• Clinical science

Abdominal hernias

Abstract

Abdominal hernias are defined as the abnormal protrusion of intra-abdominal contents through congenital/acquired areas of weakness in the abdominal wall. Abdominal hernias are anatomically classified into four categories: ventral hernias (e.g., epigastric, umbilical hernia, incisional hernias), groin hernias (inguinal and femoral hernias), pelvic hernias (obturator, sciatic, and perineal hernias), and flank/lumbar hernias. Groin hernias are discussed in more detail in their respective learning cards. Inguinal, incisional, and umbilical hernias are the most common types of hernias. Persistently raised intra-abdominal pressure (e.g., due to ascites, pregnancy, intra-abdominal tumors, chronic cough, etc.) increases the risk of developing an abdominal hernia. Uncomplicated hernias are asymptomatic, nontender, completely reducible hernias with an expansile cough impulse. Complicated hernias include incarcerated, obstructed or strangulated hernias and are characterized by tenderness, irreducibility, features of bowel obstruction, and an absent cough impulse. Hernias with a narrow neck (e.g., femoral hernia, obturator hernia, paraumbilical hernia) have a higher risk of developing complications. Abdominal hernias are often diagnosed on clinical examination. Ultrasound/CT scans are useful in doubtful cases (e.g., obese patients). Complicated hernias, or those with a narrow neck, should be surgically repaired (primary repair/mesh repair). Asymptomatic hernias, with a wide neck do not require surgical repair.

Classification

Ventral hernias

Groin hernias

Pelvic hernias (rare)

Flank hernias

References:[1][2][2][3][4][5][6][7]

Clinical features

  • Most are asymptomatic
  • Reducible hernias
    • Completely reducible nontender mass on the abdominal wall (e.g., epigastric region, umbilicus, groin, etc.)
    • Increases on straining (e.g., coughing/lifting heavy objects)
    • Decreases on lying down
    • Edges of the fascial defect are palpable
    • Bowel sounds may be heard (If the content is bowel)
  • Irreducible/incarcerated hernias
  • Differential diagnosis: Abscess or hematoma
  • Treatment: Immediate surgical repair

The smaller the hernial orifice, the higher the risk of incarceration!

References:[8][9][1][10]

Diagnostics

  • Usually a clinical diagnosis
  • Imaging: consider if the diagnosis is unclear and/or to identify contents of the hernial sac (e.g., loops of bowel)
    • Ultrasound (e.g., to identify an epigastric, spigelian, incisional or umbilical hernia)
    • CT scan (e.g., to identify a lumbar, obturator, perineal or sciatic hernia)

References:[1]

Incisional hernia

  • Definition: Herniation of intra-abdominal contents through an incisional scar from a previous abdominal surgery
  • Incidence: ∼15% of patients who have undergone an abdominal surgery develop incisional hernias
  • Risk factors
    • Upper midline laparotomy incisions (highest risk)
    • Wound dehiscence
    • Postoperative wound infection
    • Poor wound healing
    • Emergency abdominal surgeries
  • Clinical features
    • Most; (∼ 75%) incisional hernias occur within 3 years of surgery
    • Mass/protrusion at the site of the incisional scar which increases with coughing/straining
    • Edges of the hernial defect can be palpated on reducing the hernia
  • Treatment
    • Conservative management: indications
      • Asymptomatic incisional hernias, with a wide neck (> 5–7 cm);
      • Patients who are at a high anesthetic risk (advanced age, multiple comorbidities) can be observed
    • Surgery: Indicated in symptomatic/complicated hernias or those with a narrow neck
      • Small incisional hernias (< 3 cm defect): primary repair
      • Larger incisional hernias: hernioplasty (mesh repair)
  • Recurrence: ∼ 30% of incisional hernias will recur after surgical repair (depending on the technique used)

References:[11][12][13][1][14][15]

Umbilical hernia

Umbilical hernias
Congenital umbilical hernia Acquired umbilical hernia
True (direct) umbilical hernia Paraumbilical hernia
Incidence
  • Common disorder ( ∼ 15% of infants)
  • Uncommon in adults
  • ∼ 5% of all abdominal hernias
Site of hernial defect
  • The umbilical orifice
  • The umbilical orifice
  • Adjacent to the umbilical orifice (superior/inferior/lateral)
Etiology
  • Congenitally weak abdominal wall defect
  • Congenitally weak abdominal wall defect
  • Acquired abdominal wall defect
Risk factors
  • Persistently raised intra-abdominal pressure
  • Persistently raised intra-abdominal pressure
Clinical features
  • Mass protruding through the umbilicus
  • Mass increases on crying/coughing/straining; disappears on lying down
  • Hernia can be completely reduced (unless complicated)
  • Mass protruding through the umbilical orifice
  • Mass protruding adjacent to the umbilical orifice pushing the umbilicus into a crescent shape
  • Fascial defect is small

Risk of developing complications

(Incarceration/obstruction/strangulation)

  • Low
  • Low
  • High
Treatment
  • Conservative: ∼ 90% will spontaneously close by 5 years of age
  • Surgery (rarely necessary)
  • Surgery (primary repair/mesh plasty): All paraumbilical hernias
Differential diagnosis
  • Diagnosis is usually clear
  • Diagnosis is usually clear

References:[1][16][17][18]

  • 1. Brooks DC. Overview of abdominal wall hernias in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-abdominal-wall-hernias-in-adults. Last updated January 21, 2017. Accessed February 14, 2017.
  • 2. Howard FM, Perry P, Carter J, El-Minawi AM. Pelvic Pain: Diagnosis and Management. Lippincott Williams & Wilkins; 2000.
  • 3. Desai PK, et al. Spigelian hernia. https://radiopaedia.org/articles/spigelian-hernia-1. Updated March 1, 2017. Accessed March 1, 2017.
  • 4. Cima RR. Parastomal hernia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/parastomal-hernia. Last updated February 8, 2017. Accessed March 1, 2017.
  • 5. Mizrahi H, Geron N, Parker MC. Parastomal Hernia Is a Problem Yet to Be Solved. Journal of Current Surgery, North America. 2015; 5(2-3): pp. 151–156. doi: 10.14740/jcs268w.
  • 6. Perry CP, Echeverri JD. Hernias as a cause of chronic pelvic pain in women. JSLS. 2006; 10(2): pp. 212–215. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016116/.
  • 7. Khaladkar SM, Kamal A, Garg S, Kamal V. Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature. Radiol Res Pract. 2014; 2014. doi: 10.1155/2014/625873.
  • 8. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. Schwartz's Principles of Surgery. McGraw-Hill Education; 2014.
  • 9. de Virgilio C, Frank PN, Grigorian A. Surgery: A Case Based Clinical Review. Springer; 2015.
  • 10. Shah AR. Hernia Reduction. In: Hernia Reduction. New York, NY: WebMD. http://emedicine.medscape.com/article/149608-overview. Updated February 28, 2017. Accessed March 1, 2017.
  • 11. Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ. 2012; 344(e2843). doi: 10.1136/bmj.e2843.
  • 12. Kingsnorth A. The management of incisional hernia. Ann R Coll Surg Engl. 2006; 88(3): pp. 252–260. doi: 10.1308/003588406X106324.
  • 13. Brooks DC, Cone J. Incisional hernia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/incisional-hernia. Last updated October 27, 2016. Accessed February 14, 2017.
  • 14. Calisto JL. Laparoscopic Incisional Hernia Repair. In: Laparoscopic Incisional Hernia Repair. New York, NY: WebMD. http://emedicine.medscape.com/article/1892407-overview. Updated October 16, 2015. Accessed March 1, 2017.
  • 15. Schumpelick V, Nyhus LM. Meshes: Benefits and Risks. Springer; 2004.
  • 16. Palazzi DL, Brandt ML. Care of the Umbilicus and Management of Umbilical Disorders. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/care-of-the-umbilicus-and-management-of-umbilical-disorders. Last updated February 8, 2017. Accessed February 14, 2017.
  • 17. Taylor D. Umbilical Hernia Repair. In: Umbilical Hernia Repair. New York, NY: WebMD. http://emedicine.medscape.com/article/2000990-overview. Updated October 19, 2015. Accessed February 14, 2017.
  • 18. Schumpelick V, Fitzgibbons RJ, Conze J, Prescher A, Schlächter M, Schumacher O. Recurrent Hernia: Prevention and Treatment. Springer; 2007.
last updated 10/19/2018
{{uncollapseSections(['3iaSr4', '4Vc3uY0', 'kiam74', 'OVcIuY0', 'Qlcu9c0', 'Rlcl9c0'])}}