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

  • 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)
    • 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

Hernia Locations.jpeg

Differential Diagnosis

Testicular Diagnoses

Evaluation

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)

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 Trendelenberg 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
    • Obstruction
    • Peritonitis

Disposition

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

See Also

References

Last modified on 30 March 2017, at 11:27