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