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 Guzma´n, M.D.a, Joaquı´n Picazo-Yeste, M.D.,
Ph.D.a,*, Jose Marı´a Tenı´as-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 Constitucio´n, 3.13600
Alca´zar 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 analytic
Intestinal obstruction; parameters associated with intestinal ischemia in patients with an incarcerated femoral hernia.
Risk factors
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 Guzma´n 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.1–4 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. 5–7
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. 13–15
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 Guzma´n 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 patient’s 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 (1.15–3.67)
Oral anticoagulants .016 9.6 (1.53–60.76)
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)
4 (30.8) .016
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 reports3,6,16–19 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†
´ 3
1992–2001 77 16 (20.8) .065 3 (3.9) .9
Alvarez et al
Derici et al6 1998–2006 19 4 (21) .3 1 (5.3) .95
Kurt et al16 1997–2001 13 5 (38.5) .014 d d
Suppiah et al17 2000–2004 28 8 (28.6) .025 1 (3.6) .75
Ge et al18 1999–2009 28 13 (46.4) ,.001 d d
Kulah et al19 1996–2001 42 17 (41) .0001 3 (7) .4
This study 1995–2009 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 Guzma´n 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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