The American Journal of Surgery (2013) 205, 188-193

Clinical Science

Improved outcomes of incarcerated femoral hernia:

a multivariate analysis of predictive factors of bowel
ischemia and potential impact on postoperative
complications
Cristina Alhambra-Rodriguez de Guzman, M.D.a, Joaqun Picazo-Yeste, M.D., Ph.D.a,*,
Jose Mara Tenas-Burillo, M.D., Ph.D.b, Carlos Moreno-Sanz, M.D., Ph.D.a

a
Department of General and Digestive Surgery, Hospital General La Mancha, Centro Avenida de la Constitucion, 3.13600
Alcazar de San Juan, Ciudad Real, Spain; bDepartment of Epidemiology and Preventive Medicine, Hospital General La
Mancha, Ciuda Real, Spain

KEYWORDS: Abstract
Femoral hernia; BACKGROUND: Although much of the literature focuses on risk factors for intestinal resection in
Ischemia; groin hernias, little is known specifically for the femoral type. This study identifies clinical and
Intestinal obstruction; analytic parameters associated with intestinal ischemia in patients with an incarcerated femoral
Risk factors hernia.
METHODS: Eighty-six patients with an incarcerated femoral hernia were included in an analytic,
longitudinal, observational, retrospective cohort study. Clinical presentation, the duration of symptoms,
analytic and radiologic studies, complications, and mortality rates were analyzed.
RESULTS: Eight (9.3%) patients underwent intestinal resection. Factors related to intestinal ische-
mia were oral anticoagulants intake (odds ratio 5 9.6) and a duration of symptoms longer than 3 days
(odds ratio 5 2.1). There was no relationship between leukocytosis (P 5 .02) or radiographic signs of
intestinal obstruction (P 5 .28) and bowel resection.
CONCLUSIONS: Patients with a duration of symptoms longer than 3 days and, interestingly, those
having oral anticoagulant therapy appeared to be at a higher risk for developing intestinal ischemia.
A remarkable reduction in morbimortality can be achieved through an earlier referral to the hospital,
quick preoperative workup, and urgent operation.
2013 Elsevier Inc. All rights reserved.

Hernia surgery is one of the most frequently performed
operations in the Western world. Despite this universally
acknowledged fact, scant attention has been paid to
* Corresponding author. Tel.: 134-629-149031; fax: 134-926-580669.
E-mail address: salvelio@yahoo.es
Manuscript received December 18, 2011; revised manuscript February
2, 2012
the prevalence, resulting disability, recurrence, and socio-
economic implications of hernias. The incidence of femoral
hernia is reported to be 2% to 8% of all groin hernias in adult
patients. This type of hernia, which is very rare in children, is
most commonly observed between the fourth and seventh
decades of life and is 4 to 5 times more common in women.
In addition, for reasons yet unknown, right-sided presenta-
tion is more common than left-sided presentation.1

0002-9610/$ - see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2012.03.011
C. Alhambra-Rodriguez de Guzman et al. Outcomes of incarcerated femoral hernia
Although the incidence of femoral hernias is low, they
are of high clinical importance because they often present
with strangulation. The incidence of strangulation reaches
38% in some reports, leading to high morbidity and
mortality rates.14 The importance of an early diagnosis
of incarceration is paramount because a delay increases
the risk of ischemia and necrosis of the incarcerated tissue,
thus augmenting the need for intestinal resection with its
consequently higher morbidity and mortality rates.57
The only satisfactory treatment for incarcerated femoral
hernia is an urgent operation. Over the past several years,
many published studies have examined the efficacy of
different hernia repair techniques, which have undergone a
remarkable evolution with the development of prosthetic
materials. Currently, the Lichtenstein femoral plug repair is
the most widely used technique. It is reliable, safe, and
easily reproducible and has become the gold standard for
both elective and emergency hernia repair. Although pre-
peritoneal hernia repair is as reliable and safe as the
anterior approach,8 it requires specific training, and some
surgeons find it more difficult to perform. With regard to
complications, available studies have found no differences
between anterior and preperitoneal techniques with respect
to wound infection, seroma formation, or hematomas.9
Although prostheses are widely used in elective groin
hernia repair, the use of synthetic materials is considered
controversial in emergency operations because of the
inherent risk of sepsis.10 Moreover, some surgeons consider
the presentation of strangulated hernia to be an absolute
contraindication for the use of prosthetic meshes because
of a higher risk of infection.11 However, others such as
Pans et al12 consider the risk of sepsis to be overestimated.
They insist that with careful attention to local antisepsis and
the use of systemic antibiotic therapy there should be no
additional risk of local infection when inserting a prosthesis
during an emergency herniorraphy procedure.1315
Late admission to the hospital is perhaps the most
important factor in the evolution of an incarcerated femoral
hernia because the prolonged duration of symptoms leads to
a higher risk of intestinal ischemia and necrosis of the
incarcerated tissue. Some reports show that bowel obstruc-
tion significantly increases the mortality rates associated
with hernias. Several studies have analyzed the risk factors
for intestinal resection in groin hernias but not specifically
for the femoral type. Our special concern regarding abdom-
inal wall pathology led us to develop and maintain a reliable
database during the last 16 years. The awareness of a
surprisingly low rate of bowel resection made us investigate
this issue. As far as we know, this article reports on one of
the largest single-institution series dealing with incarcerated
femoral hernias. To anticipate bowel necrosis and its
catastrophic consequences, we investigated the relationship
between several preoperative clinical, radiologic, and lab-
oratory findings and the occurrence of irreversible ischemia
in incarcerated femoral hernias. This article also focuses on
potential strategies aiming to achieve the best control of
intestinal viability upfront bowel necrosis.
189
Methods
Study design and patients
We conducted an analytic, longitudinal, observational,
retrospective cohort study with 86 adult patients undergo-
ing emergency treatment for incarcerated femoral hernias at
La Mancha Centro General Hospital, Ciudad Real, Spain,
between 1995 and 2009. All patients underwent a routine
preoperative workup including blood analysis, an electro-
cardiogram, chest and abdominal radiographs, and anes-
thesiology consulting. Because incarcerated femoral hernia
is mainly determined by a clinical diagnosis, other radio-
logic studies (ie, ultrasonography, a computed tomography
scan, and magnetic resonance imaging) were deemed
unnecessary. Attempts for the manual reduction of femoral
hernias are forbidden in our hospital. A hematologist was
consulted for patients on anticoagulant therapy, proceeding
for immediate reversal (ie, vitamin K, plasma infusion, and/
or activated prothrombin complex). All operations were
performed as soon as possible once the patient was
prepared for surgery. Depending on the surgical team
preference, the anterior or preperitoneal approach was used.
The following patient information was recorded: sex, age,
personal health history, a history of cardiopulmonary dis-
eases, a history of intake of oral anticoagulants, the presence
of diabetes mellitus, clinical presentation (ie, tumor, pain,
nausea and vomiting, and fever), time until the operation,
laboratory results (ie, white cell blood count), radiologic
studies (ie, signs of bowel obstruction), postoperative med-
ical complications (ie, heart failure and pneumonia), wound
infection and the presence of fistula, the surgical technique
used (anterior vs preperitoneal approach), the length of
hospital stay, and mortality.
Analysis
All continuous data were expressed with central ten-
dency measures as means and dispersion measures as
standard deviations. Qualitative data are expressed as
absolute and relative frequencies (percentages). Statistical
analyses were performed using either the t test, chi-square
test, or Fisher exact test. Differences were considered to be
significant at P , .05.
To identify predictive factors for bowel resection caused
by ischemia, a predictive model was created with the aid of
multiple logistic regression analysis. The dependent variable
was the presence or absence of bowel ischemia. First, we
performed a simple logistic regression to determine the
relationship between each potential predictor variable with
bowel resection caused by ischemia. Those variables with a P
value %.25 were selected for the multiple logistic regression
analysis. The Hosmer-Lemeshow test was performed for in-
ternal calibration of the model. The capability of discrimina-
tion of the model was calculated by the area under the
receiver operating characteristic curve. All analyses were
190 The American Journal of Surgery, Vol 205, No 2, February 2013

performed with SPSS software (version 18.0; SPSS Inc, Chi-
cago, IL).
Results
During the study period, a total of 86 adults with
incarcerated femoral hernias were included in the analysis,
20 men (23.3%) and 66 women (76.7%). The average age of
the patients was 68.4 6 18.3 years (range 27.6 to 93.9
years). Twenty-nine (33.7%) patients suffered from cardi-
opulmonary disease; 4 (4.7%) had diabetes mellitus; and
10 (11.6%) patients were taking oral anticoagulants for the
treatment of atrial fibrillation (7 cases), previous deep
venous thrombosis (2 cases), and dilated cardiomyopathy
(1 case). The most common complaint was pain in 77 cases
(89.5%) followed by the presence of a femoral bulge in 64
cases (74.4%), nausea and vomiting in 44 cases (51.2%),
and fever in 2 patients (2.3%). Leukocytosis above 11,000
was present in 31 cases (36%), and radiographic signs of
bowel obstruction were observed in 37 patients (43%).
In all 86 cases, the repair was buttressed with a
polypropylene mesh. Forty-six cases (53.5%) were oper-
ated using the anterior approach (ie, placing a plug into the

Table 1 Characteristics of patients with and without bowel resection

Total No bowel resection Bowel resection
Variables (N 5 86) (N 5 78) (N 5 8) P value
Sex (%)
Male 20 (23.3) 17 (21.8) 3 (37.5) .38
Female 66 (76.7) 61 (78.2) 5 (62.5)
Age (y) 68.4 6 18.3 67.7 6 18.8 75.7 6 10.4 .24
Duration of symptoms 2.2 6 1.3 2.1 6 1.2 3.3 6 1.5 .017
Concomitant disease (%)
Without 56 (65.1) 53 (67.9) 3 (37.5) .121
With 30 (34.9) 25 (32.1) 5 (62.5)
Cardiopulmonary diseases (%)
Without 57 (62.3) 52 (66.7) 5 (62.5) 1
With 29 (33.7) 26 (33.3) 3 (37.5)
Anticoagulants oral (%)
Without 76 (88.4) 71 (91.1) 5 (62.5) .047
With 10 (11.6) 7 (8.9) 3 (37.5)
Diabetes mellitus (%)
Without 82 (95.3) 74 (94.9) 8 (100) 1
With 4 (4.7) 4 (5.1) 0 (0)
Femoral tumor (%)
Without 22 (25.6) 21 (26.9) 1 (12.5) .674
With 64 (74.4) 57 (73.1) 7 (87.5)
Pain (%)
Without 9 (10.5) 7 (8.9) 2 (25) .196
With 77 (89.5) 71 (91.1) 6 (75)
Nausea and vomiting (%)
Without 42 (48.8) 40 (51.3) 2 (25) .266
With 44 (51.2) 38 (48.7) 6 (75)
Fever (%)
Without 84 (97.7) 78 (100) 6 (75) .008
With 2 (2.3) 0 (0) 2 (25)
Signs of bowel obstruction at abdomen radiography (%)
Without 49 (56.9) 46 (58.9) 3 (37.5) .282
With 37 (43.1) 32 (41.1) 5 (62.5)
Leukocytosis* (%)
Without 55 (63.9) 53 (67.9) 2 (25) .023
With 31 (36.1) 25 (32.1) 6 (75)
Length of stay (d) 5.6 6 3.6 4.8 6 2.6 13.3 6 3.1 ,.001
Surgical technique (%)
Anterior 46 (53.5) 44 (56.4) 2 (25) .138
Preperitoneal 40 (46.5) 34 (43.6) 6 (75)
*The presence of leukocytosis: values above 11,000; absence: values below 11,000.
The Fisher exact test.
t test for independent samples.
C. Alhambra-Rodriguez de Guzman et al. Outcomes of incarcerated femoral hernia
Table 2 The duration of symptoms of patients at the moment of hospital admission
Duration of symptoms Total (N 5 86) No bowel resection (N 5 78) (%)
%3 days 73 69 (94.5)
.3 days 13 9 (69.2)
*The Fisher exact test was used unless otherwise indicated.
femoral ring), whereas 40 patients (46.5%) underwent a
modified open preperitoneal hernioplasty as previously
described by our group.8 Briefly, the procedure consists
of an open preperitoneal approach (ie, the Nyhus approach)
to insert a patch of polypropylene individually fashioned in
an approximately 12 ! 10 cm M-shaped piece to con-
form to each patients anatomy and placed without fixation
and covering all potential hernial orifices. The aim here is
to create 3 prolongations (flaps) in the mesh for proper
self-anchorage in the preperitoneal space. Because the sper-
matic cord is parietalized under the central flap, a slit in
the prosthesis is unnecessary, thus avoiding its weakening.
Bowel resection because of ischemia was required in 8
cases (9.3%). Demographic and clinical characteristics of
patients with or without bowel resection are given in Table
1. Patients who required bowel resection were older (75.7
6 10.4 vs 67.7 6 18.8 years, P 5 .24) and had a longer
hospital stay (13.3 vs 4.8 days, P , .001). Seventy-three
(85%) of the 86 patients were admitted to the hospital
within the first 3 days after the onset of symptoms. The du-
ration of symptoms was longer in patients who required
bowel resection (3.3 6 1.5 vs 2.1 6 1.2 days, P 5 .02)
with a significant cutoff point at 3 days (Table 2).
A multivariable logistic regression model identified
2 variables that were independent risk factors for
bowel resection because of ischemia (Table 3): oral antico-
agulants intake (odds ratio 5 9.6 [95% confidence interval,
1.5 to 60.8], P 5 .016) and a duration of symptoms .3 days
(odds ratio 5 2.1 [95% confidence interval, 1.1 to 3.7],
P 5 .015). Patients whose blood analysis showed over
11,000 leukocytes presented almost a 3-fold risk of bowel
resection because of ischemia compared with those with
lower values although the difference was not statistically
significant (P 5 .176). Two patients had fever; both be-
longed to the group requiring bowel resection because of
ischemia (P 5 .008).
Severe postoperative complications are listed in Table 4.
Bowel resection was associated with a higher likelihood of
complications, including both medical condition and
Table 3 Risk factors for bowel resection because of ischemia
Risk factors P value OR (95% CI)*
Duration of symptoms .3 days .015 2.1 (1.153.67)
Oral anticoagulants .016 9.6 (1.5360.76)
CI 5 confidence interval; OR 5 odds ratio.
*Odds ratio derived from logistic regression; values in parentheses
are 95% confidence intervals.
191
Bowel resection (N 5 8) (%) P value*
4 (5.5)
.016
4 (30.8)
wound infection. There were 9 complications (10.5%); 2
patients developed pneumonia, and 7 presented with wound
infection (62.5% vs 5.1%, P , .001). In 6 (86%) of 7 com-
plicated wounds, the infections were located in the superfi-
cial site, and all healed with conservative treatment. The
only patient with deep site infection (she had received a
Lichtenstein plug repair with bowel resection through the
femoral canal) developed a chronic cutaneous fistula. She
was scheduled for removal of the plug 6 months after the
first operation. The inguinofemoral area was reinforced
with a new preperitoneal mesh with an uneventful recovery.
Fifty percent of patients who underwent bowel resection
developed wound infection, whereas this complication
arose in only 3.8% of cases with no bowel resection.
Two patients died, accounting for a global mortality rate of
2.3%. Both patients belonged to the bowel resection group
(P 5 .008). Indeed, mortality and general complications
were both significantly associated with bowel resection.
Comments
Our results indicate 2 independent risk factors for bowel
resection in patients with incarcerated femoral hernia. First,
patients taking oral anticoagulants have a much higher risk
of having bowel ischemia. Although it is not easy to find a
physiopathological reason for this association, we suggest
that patients receiving these medications may have some
underlying disease that predisposes them to bowel ische-
mia. If this hypothesis is considered plausible, it raises
serious doubts about the opinion that anticoagulant thera-
pies may protect against ischemic complications. More-
over, reversion of anticoagulant effects before surgery
should be undertaken as quickly as possible. Considering
that our favorable results may be related to this way of
proceeding, we should emphasize the role of operating as
soon as possible, even more in the presence of anticoag-
ulant therapy. In our experience, this management has led
us to frequently find cyanotic but viable intestinal loops
within the hernia sac. Second, we found a relationship
between the prolonged duration of symptoms (.3 days) up
to the time of surgery and a higher risk of bowel resection,
which is consistent with the findings reported by Kurt
et al.16 Being female and/or being over the age of 65 years
have been reported by several authors to be risk factors for
incarcerated femoral hernia,16,17 but our study found no
evidence of this.
Ge et al18 retrospectively analyzed 182 patients who had
undergone emergency surgery for incarcerated groin hernia,
192 The American Journal of Surgery, Vol 205, No 2, February 2013

Table 4 Postoperative complications of patients with and without bowel resection

Variable Total (N 5 86) No bowel resection (N 5 78) Bowel resection (N 5 8) P value*
General complications (%)
Without 77 (89.5) 74 (94.9) 3 (37.5) ,.001
With 9 (10.5) 4 (5.1) 5 (62.5)
Pneumonia (%)
Without 84 (97.7) 77 (98.7) 7 (87.5) .18
With 2 (2.3) 1 (1.3) 1 (12.5)
Wound infection (%))
Without 79 (91.9) 75 (96.2) 4 (50) .001
With 7 (8.1) 3 (3.8) 4 (50)
Mortality (%)
Without 84 (97.7) 78 (100) 6 (75) .008
With 2 (2.3) 0 (0) 2 (25)
*The Fisher exact test was used unless indicated otherwise.

28 of them with the femoral type. They observed a rate of
bowel resection for femoral hernias of approximately 46%.
This resection rate, the highest we have found in the liter-
ature, is consistent with several other reports3,6,1619 in
which the rate ranges from 20.8% to 38.5%. In contrast,
our study showed a significantly lower resection rate of
only 9.3% (Table 5).
This marked difference must be highlighted because it
raises doubts about previously asserted associations. In our
series, 73 (85%) patients experienced a duration of symp-
toms of 3 days or less before seeking specialized medical
help, perhaps because of quick referrals on the part of their
general practitioners. This suggests that minimizing the
preoperative period in patients with incarcerated femoral
hernias may be a way to lower bowel resection rates.
The development of bowel necrosis and subsequent
bowel resection has been associated with longer hospital
stays and worse outcomes for patients with incarcerated
femoral hernia; indeed, some studies have shown that
bowel resection has a direct effect on morbidity and
mortality.5 This supposition is confirmed in our study be-
cause patients who underwent bowel resection had longer
postoperative hospital stays, mainly because of surgical
wound infections. Moreover, we observed a mortality rate
of 25% after bowel resection, which is higher than the
results published by Kulah et al19 (17.6%) although the dif-
ferences are not statistically significant (P 5 .91). Suppiah
et al17 found morbidity and mortality rates of 21.4% and a
3.6%, respectively, after emergency or elective femoral her-
nia surgery, both of which exceed the rates observed in our
study.
Alterations in skin color and the presence of leukocy-
tosis are usually considered to be signs of strangulated
femoral hernia. However, we were not able to show an
association between leukocytosis and bowel ischemia in
our study. Although there was a clearly higher rate of bowel
resection in patients with leukocyte values above 11,000,
this association was not found to be statistically signifi-
cant.12 Our data likewise showed no association between
the suspicion of intestinal obstruction as seen in abdominal
radiography and bowel ischemia. This is consistent with
observations made by Sarr et al,20 who found no preopera-
tive clinical parameters including the presence of continu-
ous abdominal pain, fever, peritoneal signs, leukocytosis,
or acidosis, or a combination thereof, proved to be sensi-
tive, specific, and predictive for strangulation.
The principal limitation of our study is its retrospective
nature, and further prospective studies are needed for a better
assessment of the proposed risk factors. However, some of
the key issues discussed in this article may be integrated into

Table 5 Literature reports of bowel resection and mortality in femoral hernia and comparison with this study
Patients with emergency
Reference Study period femoral hernia Resection rate (%) P value* Mortality rate (%) P value
Alvarez et al3 19922001 77 16 (20.8) .065 3 (3.9) .9
Derici et al6 19982006 19 4 (21) .3 1 (5.3) .95
Kurt et al16 19972001 13 5 (38.5) .014 d d
Suppiah et al17 20002004 28 8 (28.6) .025 1 (3.6) .75
Ge et al18 19992009 28 13 (46.4) ,.001 d d
Kulah et al19 19962001 42 17 (41) .0001 3 (7) .4
This study 19952009 86 8 (9.3) d 2 (2.3) d
*P value: result of the comparison of the resection rate between this study and the rest.
P value: result of the comparison of the mortality rate between this study and the rest.
C. Alhambra-Rodriguez de Guzman et al. Outcomes of incarcerated femoral hernia
a strategy to achieve the highest advance before the devel-
opment of irreversible bowel necrosis. In that sense, we
should underline the following: improving the level of
suspicion of incarcerated femoral hernia at primary care
providers (maybe through specific medical instruction);
stating clearly that any attempt of manual hernia reduction
should be avoided at all levels of health care (ie, general
practitioners, emergency room staff members, residents, and
surgeons) when a femoral hernia is suspected; and preparing
the patients for surgery as soon as possible, especially if they
are receiving anticoagulant therapy or we think that the
duration of symptoms is about 3 days or more.
Conclusions
Similar to previously published results, our study found
that physical signs, leukocytosis, and radiologic data of
intestinal obstruction are not useful for anticipating intes-
tinal ischemia. Our main finding was that there is a strong
association between the intake of oral anticoagulants and
the prolonged duration of symptoms in patients with
incarcerated femoral hernia and the presence of bowel
necrosis. In these circumstances, a prompt operation is
necessary. We also showed that the average rate of bowel
resection among patients with incarcerated femoral hernia
can be reduced from those in previously reported series if
the aforementioned factors are properly controlled.
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