A 50-year-old obese woman (BMI 34) presents with a painful, irreducible femoral hernia. She has hypertension and is on antiplatelet therapy. At laparotomy, the hernia sac contains 10 cm of ischaemic small bowel. After reduction and assessment, the bowel does not recover despite 5 minutes of warm towel application and lack of Doppler signal. What is the correct sequence of surgical steps?

• A Divide the lacunar ligament medially (not the inguinal ligament), resect non-viable bowel with primary anastomosis, perform femoral hernia repair without mesh in contaminated field ✓
• B Divide the inguinal ligament to facilitate reduction, then resect ischaemic bowel, mesh femoral defect, close
• C Divide the inguinal ligament, reduce hernia, perform mesh repair with polypropylene, resect bowel, primary anastomosis
• D Hartmann's procedure with end ileostomy, mesh femoral repair, return to OR in 6 weeks for bowel reconstruction

Explanation

In strangulated femoral hernia, the neck is bounded laterally by the femoral vein and medially by the lacunar (Gimbernat's) ligament. The lacunar ligament should be divided medially (not the inguinal ligament) to safely enlarge the neck and allow reduction without vascular injury. In a contaminated field with bowel resection, synthetic mesh placement increases infection risk; tissue-based repair or delayed mesh insertion is preferred. Primary anastomosis is appropriate in healthy proximal bowel without faecal contamination. Hartmann's procedure is reserved for colonic contamination or hemodynamically unstable patients, not small bowel resection.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.