouldgive the added advantage of an easy, securerepair since recurrence rates are high fol-lowing repairs for strangulated femoral her-nia, especially where there is gangrenousbowel.5, 28, 36, 38

Results of Treatment: This study onacutely incarcerated and strangulated fem-oral hernia was undertaken primarily todiscover the results of treatment for thiscondition and the factors significantly ef-fecting these results. The data from avail-able clinical charts was tabulated by I.B.M.machine. Because of the mass of detaileddata available with the use of I.B.M. tab-ulation only brief comments will be made

Annals of SurgeryJanuary 1959

regarding the data to be presented on mor-

tality. The tables referred to stummarize thedata stuccinctly.The results of treatment are affected by

many variables. The effect of long durationof symptoms and the importance of diag-nostic accuracy have already been pointedout. In Table 9 the results of operativetreatment for right and left strangulatedfemoral hernia are summarized. The markeddifference in mortality is difficult to explain.An analysis of data which might producedifferences in fatality results on oppositesides was carried out. Conditions such as

the contents of the sac, associated diseases,duration of operative procedure, the inci-dence of non-viable bowel and age and sex

were used. No one factor or set of condi-tions seem to fully explain the difference inmortality between the right and left hernias.

Duration of Operation: Table 10 indi-cates the number of procedures which were

done in arbitrary divisions of operativetime. No effort is made here to tabulateseparately the operative times for cases re-

FIG. 1. (A) Through a supra pubic transverseor vertical incision the fascia over the recti musclesis divided, the right rectus muscle is retractedlaterally and the underlying peritoneal sac is easilypushed away from the inner surface of the inguinalligament and superior ramus of the pubis (Cheatle-Henry approach to the retropubic space). In thisphotograph the femoral hernia defect is seenmedial to the femoral vein bounded by the in-guinal ligament above, the lacunar (Qimbernat's)ligament medially and the superior right pubicramus inferiorly covered by Cooper's ligament.This approach affords an excellent view of thefemoral canal area as well as the obturator nerveand lateral femoral and iliac lymph node areas.

-..N f._

FIG. 1. (B) The transversalis fascia is pulleddownward to approximate with Cooper's ligamentand effectively close the femoral defect.

FIG. 1. (C) The repair has been completed byuniting the transversalis fascia to Cooper's ligamentwith interrupted sutures of cotton.

quiring bowel resection and those whereother simpler procedures were carried out.This analysis, however, shows that themortality rate remained approximately 8per cent for all operative procedures per-

formed in 100 minutes or less. The 43 pro-

cedures which required more than 100 min-utes produced eight deaths or a mortalityof 20 per cent. When the length of theoperative procedure was related to thevarious surgical approaches it was notedthat less operating time, regardless of pro-

cedure, was required for the retropubic or

Cheatle-Henry approach. The effect oflonger operating time was more notablewhen related to the presence or absence ofother associated diseases (Table 16).

Sac Contents: The contents of the herniasac influence greatly the results of surgical

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Volume 149 STRANGULATEDNumber 1

treatment. In Table 11 are summarized theviscera uisually encountered in the femoralhernia. Several studies 1. 6, 1(. 16. 31 havepointed ouit the high mortality associatedwith incarcerated small bowel as comparedwith other incarcerated or strangulated vis-cera. In Table 11 omentum was also presentin many of the cases tabulated under smallbowel or ileum. In this study the presenceof omentum with loops of small intestine inthe sac did not significantly lessen the seri-ousness of the hernia. When omentum alonewas strangulated, the mortality was low.There were a large number of Richter'shernias in this series. Koontz recorded anincidence of 3.6 per cent in his series ofelective and emergency hernias, while Jar-boe and Pratt noted a 14.4 per cent inci-dence. No case of a Littre's hernia 30 OCcurred in this series. There was no case ofgangrene involving colon, ovary and tubeor cecum or appendix.The clinical signs and symptoms are less

dramatic and severe when the strangulationdoes not involve bowel. The chief factorsinfluencing symptomatology and prognosisare presence or absence of small bowel inthe hernia sac and the presence or absenceof gangrene. The combination of gangrenein a loop of small bowel is a lethal combina-tion. Table 12 tabulates the mortality percent associated with gangrenous bowel invarious series since 1900. The average mor-tality for these 16 series is 54 per cent.Table 13 lists the operative mortality ofseveral series dealing with strangulatedfemoral hernia. The average mortality forthese 11 series reports was 21 per cent.These tables indicate very little improve-ment in mortality statistics over the years.The most difficult problem associated

TABLF 9. Operation Performed

Right femoral hernia 115deaths 17 mortalitV 15.5%

Left femoral hernia 49deaths 3 mortality 6.0%/o

FEMORAL HERNIA 15TABLE 10. Operative Timte

Cases Deaths

20-4040-6060-8080-100100 and over

17 037 544 225 443 8

8/

20%

with the surgical treatment of the stran-gulated femoral hernia involves the properrecognition and treatment for gangrenousbowel. A careful study of some series indi-cates that occasionally fatalities resultedwhere nonviable bowel was returned to theabdominal cavity following release and re-pair of the hernia. There were no such in-stances in this series. There were 35 smallbowel resections with nine deaths, a mor-tality of 26 per cent. Most of the anastomo-ses were done with end-to-end open twolayer suture technics. There were no deathsfrom leaking anastomoses.Although several tests have been de-

scribed to determine bowel viability3 40 theneed for resection should be obvious to theexperienced surgeon. The fluoroscein andprocaine tests are time consuming and stillrequire experienced interpretation. If doubtexists, resection is the safer course.Table 14 summarizes the operations per-

formed for this series of cases and indicatesthat the majority were treated by release ofthe incarcerated or strangulated viscera andrepair of the hernia. In four patients whoseconditions were critical no attempt at re-pair was made and the sac contents weresimply released, with one fatality. A bi-lateral repair was done in three instancesusing the retropubic extraperitoneal ap-proach. The mortality associated with re-lease and repair of 160 hernias was 12 percent.The twofold increase in mortality asso-

ciated with resection of gangrenous bowelemphasizes the seriousness of this condi-tion. In several instances it was necessary tosection the lacunar ligament to release theconstricted sac. Dennis and Varco have out-

Annals of SurgeryJanuary 1959

lined a method of dividing the inguinalligament in cases requiring bowel resection.Their subsequent repair of the hernia wasdone after the method of McVay and Har-kins. Division of the inguinal ligament wasnot done in the present series.The presence of gangrenous bowel within

the femoral hernia sac is usually made ob-vious by the dark, odorous, hemorrhagicfluid. In this situation Dennis and Varcohave recommended deferring release of thehernia until the blood supply to the gan-grenous loop has been divided. The experi-mental work of Knight and others has in-dicated the presence of a highly toxic sub-stance with depressor effect in exudate fromnonviable segments of intestine.The resection of gangrenous bowel must

be adequate. A careful examination of thestrangulated portion of bowel, as well asproximal and distal bowel, must be made inquestionable cases. Although rare, gangrenehas occurred in a segment of bowel withinthe abdomen. This has been referred to as"retrograde strangulation." It was describedby Laroyenne in 1910 and has been referredto as a "W" or Maydl's hernia.24 In this typeof hernia segments of bowel proximal anddistal to an infolded portion of bowel maybe come incarcerated within the hernia sacwithout loss of viability. However the in-folded loop by strangulation may becomeinfarcted. Another explanation for intra-ab-dominal gangrenous bowel is the extensionof a thrombotic process from clotted vesselswithin the herniated intestine mesentary.

In many Richter's hernias only a portionof the circumference of the occluded loopis non-viable. This represents a specific

TABLE 11. Sac Contents and Mortality

Per CentCases Mortality

Small bowel; ileum 130 17Colon 2Ovary and tube 2Cecum or appendix 1Omentum 41 5

TABLE 12. Summary of Mortality Associatedwith Gangrenous Bowel

CasesGangrenous Per Cent

Author Year Bowel Deaths Mortality

Gibson 1900 354 120 34Becker 1922 24 6 25Springer 1924 16 9 56Frankau 1931 116 40 34McIver 1933 8 4 50Bowers 1935 5 4 80Dunphy 1940 20 10 50McNealy 1942 33 20 60Dean 1942 83Adelaide 1943 12 8 66Hay 1943 6 6 100Jens 1943 19 10 53Jarboe 1949 26 19 73Pfeiffer 1951 12 3 25Peden 1951 40 18 46Rogers 1958 35 9 26

problem. In the past many such areas havesimply been inverted with a series of in-terrupted sutures placed in the transverseaxis of the bowel (Summer's stitch). Sixcases in this series received such treatmentwith one death. Other records show as highas 40 per cent mortality with this technic.With any extensive necrosis, a resection isindicated. Four of five cases in the Mayoclinic group 15,16 treated with inversiondied directly due to the use of this technic.Three of these were obstructed at the siteof inversion and the fourth died from per-

foration and leakage.Proximal decompressing enterostomy was

not done in this series of cases, and no case

was treated by double barrelled enteros-tomy. In other series where exteriorizingprocedures have been carried out the mor-

tality has been extremely high. Peden re-

ported seven cases treated by exterioriza-tion, all of whom died. McNealy reportednine deaths in eleven such cases.

The Influence of Associated Diseaseson Mortality: Of particular influence onthis group of patients reported from theLos Angeles General Hospital was the pres-

ence of associated diseases. Table 15 listsseven disease categories and the numbers

16 ROGERS

Volume 149 STRANGULATEDNumber 1

of patients afflicted in each group. Includedin these categories are such associated dis-eases as congestive heart failure, myocar-dial infarction, pulmonary tuberculosis,chronic glomerulonephritis, cerebral vascu-lar accidents, severe degrees of malnutri-tion and infections in systems other thanthe gastro-inestinal tract. There were 26males and 54 females who had one or moreassociated diseases severe enough to def-initely increase their operative risk. Al-though the same relative numbers of malesand females had associated diseases, onceagain the marked disparity in mortality wasseen with a 35 per cent mortality for malesand 18.5 per cent for females.The influence of prolonged operative

time on patients with and without associ-ated disease is summarized in Table 16. Al-though Table 11 indicated no sharp in-crease in mortality for the combined groupuntil after 100 minutes of operative time,the effect of associated disease is clearlyseen when the factors of prolonged surgeryand combined diseases are analyzed to-gether. Patients with no associated diseasewithstood the longer operating times withno significant increase in deaths, while inthose with associated diseases the deathsincreased many-fold.

Anesthesia: The effect of the method ofanesthesia on the results of surgical treat-ment was not specifically studied in this

TABLE 13. Operative Mortality of StrangulatedFemoral Hernia

Per CentAuthor Year Cases Mortality

Gibson 1900 101 23.8Beller; Colp 1926 76 20.0Frankau 1931 680 12.9McIver 1932 34 17.7Fergusson 1937 23.1Shelley 1940 37 25.9Dean 1942 31 32.0Jens 1943 100 14.0Jarboe; Pratt 1949 104 23.1Peden 1951 107 23.8Rogers 1958 170 13.0

FEMORAL HERNIA 17TABLE 14. Operation Performed

Per CentCases Deaths Mortality

Release sac contents 4 1Release and repair 160 19 12Small bowel resection 35 9 26Invert bowel wall 6 1Bilateral repair 3 0

series. Some authors 1, 6, 7,17, 38, 40 have beenemphatic in preference for local anesthesia.In Peden's series the mortality was lowestwhen spinal anesthesia was used and high-est with local anesthesia. From a study ofthis group of patients it is- felt that localanesthesia is inadequate to deal properlywith complications such as gangrenous saccontents. The large number of patients whohave intestinal obstruction increases thehazard of vomiting during surgery. Thegeneral trend in handling this type of pa-tient has been to empty the stomach pre-operatively and send the patient to the op-erating room with an indwelling naso-gas-tric tube. The preference for endotrachealanesthesia with inflated cuff has been notedrecently and is felt to be the anesthetic ofchoice. A high concentration of oxygen canbe given and the dangers of aspiratingvomitus and the problem of hypotensionoccasionally associated with elderly pa-tients in boderline shock are avoided.

Influence of Age on Mortality: The ad-verse influence of advanced age on the re-sults of treatment is seen by the tabulatedsummary in Table 17. Here the numbers ofpatients in each sex are listed by decade.Only one patient under the age of 50died, an operative mortality of less than 5per cent. Above the age of 50 the mortalitygenerally increases with age, although thetwo female patients, aged 92 and 98 re-spectively, both survived their illness.

Variation in Mortality Between Sexes:The strildng difference in mortality formales and females has frequently not beencited in previous reviews on this type ofacute hernia. Peden found an operative

Annals of SurgeryJanuary 1959

mortality of 26.1 per cent in females and18.7 per cent in males. Table 18 indicatesclearly that the mortality among the maleswas a good deal higher than that amongfemale patients in this study, and this wasalso true in the review of 680 cases byFrankau. The over-all mortality was 13 percent. Females withstood the effects of acutefemoral hernia incarceration far better thanmales and exhibit a 10 per cent mortalitywith eleven deaths in 116 cases. The malemortality was double this with elevendeaths among 54 patients, a 20 per centmortality. All of the female patients wereoperated. Two of the male patients diedunoperated, and the correct diagnosis wasmade at autopsy.

It is difficult to fully explain the variationin mortality between the sexes. There weremore delayed diagnoses among male pa-tients to partially account for this differ-ence. Delay in correct diagnosis gave rise todelay in surgical treatment and was asso-ciated with a sharp rise in mortality.An analysis was done to ascertain the

seriousness of the side of the hernia in eachsex. It was found that there were 7 per centmore right-sided male hernias than female.This becomes significant when it is relatedto the increased incidence of small bowelincarceration in right-sided hernias. Theratio of right-sided hernias to left was 2 to1. The ratio of hernias on the right sidewhich contained strangulated small bowelto those on the left side was 3 to 1.However, there were essentially the same

relative number of elderly male and femalepatients, and the per cent of associated dis-eases was equal in both sexes. A survey of

TABLE 15. Associated Diseases

Cardiovascular 43Pulmonary 13Renal 8C.N.S. 14Malignancy 4Malnutrition 4Infection; sepsis 11

TABLE 16. Effect of Operative Time on Patients Withand Without Associated Diseases

Minutes

20-60 Over 60

Associated disease 25 53deaths 4 13

No associated disease 29 59deaths 1 2

the numbers of male and female patientswhose hernia sac contained small bowel re-

vealed essentially no difference and thesame ratio of right to left hernia existed.On both medical school services at the LosAngeles General Hospital from 1941 to 1955there were a total of 72 patients with stran-gulated femoral hernia who required bowelresection. There were 50 females and 22males, the same ratio of sexes as was notedfor femoral hernia in general. Of this largergroup of patients requiring small bowel re-

section there were only 10 female deathswith an operative mortality of 20 per cent,while the male operative mortality was 60per cent.

Postoperative Complications: Therewas a total of 42 postoperative complica-tions in 37 cases. The wound infection in-cidence was 6.6 per cent with 11 patientsmanifesting some degree of suppuration inoperative incisions. The majority of thesewere noted in patients who had had exci-sion of gangrenous small bowel.There appeared to be no relationship

between prolonged operating intervals andan increase in the number of postoperativecomplications but a definite relation was

seen, as would be expected, among thosecases with other associated diseases. Table19 lists the more severe postoperative com-

plications and gives the number of deathsattributable to each of these. Shock ac-

counted for the largest number of postop-erative deaths, while atelectasis with pneu-

monia and shock occurred as postoperativecomplications most frequently and were

seen in a total of 24 instances. Congestive

18 ROGERS

Nolume 149 STRANGULATED FEMORAL HERNIA 19Number 1

heart failure, renal failure, cerebral vascularaccidents, pulmonary embolism, coronaryocclusion, phlebothrombosis and gastro-intestinal hemorrhage were problems inother postoperative cases.

Summary

The general features of strangulated fem-oral hernia have been outlined and resultsfrom a study of 170 cases of acute incar-cerated femoral hernia from the College ofMedical Evangelists Surgery Service at theLos Angeles County Hospital have beencompiled.There were 116 females and 54 males,

71 per cent of whom were in the agedecades 60 to 90.The seriousness of delayed or incorrect

diagnosis is emphasized. The influence ofage, sex, presence of other associated dis-eases, electrolyte imbalance, duration ofoperative time, sac contents and the sideaffected on mortality is summarized.An adequate surgical approach is im-

portant and the excellence of the Cheatle-Henry extraperitoneal, retropubic operationis described.The overall mortality for this group was

13 per cent. The male operative mortalitywas 20 per cent while that female patientswas only 10 per cent. The results of thisgroup are compared to other reports.There were 35 bowel resections for gan-

TABLE 17. Age Decade, Sex and Mortality

Total Male FemaleAge Cases Cases Deaths Cases Deaths

0-9 2 1 110-19 2 1 1 120-2930-39 7 2 540-49 1 1 3 850-59 28 13 3 15 260-69 38 13 1 25 270-79 58 12 3 46 480-89 22 9 3 13 390-99 2 2

170 54 11 116 11

TABLE 18. Mortality

Over-all Mortality-13%o

Females 116deaths 11mortality 10%

Males 54deaths 11mortality 20%

TABLE 19. Postoperative Complications

Cases Deaths

Atelectasis; pneumonia 12 7Shock 12 10Heart failure 5 5Renal failure 4 4C.V.A. 2 1Pulmonary embolus 1 1Coronary occlusion 1 0Phlebothrombosis 2 0G.I. hemorrhage 3 1

grenous small bowel with nine deaths, a26 per cent mortality. No deaths were dueto faulty anastomoses. Postoperative com-plications occurred in 37 patients and therewas a 6.6 per cent wound infection rate.An elective repair of all femoral hernias

is advisable.

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