|

| Home  |  Specialties | Resource Centers |  Learning Centers  |  CME  |  Contributor Recruitment

|

Articles Images CME Advanced Search  Consumer Health | Link to this site

You are in: eMedicine Specialties > Emergency Medicine > Gastrointestinal

Hernias
Last Updated: January 3, 2007

Rate this Article
Email to a Colleague
Get CME/CE for article

Synonyms and related keywords: hernia, abdominal wall hernia, indirect inguinal hernia, indirect hernia, direct inguinal hernia, direct hernia, femoral hernia, umbilical hernia, Richter hernia, incisional hernia, spigelian hernia, obturator hernia, reducible hernia, incarcerated hernia, strangulated hernia

| AUTHOR INFORMATION | Section 1 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Author: David Manthey, MD, Director of Undergraduate Medical Education, Associate Professor, Department of Emergency Medicine, Wake Forest University Baptist Medical Center
Coauthor(s): Bret A Nicks, MD, Assistant Medical Director, Clinical Instructor, Department of Emergency Medicine, Wake Forest University Baptist Medical Center

David Manthey, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Editor(s): Richard Lavely, MD, JD, MS, MPH, Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eugene Hardin, MD, FACEP, FAAEM, Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center

Disclosure

| INTRODUCTION | Section 2 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Background: In 1804, Astley Cooper stated,

A hernia is defined as a protrusion of any viscus from its proper cavity. The protruded parts are generally contained in a sac-like structure, formed by the membrane with which the cavity is naturally lined.

Several different types of abdominal wall hernias exist, along with a larger number of associated eponyms. This article reviews the pathophysiology, evaluation, and treatment of most of these hernias from an emergency medicine perspective. Hernias are brought to the attention of an emergency physician either during a routine physical examination or when the patient has developed a complication associated with the hernia.

Pathophysiology:

Indirect hernia
An indirect inguinal hernia follows the tract through the inguinal canal. This results from a persistent process vaginalis.
The canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.
Direct hernia
A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon.
Femoral hernia
The femoral hernia follows the tract below the inguinal ligament through the femoral canal. The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament.
Because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated.
Umbilical hernia
The umbilical hernia occurs through the umbilical fibromuscular ring, which usually obliterates by 2 years of age.
Umbilical hernias are congenital in origin and are repaired if they persist in children older than 2-4 years.
Richter hernia
The Richter hernia occurs when only the antimesenteric border of the bowel herniates through the fascial defect.
A Richter hernia involves only a portion of the circumference of the bowel. As such, the bowel may not be obstructed, even if the hernia is incarcerated or strangulated, and the patient may not present with vomiting. Richter hernia can occur with any of the various abdominal hernias and is particularly dangerous, as a portion of strangulated bowel may be reduced unknowingly into the abdominal cavity, leading to perforation and peritonitis.
Incisional hernia
This iatrogenic hernia occurs in 2-10% of all abdominal operations secondary to breakdown of the fascial closure of prior surgery. Even after repair, recurrence rates approach 20-45%.
Spigelian hernia
This rare form of abdominal wall hernia occurs through a defect in the spigelian fascia, which is defined by the lateral edge of the rectus muscle at the semilunar line (costal arch to the pubic tubercle).
Obturator hernia
This hernia passes through the obturator foramen, following the path of the obturator nerves and muscles. Obturator hernias occur with a female-to-male ratio of 6:1, because of a gender-specific larger canal diameter. Because of its anatomic position, this hernia presents more commonly as a bowel obstruction than as a protrusion of bowel contents.
Reducible hernia
This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually.
Incarcerated hernia
An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised. Bowel obstruction is common.
Strangulated hernia
A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents.

Frequency:

In the US:
Approximately 700,000 herniorrhaphies are performed in the United States each year.

Approximately 25% of males and 2% of females have inguinal hernias in their lifetimes; this is the most common hernia in males and females.

Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct.

Indirect inguinal hernias are the most common hernias in both men and women; a right-sided predominance exists.

Incisional and ventral hernias account for 10% of all hernias.

Only 3% of hernias are femoral hernias.

Between 10% and 30% of children have an abdominal wall hernia; most hernias of this type close spontaneously by age 1 year.

The incidence of incarcerated or strangulated hernias in pediatric patients is 10-20%; 50% of these occur in infants younger than 6 months.

Internationally:
Data from developing countries is limited; therefore, an accurate occurrence value is unavailable. Gender and anatomic distribution are believed to be similar.

Mortality/Morbidity: Morbidity is secondary to missing the diagnosis of the hernia or complications associated with management of the disease.

A hernia can lead to an incarcerated and often obstructed bowel.

The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced strangulated bowel leads to persistent ischemia/necrosis with no clinical improvement.

Ensuing surgery to repair the hernia or its complications may leave the patient at risk for future hernias or intra-abdominal adhesions.

Race:

Umbilical hernias occur 8 times more frequently in black infants than in white infants.

Sex:

Approximately 90% of all inguinal hernia repairs are performed on males.

Reduction of hernias in females may be complicated by inclusion of the ovary in the hernia.

Femoral hernias (although rare) occur almost exclusively in women because of the differences in the pelvic anatomy.

The female-to-male ratio of obturator hernias is 6:1.

Age:

Indirect hernias usually present during the first year of life, but they may not appear until middle or old age.

Direct hernias occur in older patients as a result of relaxation of abdominal wall musculature and thinning of the fascia.

Umbilical hernias usually occur in infants and reach their maximal size by the first month of life. Most hernias of this type close spontaneously by the first year of life, with only a 2-10% incidence in children older than 1 year.

| CLINICAL | Section 3 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

History: Patients with hernias present to the emergency department (ED) secondary to a complication associated with the hernia. Hernias also may be detected in the ED on routine physical examination. However, in relation to the chief complaint, the following issues must be considered:

Asymptomatic hernia

Presents as a swelling or fullness at the hernia site

Aching sensation (radiates into the area of the hernia)

No true pain or tenderness upon examination

Enlarges with increasing intra-abdominal pressure and/or standing

Incarcerated hernia

Painful enlargement of a previous hernia or defect

Cannot be manipulated (either spontaneously or manually) through the fascial defect

Nausea, vomiting, and symptoms of bowel obstruction (possible)

Strangulated hernia

Symptoms of an incarcerated hernia present combined with a toxic appearance.

Systemic toxicity secondary to ischemic bowel is possible.

Strangulation is probable if pain and tenderness of an incarcerated hernia persist after reduction.

Suspect an alternative diagnosis in patients who have a substantial amount of pain without evidence of incarceration or strangulation.

Femoral hernia: Medial thigh pain as well as groin pain are possible because of the position of this hernia.

Obturator hernia

Because this hernia is hidden within deeper structures, it may not present as a swelling.

The patient may complain of abdominal pain or medial thigh pain, weight loss, or recurrent episodes of bowel or partial bowel obstruction.

Pressure on the obturator nerve causes pain in the medial thigh that is relieved by thigh flexion. This same pain may be exacerbated by extension or external rotation of the hip (Howship-Romberg sign).

Incisional hernia

As these are usually asymptomatic, patients present with a bulge at the site of a previous incision.

Lesion may become larger upon standing or with increasing intra-abdominal pressure.

Physical: In general, the physical examination should be performed with the patient in both the supine and standing positions, with and without the Valsalva maneuver. The examiner should attempt to identify the hernia sac as well as the fascial defect through which it is protruding. This allows proper direction of pressure for reduction of hernia contents. The examiner should also identify evidence of obstruction and strangulation.

When attempting to identify a hernia, look for a swelling or mass in the area of the fascial defect.

Place a fingertip into the scrotal sac and advance up into the inguinal canal. If the hernia is elsewhere on the abdomen, attempt to define the borders of the fascial defect.

If the hernia comes from superolateral to inferomedial and strikes the distal tip of the finger, it most likely is an indirect hernia.

If the hernia strikes the pad of the finger from deep to superficial, it is more consistent with a direct hernia.

A bulge felt below the inguinal ligament is consistent with a femoral hernia.

Strangulated hernias are differentiated from incarcerated hernias by the following:

Pain out of proportion to examination findings

Fever or toxic appearance

Pain that persists after reduction of hernia

Causes: Any condition that increases the pressure in the intra-abdominal cavity may contribute to the formation of a hernia, including the following:

Marked obesity

Heavy lifting

Coughing

Straining with defecation or urination

Ascites

Peritoneal dialysis

Ventriculoperitoneal shunt

Chronic obstructive pulmonary disease (COPD)

Family history of hernias

| DIFFERENTIALS | Section 4 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Epididymitis
Hidradenitis Suppurativa
Hydrocele
Lymphogranuloma Venereum
Testicular Torsion

Other Problems to be Considered:
Groin abscess
Hematoma
Lipoma
Lymphadenitis
Pseudoaneurysm
Spermatocele
Tumor
Undescended or retracted testes
Varicocele

Quick Find

Author Information
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
Pictures
Bibliography

Click for related images.

Related Articles

Epididymitis

Hidradenitis Suppurativa

Hydrocele

Lymphogranuloma Venereum

Testicular Torsion

Continuing Education

CME available for this topic. Click here to take this CME.

Patient Education
Click here for patient education.

| WORKUP | Section 5 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Lab Studies:

Complete blood count

Test is nonspecific.

Leukocytosis with left shift may occur with strangulation.

Electrolytes, BUN, creatinine levels

Assess the hydration of the patient with nausea and vomiting.

These tests are rarely needed except as part of a preoperative workup.

Urinalysis: This test assists with narrowing the differential diagnosis of genitourinary causes of groin pain.

Imaging Studies:

Imaging studies are not required in the normal workup of a hernia.

Ultrasonography can be used in differentiating masses in the groin or abdominal wall or in differentiating testicular sources of swelling.

If an incarcerated or strangulated hernia is suspected, the following imaging studies can be performed:

Upright chest radiograph to exclude free air (extremely rare)

Flat and upright abdominal films to diagnose a small bowel obstruction (neither sensitive or specific) or to identify areas of bowel outside the abdominal cavity

CT scanning or ultrasonography may be necessary in the following cases:

To diagnose a spigelian or obturator hernia

Inability to obtain a good examination because of body habitus

| TREATMENT | Section 6 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Emergency Department Care:

Reduction of a hernia

Provide adequate sedation and analgesia to prevent straining or pain. The patient should be relaxed enough to not increase intra-abdominal pressure or to tighten the involved musculature.

Place the patient supine with a pillow under his or her knees.

Place the patient in a Trendelenburg position of approximately 15-20° for inguinal hernias.

Apply a padded cold pack to the area to reduce swelling and blood flow while establishing appropriate analgesia.

Place the ipsilateral leg in an externally rotated and flexed position resembling a unilateral frog leg position.

Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding over the ring during reduction attempts.

Firm, steady pressure should be applied to the side of the hernia contents close to the hernia opening, guiding it back through the defect.

Applying pressure at the apex, or first point, that is felt may cause the herniated bowel to "mushroom" out over the hernia opening instead of advancing through it.

Consult with a surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use repeated forceful attempts.

The spontaneous reduction technique requires adequate sedation/analgesia, Trendelenburg positioning, and padded cold packs applied to the hernia for a duration of 20-30 minutes. This can be attempted prior to manual reduction attempts.

Consultations: Consult a surgeon for the following reasons:

Inability to reduce the hernia

Concern for a strangulated bowel and a patient with a toxic appearance

Patients with comorbid risks for sedation should have a surgeon present for the initial reduction attempt.

| MEDICATION | Section 7 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

For strangulated hernias, start broad-spectrum antibiotics. Antibiotics are administered routinely if ischemic bowel is suspected.

Drug Category: Antibiotics -- These agents are to be used if the patient has a strangulated hernia.

Drug Name

Cefoxitin (Mefoxin) -- Multiple regimens that cover for bowel perforation and/or ischemic bowel can be used. Cover for both aerobic and anaerobic gram-negative bacteria.

Adult Dose | 1-2 g IV q8h
Pediatric Dose | 80 mg/kg/d IV divided into 4 equal doses q6h
Contraindications | Documented hypersensitivity
Interactions | Probenecid may increase effects; aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy | B - Usually safe but benefits must outweigh the risks.
Precautions | Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in previously diagnosed colitis

| FOLLOW-UP | Section 8 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Further Inpatient Care:

All incarcerated or strangulated hernias demand admission and immediate surgical evaluation.

Further Outpatient Care:

Schedule a follow-up visit with the general surgeon within the next 1-2 weeks for those patients with easily reducible hernias or with hernias found upon physical examination.

Discharge patients with umbilical hernias with close follow-up care if the defect is less than 2 cm in diameter and the hernia is not incarcerated or strangulated.

Educate patients to avoid those activities that increase intra-abdominal pressure.

Educate patients to return for increased pain, inability to reduce hernia, fever, and vomiting.

Deterrence/Prevention:

Counsel the patient on avoidance of activities that increase intra-abdominal pressure, such as straining at defecation or lifting heavy objects.

Complications:

If strangulation of the hernia is missed, bowel perforation and peritonitis can occur.

Hernias can reappear in the same location, even after surgical repair.

Prognosis:

The prognosis depends on the type and size of hernia as well as on the ability to reduce risk factors associated with the development of hernias.

The prognosis is good with timely diagnosis and repair.

Patient Education:

Counsel the patient to avoid those activities that increase intra-abdominal pressure, such as straining at defecation and lifting heavy objects.

Instruct the patient to apply support to the hernia.

Even with asymptomatic hernias, early repair (ie, before it enlarges) is preferred.

| MISCELLANEOUS | Section 9 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Medical/Legal Pitfalls:

Failure to consider the diagnosis of hernia in patients who present with nausea and/or vomiting

Diagnosing testicular torsion as a hernia (puts the testicle at risk)

Reducing a strangulated bowel without recognizing it (The hernia will be reduced, but the bowel will remain ischemic.)

Special Concerns:

Pain after reduction of a hernia may indicate a strangulated hernia, requiring further evaluation by a surgeon.

| PICTURES | Section 10 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Caption: Picture 1. Anatomic locations for various hernias
| View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Image

| BIBLIOGRAPHY | Section 11 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Bobrow RS: The hernia. J Am Board Fam Pract 1999 Jan-Feb; 12(1): 95-6[Medline].
Eubanks S: Hernias. In: Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 1997.
Ginsburg BY, Sharma AN: Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med 2006 Feb; 30(2): 155-7[Medline].
Kapur P, Caty MG, Glick PL: Pediatric hernias and hydroceles. Pediatr Clin North Am 1998 Aug; 45(4): 773-89[Medline].
Levine BJ, Nabha S, Bouzoukis JK: Chronic inguinal hernia. J Emerg Med 1999 May-Jun; 17(3): 515-6[Medline].
Manthey, DE: Abdominal hernia reduction. In: Clinical Procedures in Emergency Medicine. 2003.
Mensching JJ, Musielewicz AJ: Abdominal wall hernias. Emerg Med Clin North Am 1996 Nov; 14(4): 739-56[Medline].
Rutkow IM, Robbins AW: Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am 1993 Jun; 73(3): 413-26[Medline].
Scherer LR 3d, Grosfeld JL: Inguinal hernia and umbilical anomalies. Pediatr Clin North Am 1993 Dec; 40(6): 1121-31[Medline].
Wants GE: Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994.

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Hernias excerpt

About Us | Privacy | Terms of Use | Contact Us | Advertising | Institutional Subscribers

We subscribe to the
HONcode principles of the
Health On the Net Foundation

© 1996-2006 by WebMD
All Rights Reserved