Hernia

Background

• Classification
  • Reducible
    • Hernia sac soft, easy to replace back through the hernia defect
  • Incarcerated
    • Hernia sac firm, often painful, nonreducible
  • Strangulation
    • Impairment of blood flow
    • Severe pain at hernia site
    • Signs of intestinal obstruction
    • Skin changes overlying hernia sac may be seen

Types

1. Inguinal (75%)
   1. Most common type of hernia in both men and women
   2. Presents as groin mass
   3. Indirect (50%)
      1. Hernia passes from inguinal ring into scrotum (d/t patent processus vaginalis)
   4. Direct (25%)
      1. Hernia passes directly through transversalis fascia in Hesselbach triangle
2. Ventral
   1. Due to defect in anterior abdominal wall (spontaneous or acquired)
   2. Incisional
      1. Due to excess wall tension or inadequate wound healing / surgical wound infection
   3. Umbilical
      1. Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity)
   4. Spigelian
      1. Also known as lateral ventral hernia
      2. Nearly always acquired conditions
      3. Difficult to diagnose
         1. Classic presentation is abdominal pain a/w anterior lateral abdominal wall mass
         2. Physical exam is unreliable; imaging (US or CT) is often required
3. Femoral
   1. 10:1 female:male ratio
   2. Hernia sac protrudes through femoral canal
   3. Mass is typically below the inguinal ring
   4. Particularly prone to complications
4. Obsturator
   1. Bowel herniation through obturator canal
   2. Nearly always presents as partial or complete bowel obstruction
   3. High complication rate
5. Richter
   1. Involves only antimesenteric border of intestine and only portion of the wall
   2. Often presents w/o vomiting or intestinal obstruction due
      1. As a result, more likely to diagnose once wall has begun to become ischemic)

Work-Up

1. Labs
   1. Not routinely necessary
   2. Consider CBC, chemistry, lactate if concern for strangulation
2. Imaging
   1. Abd x-ray
      1. Only indicated if concern for obstruction
   2. Ultrasound
      1. Only indicated to exclude other diagnoses, exclude strangulation
   3. CT
      1. useful for uncommon hernia types (Spigelian, obturator)

Treatment

1. Reduction for incarcerated hernia
   1. If there is any concern for strangulation, do not attempt hernia reduction
      1. Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
   2. NPO (in case reduction unsuccessful)
   3. IV narcotic analgesia
   4. Supine and mild Trendelenberg positioning
   5. Apply cold packs to hernia site to reduce swelling
   6. Apply firm, steady pressure to distal part of hernia
   7. If successful observe pt in ED period of time for serial abd exams
   8. If unsuccessful after 1 or 2 attempts consult surgery
2. Abx
   1. Indicated for:
      1. Painful hernia
      2. Obstruction
      3. Peritonitis
   2. Cefoxitin

Disposition

1. Discharge with surgery referral:
   1. Easily reducible hernia
   2. Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration)

See Also

Inguinal Hernia (Peds)

Source

Tintinalli