Abdominal Hernia

Aka: Abdominal Hernia, Ventral Hernia, Incarcerated Hernia, Strangulated Hernia, Irreducible Hernia, Reducible Hernia, Hernia, Richter's Hernia, Groin Hernia, Obturator hernia

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II. Types

  1. Groin Hernia
    1. Inguinal Hernia
      1. Indirect Inguinal Hernia (most common Groin Hernias)
      2. Direct Inguinal Hernia
    2. Femoral Hernia (10% of Groin Hernias)
  2. Ventral Hernia
    1. Umbilical Hernia (congenital in children)
    2. Paraumbilical Hernia (adults)
    3. Epigastric Hernia
    4. Incisional Hernia
    5. Spigelian Hernia
    6. Obturator hernia
      1. Obturator foramen Hernia often with Bowel Obstruction
      2. Most common in women due to a larger obturator canal diameter
    7. Diastasis Recti
      1. Not a true Hernia
      2. May be confused with Umbilical Hernia

III. Findings

  1. Reducible Hernia
    1. Symptoms increase with amount of pressure on contents
    2. Mass present on standing or valsalva
    3. Mass reduces when supine and relaxed
  2. Irreducible Hernia (Incarcerated Hernia)
    1. Mass remains palpable when patient relaxed and supine
    2. Failed reduction by clinician
    3. Normal overlying skin without tense contents
    4. Bowel sounds may be audible from within Hernia
  3. Strangulated Hernia
    1. Surgical emergency
      1. High mortality (up to 8% after first 24 hours)
    2. Irreducible Hernia with compromised blood supply
      1. Richter's Hernia: Part of gut circumference pinched
    3. Early: Small Bowel Obstruction
      1. Severe pain and inflammation (tenderness, induration, redness) over the Hernia site
    4. Later: Bowel Infarction, Necrosis and peritonitis
      1. Abdominal Distention
      2. Hypoactive bowel sounds
      3. Toxic appearing febrile patient

IV. Diagnosis

  1. Hernia is a clinical diagnosis

V. Labs

  1. Indicated only in evaluating differential diagnosis or in toxicity or dehydartion

VI. Imaging

  1. Ultrasound
    1. Indications
      1. Groin Hernia differential diagnosis (e.g. Testicular Torsion, Orchitis, abscess, Hydrocele)
    2. Bedside diagnosis of Inguinal Hernia
      1. Test Sensitivity 99%
      2. Test Specificity 97.5%
    3. Findings of Strangulated Hernia
      1. Fluid surrounding bowel in Inguinal Canal
      2. Loss of peristalsis
  2. Abdominal CT with IV contrast
    1. Indications
      1. Suspected incarcerated or Strangulated Hernia with difficult localization (especially in Obesity)
      2. Small Bowel Obstruction
      3. Differentiate Femoral Hernia from Inguinal Hernia
    2. Findings of Small Bowel Obstruction
      1. Small Bowel loops dilated >2.5 cm
    3. Findings of bowel ischemia
      1. IV contrast abnormal bowel wall enhancement
      2. Bowel wall thickening
      3. Free fluid
      4. Pneumatosis
  3. Plain film imaging (e.g. CT unavailable)
    1. Abdominal flat and upright XRay
      1. Evaluate for Bowel Obstruction
    2. Upright Chest XRay
      1. Evaluate for abdominal free air

VII. Management

  1. Hernia Reduction (if not contraindicated)
  2. Strangulated Hernia (with associated peritonitis, Bowel Obstruction)
    1. Nasogastric suction
    2. Intravenous Fluids
    3. Antibiotics
  3. Surgical Consultation
    1. Emergent Consultation for Strangulated Hernia, Bowel Obstruction or signs of peritonitis
    2. Phone Consultation if unsuccessful reduction of Incarcerated Hernia
    3. Outpatient surgical evaluation within 1-2 weeks if successful Hernia Reduction (for elective repair)

VIII. References

  1. Broder (2021) Crit Dec Emerg Med 35(9): 12-3
  2. Stevens (2013) Crit Dec Emerg Med 27(9): 2

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