Hernia: Difference between revisions
 
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{{Adult top}} [[inguinal hernia (peds)]]
==Background==
==Background==
[[File:Gray1144.png|thumb|Scrotal anatomy]]
[[File:Inguinalhernia (1).gif|thumb|Anatomy of an inguinal hernia.]]
===Classification===
===Classification===
*Reducible
*Reducible
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**Impairment of blood flow
**Impairment of blood flow
**Severe pain at hernia site
**Severe pain at hernia site
**Signs of intestinal obstruction
**Signs of [[SBO|intestinal obstruction]]
**Skin changes overlying hernia sac may be seen
**Skin changes overlying hernia sac may be seen


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**Umbilical
**Umbilical
***Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity)
***Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity)
***May ulcerate from ascites, see Flood Syndrome
**Spigelian
**Spigelian
***Also known as lateral ventral hernia  
***Also known as lateral ventral hernia  
***Nearly always acquired conditions
***Nearly always acquired conditions
***Difficult to diagnose
***Difficult to diagnose
****Classic presentation is abdominal pain a/w anterior lateral abdominal wall mass
****Classic presentation is abdominal pain associated with anterior lateral abdominal wall mass
****Physical exam is unreliable; imaging (US or CT) is often required
****Physical exam is unreliable; imaging (US or CT) is often required
*Femoral
*Femoral
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**Involves only antimesenteric border of intestine and only portion of the wall  
**Involves only antimesenteric border of intestine and only portion of the wall  
**Often presents with out vomiting or intestinal obstruction
**Often presents with out vomiting or intestinal obstruction
***As a result, more likely to diagnose once wall has begun to become ischemic)
***As a result, more likely to diagnose once wall has begun to become ischemic


==Clinical Presentation==
==Clinical Features==
[[File:Hernia Locations.jpeg|thumb]]
[[File:Inguinal hernia right view.jpg|thumb|Adult male right-sided with inguinal hernia.]]
[[File:Inguinal hernia.JPG|thumb]]
[[File:Hernia umilicalis.jpg|thumb|]]
*Hernia (usually) palpable on exam
**If incarcerated, nonreducible
**If strangulated, nonreducible and may have overlying skin changes
*+/- [[abdominal pain|abdominal]]/groin/[[testicular Pain]]
*+/- signs/symptoms of [[SBO]], [[peritonitis]] if strangulated


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Testicular DDX}}
{{Template:Testicular DDX}}


==Diagnosis==
==Evaluation==
[[File:Hernia Locations.jpeg|thumb]]
===Work-Up===
===Work-Up===
*Labs
*Labs
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**Consider CBC, chemistry, lactate if concern for strangulation
**Consider CBC, chemistry, lactate if concern for strangulation
*Imaging
*Imaging
**Abd x-ray
**CT, if concern for obstruction/strangulation
***Only indicated if concern for obstruction
**Ultrasound (only indicated to exclude other diagnoses)
**Ultrasound
 
***Only indicated to exclude other diagnoses, exclude strangulation
===Diagnosis===
**CT
***useful for uncommon hernia types (Spigelian, obturator)


==Management==
==Management==
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***Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
***Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
**NPO (in case reduction unsuccessful)
**NPO (in case reduction unsuccessful)
**IV narcotic analgesia
**IV [[opioid]] analgesia
**Supine and mild Trendelenberg positioning
**Supine and mild Trendelenburg positioning
**Apply cold packs to hernia site to reduce swelling
**Apply cold packs to hernia site to reduce swelling
**Apply firm, steady pressure to distal part of hernia
**Apply firm, steady pressure to distal part of hernia
**If successful observe patient in ED period of time for serial abd exams
**If successful observe patient in ED period of time for serial abdominal exams
**If unsuccessful after 1 or 2 attempts consult surgery
**If unsuccessful after 1 or 2 attempts consult surgery
*Antibiotics (e.g. [[Cefoxitin]]) for
*Antibiotics (e.g. [[Cefoxitin]]) for
**Obstruction
**[[Bowel obstruction]]
**Peritonitis
**[[Peritonitis]]


==Disposition==
==Disposition==

Latest revision as of 01:01, 1 February 2024

This page is for adult patients. For pediatric patients, see: inguinal hernia (peds)

Background

Scrotal anatomy
Anatomy of an inguinal hernia.

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

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

Clinical Features

Adult male right-sided with inguinal hernia.
Inguinal hernia.JPG
Hernia umilicalis.jpg
  • Hernia (usually) palpable on exam
    • If incarcerated, nonreducible
    • If strangulated, nonreducible and may have overlying skin changes
  • +/- abdominal/groin/testicular Pain
  • +/- signs/symptoms of SBO, peritonitis if strangulated

Differential Diagnosis

Testicular Diagnoses

Evaluation

Hernia Locations.jpeg

Work-Up

  • Labs
    • Not routinely necessary
    • Consider CBC, chemistry, lactate if concern for strangulation
  • Imaging
    • CT, if concern for obstruction/strangulation
    • Ultrasound (only indicated to exclude other diagnoses)

Diagnosis

Management

  • Reduction for incarcerated hernia
    • If there is any concern for strangulation, do not attempt hernia reduction
      • Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
    • NPO (in case reduction unsuccessful)
    • IV opioid analgesia
    • Supine and mild Trendelenburg positioning
    • Apply cold packs to hernia site to reduce swelling
    • Apply firm, steady pressure to distal part of hernia
    • If successful observe patient in ED period of time for serial abdominal exams
    • If unsuccessful after 1 or 2 attempts consult surgery
  • Antibiotics (e.g. Cefoxitin) for

Disposition

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

See Also

References

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