Abdominal hernias

Last updated: March 22, 2022

Summarytoggle arrow icon

Abdominal hernias are a protrusion of intraabdominal contents through a congenital or acquired defect in the abdominal wall. Abdominal hernias are broadly classified by location (anterior wall, lateral wall, groin, or pelvis) and presentation (reducible, irreducible, obstructed, or strangulated). Physiological states that increase intraabdominal pressure (e.g., ascites, pregnancy, obesity, intraabdominal tumors, chronic cough) increase the risk of developing an abdominal hernia. Clinical presentation ranges from an asymptomatic mass in reducible hernias, to pain, bowel obstruction, and systemic symptoms in strangulated hernias. Abdominal hernias are typically a clinical diagnosis made on physical examination. Imaging (e.g., ultrasound, CT scan) may be used if the examination is difficult or atypical, and before surgery. Treatment is primarily surgical repair with or without a mesh, though observation may be adequate in some patients. Emergency surgery is always required for an obstructed or strangulated (i.e., ischemic) hernia. Congenital umbilical hernias typically close spontaneously by 5 years of age and have a wide neck, and the risk of complications is low; surgical intervention is rarely necessary.

See “Inguinal hernias” and ”Femoral hernias” for more detail on these hernia types.

By anatomical location [1][2]

By degree of complication [1][10]

  • Reducible hernia: Hernia contents can be completely returned to the peritoneal cavity.
  • Irreducible hernia (also known as incarcerated hernia): Hernia contents cannot be completely returned to the peritoneal cavity. [11]
  • Obstructed hernia: a hernia in which the lumen of the intestine within the hernial sac has become completely obstructed
  • Strangulated hernia
  • Complex hernia: a hernia that is technically challenging to repair, requires a longer operative time, and has greater associated perioperative morbidity than a simple hernia [14]

Intermediate-sized abdominal wall defects have the highest risk of causing an incarcerated hernia. Small wall defects are less likely to allow a visceral protrusion and large wall defects are less likely to cause mechanical impingement of the contents of the hernial sac.

Reducible hernia [15][16][17]

  • History
    • Symptomatic or asymptomatic mass or fullness
    • Size decreases with recumbency
    • Size increases with sitting, standing, and/or straining
  • Physical examination
    • Nontender mass that returns to the peritoneal cavity with mild, externally applied pressure
    • Visible or palpable cough impulse: expansion of the mass with increased abdominal pressure
    • Edges of the fascial defect may be palpable.
    • Bowel sounds may be present over the mass if part of the bowel is present in the hernial sac.

Irreducible (incarcerated) hernia [15][16][17]

  • Chronic incarceration: nontender or minimally tender mass
  • Acute incarceration: Mass may be painful.
  • Neither recumbency nor external pressure significantly reduce mass size.
  • Cough impulse may be present.

Obstructed hernia [15][16][17]

Strangulated hernia [15][16][17]

Intestinal strangulation can lead to gangrene, which can be fatal if not treated promptly.

Unusual presentations [1][15][16][17]

General principles

Imaging [4][18][19]

Indications [20]

Modalities

  • CT abdomen
    • Sensitive imaging study for suspected bowel obstruction or strangulation [10]
    • Typically performed with both IV and PO contrast (unless contraindicated because of obstruction)
    • Can facilitate planning for complex hernia repair [21]
  • Ultrasound
  • MRI abdomen
    • Indications: to rule out musculoskeletal disorders and occult groin hernia [22]
    • Like ultrasound, MRI allows for dynamic assessment.
  • Abdominal x-ray: may be used to rapidly evaluate for bowel obstruction and perforation

Findings

Laboratory studies [24]

Laboratory studies may show characteristic findings if a hernia is obstructed and/or strangulated, including:

Differential diagnoses of ventral hernias

Rectus sheath hematoma

Differential diagnoses of other hernias

The differential diagnoses listed here are not exhaustive.

Surgical repair is the definitive treatment for abdominal wall hernias, but management with watchful waiting may be appropriate in select patients. See also “Incisional hernia” and “Umbilical hernia” for management specific to these hernia types.

Initial management [28][29]

Treat strangulated hernias and obstructed hernias as surgical emergencies, for which operative repair is indicated within hours to prevent complications (e.g., intestinal ischemia, sepsis, and death).

Manual hernia reduction [29][30][31]

  • Indications: acutely incarcerated hernias with no signs of strangulation
  • Preparation: Administer analgesia; consider the need for procedural sedation.
  • Procedure
    • Ask the patient to lie in the supine position.
    • Apply ice or a cold compress over the hernia.
    • Apply slow, steady pressure to the hernia sac for up to 20 minutes.
  • Next steps
    • Reduction successful
      • Typically, patients are admitted for observation for at least 12 hours.
      • Schedule early surgical repair (often performed during the same admission).
    • Unsuccessful reduction or new signs of strangulation: prompt surgical intervention
  • Complications: visceral rupture or perforation, peritonitis, worsened ischemia

Do not attempt to reduce a strangulated hernia! Gangrenous bowel may be forced into the abdominal cavity, which can lead to peritonitis and sepsis. [28]

Nonoperative and preoperative management

Surgical management [1]

Umbilical hernias are defined as midline hernias at the level of the umbilicus. Ninety percent of umbilical hernias are acquired, usually as a result of increased abdominal pressure. [2][3]

Congenital vs. acquired umbilical hernias [42]

Congenital umbilical hernia [43][44][45]

Acquired umbilical hernia [1][4]

Epidemiology
Site of hernial defect
  • Umbilical orifice
  • Direct: umbilical orifice
  • Indirect (paraumbilical hernia): adjacent to the umbilical orifice
Etiology
  • Reopening of the previously closed umbilical ring or surrounding tissue
Risk factors
Clinical features
  • Mass that protrudes through the umbilicus covered by skin
  • Mass increases with increased abdominal pressure (e.g., as a result of crying, coughing, straining)
  • Reduces in size in recumbent position
  • Hernia can be completely reduced (unless incarcerated).
  • Direct hernia: mass that protrudes symmetrically through the umbilicus
  • Indirect hernia: mass that protrudes adjacent to the umbilical orifice, pushing the umbilicus into a crescent shape
  • Fascial defect is often small.

Risk of developing complications

(incarceration, obstruction, strangulation, or rupture)

  • Low
Treatment
  • Conservative: ∼ 90% will spontaneously close by 2 years of age
  • Surgery (rarely necessary)
    • Large umbilical hernias (defect > 1.5–2 cm) in children > 2–3 years of age
    • No evidence of spontaneous closure by 5 years of age
    • Patients with incarcerated, obstructed, or strangulated umbilical hernias
Differential diagnosis

Up to 20% of patients with cirrhosis develop an umbilical hernia. [28]

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