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Abdominal hernias

Last updated: June 16, 2021

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Abdominal hernias are defined as the abnormal protrusion of intra-abdominal contents through congenital/acquired areas of weakness in the abdominal wall. The four categories of anatomically-classified abdominal hernias include the following: ventral hernias (e.g., epigastric, umbilical, 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 articles. 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, and completely reducible with an expansile cough impulse. Complicated hernias include incarcerated, obstructed, and strangulated hernias and are characterized by tenderness, irreducibility, features of bowel obstruction, and an absent cough impulse. Abdominal hernias are often diagnosed on clinical examination. Imaging (e.g., ultrasound, CT scan) is used to confirm the diagnosis and evaluate the contents of the hernia. Complicated hernias and those with a narrow neck (e.g., femoral hernia, obturator hernia, paraumbilical hernia) should be surgically repaired (primary repair/mesh repair). Congenital umbilical hernias typically close spontaneously by 5 years of age, have a wide neck, and a low risk of complications; surgical intervention is rarely necessary.

Ventral hernias

Groin hernias

Pelvic hernias (rare)

Flank hernias

References:[1][2][3][4]

Reducible hernia

  • Hernial contents completely return to the abdominal cavity through the abdominal wall defect on lying down or upon application of mild external pressure.
    • Most reducible hernias manifest as an asymptomatic nontender mass.
      • Increases on straining (e.g., sitting up from a recumbent position)
      • Decreases completely on lying down
    • Visible cough impulse present: expansion of the hernia when the patient is asked to cough
    • Edges of the fascial defect are palpable
    • Bowel sounds may be heard over the mass (if the hernial content is bowel)

Irreducible/incarcerated hernia

  • Hernial contents become adhered to the hernial sac and cannot be reduced into the abdominal cavity.
    • Irreducible nontender mass
    • Visible cough impulse present
    • May decrease partially on lying down
    • Increased risk of obstruction and strangulation

Obstructed hernia

Strangulated hernia

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

References:[5][6]

Abdominal hernias are usually a clinical diagnosis.

The differential diagnoses listed here are not exhaustive.

  • Definition: Herniation of intraabdominal contents through an abdominal wall defect created during a previous abdominal surgery.
  • Incidence: ∼ 15% of patients who have undergone abdominal surgery develop incisional hernias.
  • Risk factors [7]
  • 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 is indicated in:
      • Asymptomatic incisional hernias, with a wide neck
      • Patients who are at a high anesthetic risk (advanced age, multiple comorbidities) [7]
    • Surgery is indicated in symptomatic/complicated hernias or those with a narrow neck.
  • Complications: ∼ 30% of incisional hernias will recur after surgical repair (depending on the technique used) [9]

References:[10]

Congenital vs. acquired umbilical hernia [11]
Congenital umbilical hernia

Acquired umbilical hernia (Paraumbilical hernia)

Epidemiology
  • Accounts for ∼ 5% of all adult abdominal hernias
Site of hernial defect
  • Umbilical orifice
  • Adjacent to the umbilical orifice (superior/inferior/lateral)
Etiology
  • Failed spontaneous closure of the umbilical ring following physiological herniation of the midgut patent umbilical orifice
  • For more information, see “Embryology” in “Gastrointestinal tract.”
Risk factors
  • Persistently raised intra-abdominal pressure
Clinical features
  • Mass protruding through the umbilicus and covered by skin
  • Mass increases with ↑ abdominal pressure (e.g., as a result of crying, coughing, straining)
  • Reduced in size on lying down
  • Hernia can be completely reduced (unless incarcerated)
  • 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
  • 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

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