Updated: 12/19/2017

Abdominal Wall Hernias

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Overview
 
Snapshot
  • A 54-year-old male comes to the emergency room with right-sided groin pain, swelling, colicky abdominal pain and abdominal distension, nausea and 2 episodes of vomiting. He had been having intermittent pain and swelling in the right groin for 2 years always triggered by straining during defecation. He recalls that on all previous occasions, the swelling was reduced with gentle finger massage. However, finger massage was ineffective this time. He has a 20 pack-year smoking history. Examination reveals an overweight male with abdominal distension. There is a red, tender swelling in his right groin, descending into his right scrotum. Radiographs reveal dilated small bowel loops. He was diagnosed with an incarcerated, obstructed,indirect right inguinal hernia. 
Introduction
  • Clinical definition
    • a hernia is a protrusion of an organ (or a portion of the organ) through a body wall
      • can be congenital or acquired
        • congenital causes are due to an abdominal wall defect present at birth
        • acquired causes are due to weakening of the abdominal wall fibromuscular tissue
  • Epidemiology
    • inguinal hernia
      • incidence
        • of all hernias, approximately 75% are inguinal with
          • 50% of cases due to an indirect inguinal hernia
          • 25% of cases due to a direct inguinal hernia
      • demographics
        • more common in men
      • risk factors
        • aging
        • male sex
        • increased intra-abdominal pressure secondary to
          • heavy lifting
          • chronic coughing
          • chronic obstructive pulmonary disease (COPD)
        • family history
        • smoking
        • prior history of hernia
        • prior history of hernia repair
    • femoral hernia
      • incidence
        • 3-5% of all hernias are femoral hernias
      • demographics
        • more common in women
      • risk factors
        • look at risk factors for inguinal hernias above
    • umbilical hernia
      • incidence
        • approximately 14% of all hernias are umbilical hernias
      • demographics
        • premature children
        • in adults, it is more common in women
      • risk factors
        • prematurity
        • African American race
        • low birth weight
        • congenital syndromes such as
          • Beckwith Wiedemann syndrome
          • Down syndrome
Inguinal and Femoral Hernia
  • Pathophysiology
    • pathoanatomy
      • indirect inguinal hernia
        • hernia protrudes via the internal inguinal ring and lateral to the inferior epigastric vessels
      • direct inguinal hernia
        • hernia protrudes via the Hesselbach's triangle and medial to the inferior epigastric vessels
          • Hesselbach's triangle consists of the
            • inferior - inguinal ligament
            • lateral - inferior epigastric artery
            • medial - conjoint tendon
      • femoral hernia
        • hernia protrudes through the femoral ring which is inferior to the inguinal ligament
          • the femoral ring is medial to the femoral vein and lateral to the lacunar ligament
  • Presentation
    • symptoms
      • asymptomatic
      • localized pain
      • heavy sensation in the groin
      • hernia may worsen with activities that increase intra-abdominal pressure
    • physical exam
      • groin fullness/swelling
      • in cases of strangulated hernia the patient may present with
        • signs of sepsis
      • provocative tests
        • includes coughing and Valsalva maneuver
  • Imaging
    • ultrasonography
      • indication
        • when diagnosis is uncertain
  • Studies
    • diagnostic criteria
      • in the majority of cases, inguinal hernias can be diagnosed clincially
  • Treatment
    • conservative
      • watchful waiting
        • indication
          • in cases of inguinal hernia with little or no symptoms
    • operative
      • surgical repair
        • indications
          • in cases of strangulation or bowel obstruction
          • as an elective procedure in uncomplicated femoral hernia
          • in cases of inguinal hernia with moderate-to-severe symptoms
Umbilical Hernia
  • Pathophysiology
    • pathoanatomy
      • failure to spontaneous close the umbilical ring
  • Presentation
    • symptoms
      • painless protrusion of the umbilicus in the infant or child
      • strangulation
        • more common in adult men
    • physical exam
      • a reducible mass of the umbilicus
  • Studies
    • diagnostic criteria
      • a clinical diagnosis
  • Treatment
    • conservative 
      • watchful waiting
        • typically done because most cases spontaneously close in infants/children
        • in adults with a very small hernia that is asymptomatic
    • operative
      • surgical repair
        • indications
          • in children with symptoms and signs of strangulation or severe symptoms
          • can be considered in children with persistent hernia after 3 years of age
Differential Diagnoses
  • Hydrocele
  • Varicocele
  • Lipoma
  • Testicular torsion
  • Epididymitis
  • Inguinal adenopathy
  • Groin abscess
Complications
  • Complications include
    • incarcerated or obstructed bowel
    • strangulated bowel (vascular compromise)
      • reduction of strangulated bowel may lead to reduction of ischemic bowel into peritoneal cavity, resulting in perforation 

References

 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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