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Updated: Dec 15 2021

Abdominal Wall Hernias

  • 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
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