A 65-year-old woman comes to the emergency department due to nausea, vomiting, and abdominal pain that began about 6 hours ago. She has also had vague pelvic pain over the last few months but says her pain has never been this severe. Temperature is 38.4 C (101 F), blood pressure is 141/90 mm Hg, pulse is 92/min, and respirations are 18/min. Physical examination shows a moderately distended abdomen. There is a tender bulge below the inguinal ligament, lateral to the pubic tubercle. The overlying skin is erythematous. Which of the following structures is most likely immediately lateral to the bulge?

Question

A 65-year-old woman comes to the emergency department due to nausea, vomiting, and abdominal pain that began about 6 hours ago.  She has also had vague pelvic pain over the last few months but says her pain has never been this severe.  Temperature is 38.4 C (101 F), blood pressure is 141/90 mm Hg, pulse is 92/min, and respirations are 18/min.  Physical examination shows a moderately distended abdomen.  There is a tender bulge below the inguinal ligament, lateral to the pubic tubercle.  The overlying skin is erythematous.  Which of the following structures is most likely immediately lateral to the bulge?

Quizplus · Accepted Answer

11ec160b_3581_4c7e_9249_f9c35f3e456f_MD0001_00 This patient has a femoral hernia, which characteristically presents with upper thigh, groin, or pelvic discomfort and a tender bulge below the inguinal ligament, lateral to the pubic tubercle and lacunar ligament. Femoral hernias are more common in women and tend to occur on the right side. Advanced age is the most important risk factor. Over time, the femoral ring becomes lax and can widen, allowing bowel to protrude into the femoral canal, the medial most compartment within the femoral sheath. The femoral vessels travel within other compartments of the femoral sheath, with the femoral vein running immediately lateral to the hernia. Because the femoral canal is small, femoral hernias are prone to incarceration. Incarcerated hernias cannot be reduced; if a segment of bowel is present in the hernia sac, incarceration can cause bowel obstruction (eg, nausea, vomiting, abdominal pain and distension). Incarceration can also cause impaired blood flow to contents trapped in the hernia sac, resulting in strangulation (ischemia and necrosis) with potential systemic complications such as sepsis. (Choice B) Direct inguinal hernias protrude through weakened transversalis facia, medial to the inferior epigastric vessels, and emerge into the Hesselbach triangle. Indirect inguinal hernias protrude lateral to the inferior epigastric vessels before running through the deep (internal) inguinal ring and into the inguinal canal. (Choice C) The pectineal ligament (inguinal ligament of Cooper) is a thickened part of the pectineal fascia. It overlies the pectineal ridge of the pubic bone and is located posterior to the femoral canal. (Choice D) The rectus muscle sheath forms the medial border of the Hesselbach triangle. Direct inguinal hernias are located just lateral to the rectus abdominis muscle sheath. (Choice E) The round ligament in women is homologous to the spermatic cord in men. It leaves the pelvis through the deep inguinal ring and passes through the inguinal canal. (Choice F) The transversalis fascia is found between the transversalis muscle and the extraperitoneal fat. It forms the posterior wall of the inguinal canal. The deep (internal) inguinal ring is an opening in the transversalis fascia and is the site of protrusion of indirect inguinal hernias. Educational objective: Femoral hernias can present with groin discomfort and a tender bulge on the upper thigh inferior to the inguinal ligament, lateral to the pubic tubercle and lacunar ligament. The structure that lies immediately lateral to the hernia within the femoral sheath is the femoral vein. Incarceration and strangulation are common complications of femoral hernias.

A 65-Year-Old Woman Comes to the Emergency Department Due to Nausea