Inguinal and femoral hernias in women

Photo of a woman (PantherMedia / imagepointfr) The treatment of inguinal hernias is sometimes different in women than in men. Doctors usually recommend surgery. This is because women who have an inguinal hernia are more likely to have a "hidden" femoral hernia too. The risk of complications is greater with femoral hernias.

Inguinal hernias often don't cause any severe symptoms, and can be treated quite effectively with surgery. Femoral hernias, on the other hand, can cause more problems because they are more likely to "pinch" a part of the bowel. Both of these groin hernias are usually treated with laparoscopic surgery with the use of a mesh. Laparoscopic surgery is also known as "minimally invasive" or "keyhole" surgery.

What causes inguinal and femoral hernias?

Inguinal hernias can occur if there's a weak point in the inguinal canal in the front abdominal wall. This canal runs diagonally from the hip bone down to the pubic bone, connecting the abdomen with the groin area. It contains nerves, blood vessels and lymphatic vessels. In women, it also contains the round ligament that supports the uterus (womb). Inguinal hernias occur when part of the peritoneum, bowel, or fat tissue bulges through a gap in the abdominal wall. The peritoneum is the membrane that lines the abdominal cavity and (completely or partly) encloses most of the organs in the abdomen.

Inguinal hernias are much less common in women because their inguinal canal is narrower. But weak connective tissue can increase the likelihood of having an inguinal hernia. The risk also increases with age. Lifting or carrying heavy objects probably doesn't affect the risk, or only plays a small role at the most.

Femoral hernias occur in the upper part of the thigh, just below the inguinal ligament. They are most common in women over the age of 65. Because they don't cause a visible bump, they are often not noticeable at first. The first sign is usually pain instead. Femoral hernias are sometimes confused with inguinal hernias, but are more painful.

When is surgery considered?

Unlike men, women are advised to have surgery for symptom-free inguinal hernias too because their risk of complications is higher. Also, women who have an inguinal hernia are more likely to have a "hidden" femoral hernia as well. This can often only be determined during surgery. Femoral hernias are associated with a high risk of complications if surgery isn’t performed. Part of the bowel could become "trapped" in the gap in the abdominal wall, and that could lead to a blocked bowel (obstruction) or an inflammation of the peritoneum (peritonitis). About half of all women who have a hidden femoral hernia end up needing emergency surgery.

What are the different types of surgery?

During surgery, the hernia sac is moved back into the abdomen together with its contents. The gap in the abdominal wall is then closed off. It can also be reinforced with tissue from another part of the body or with a fine synthetic mesh.

There are three main types of surgery:

  • Open surgery without mesh: Surgery is performed from outside the body through quite a long cut, and the gap is sewn together with neighboring connective tissue.
  • Open surgery with mesh: The area where the gap used to be is covered with a synthetic mesh to strengthen the abdominal wall.
  • Minimally invasive surgery (also known as keyhole or laparoscopic surgery): Three small incisions are usually made in the skin (5 to 10 mm long). A camera and surgical instruments can then be inserted into the abdomen or as far as the abdominal wall through these cuts. In minimally invasive surgery, the area where the opening of the hernia used to be is always covered with synthetic mesh.

Which types of surgery are most suitable?

In women, inguinal and femoral hernias are usually treated with minimally invasive surgery including the use of a mesh. Adding a synthetic mesh strengthens the abdominal wall somewhat better than only closing the gap by sewing it on to neighboring connective tissue. This also makes it possible to return to normal activities sooner after the surgery.

There are two main types of minimally invasive surgery:

  • TAPP (transabdominal preperitoneal): The surgery is performed via the abdomen. To do so, small cuts have to be made in the abdominal wall. The synthetic mesh is then attached between the peritoneum and the abdominal muscles.
  • TEP (totally extraperitoneal): Surgery is performed on the abdominal wall only. This means that the surgical instruments aren't inserted as deeply as they are in TAPP. The synthetic mesh is then attached between the peritoneum and the abdominal muscles.

TEP surgery is the more complex approach and more difficult for surgeons to learn.

Open surgery usually isn't recommended in women because their risk of developing another hernia is greater after open surgery.

What are the side effects of surgery?

Hernia operations are among the most commonly performed surgical procedures in Germany. Although complications are rare, side effects are possible. And anesthetics are always associated with risks.

Pain resulting from surgery in the groin area usually goes away within a few days. But about 10 out of 100 people have long-term pain following the surgery. The pain may be caused by nerve damage or reactions to the synthetic mesh. This kind of long-term pain is more common in women than in men.

Fewer than 1 out of 100 people have more serious complications after surgery. These include damage to blood vessels or the nerves inside the inguinal canal. Wound-healing problems and inflammations may occur too.

What do I need to know after having surgery?

You can return to physical activity very soon after having hernia surgery with the use of mesh. Walking and gentle physiotherapy exercises are already possible just a few hours later. The type and intensity of exercise should be chosen based on how you feel and how you are coping with the exertion. It is better to avoid lifting heavy objects in the first 2 to 3 weeks.

What can you do if the hernia comes back?

The risk of developing another hernia is greater in women than it is in men. Because of this, doctors generally recommend already using mesh the first time the hernia is operated on. If another hernia occurs, the recommended treatment is minimally invasive surgery using mesh again.

What if you develop a hernia during pregnancy?

It is very rare for inguinal or femoral hernias to occur during pregnancy. But if they do, doctors recommend waiting and having the hernia surgery after the pregnancy. Urgent surgery is only needed if the hernia pinches something and there's a risk of complications. But this very rarely happens in pregnant women. The hernia won't affect the pregnancy.