Abdominal Hernia

Abdominal hernias are one of the most common surgical problems. By definition, a hernia is an abnormal protrusion from one anatomic space to another, with the protruded parts generally contained in a saclike structure formed by the membrane that naturally lines the cavity. They are a one of the leading causes of morbidity and can be lethal.

This disease is triggered by anatomic/foreign processes.

Presentation

The hernia presents as a protrusion that gets bigger with increased intraabdominal pressure such as during coughing. They patient may present in an emergency situation with a strangulated hernia, or it may be found on routine examination. The protrusion may be intermittent or constant.

If strangulated, there is pain, swelling and erythema at the hernia site. There may be associated symptoms of intestinal obstruction like abdominal pain, vomiting and nausea. There may be peritonitis if the bowel gets gangrenous and perforates [7].

Workup

Laboratory diagnosis

There are no specific laboratory studies specific for hernia, but they may help in toxic patients.

Imaging

CT scan, ultrasound and radiographs are not usually required but may be used to confirm the diagnosis if there is doubt. The bulk of the diagnosis is clinical. In acquired hernias, workup of the underlying cause will have to be searched for, for example ascites [8].

Treatment

In adults most hernias should be repaired to prevent complications. Reduction should be avoided if there are signs of inflammation or strangulation. Usually all inguinal hernias should be repaired. Umbilical hernia repair should be carried out in adults. In children most will close by the age of five, unless they are large. Elective repair is preferred to acute repair. There are number of methods that can be used, for example the use of meshes and special suturing techniques.

Prognosis

This is dependent on the type of hernia present and its size and location. The largest risk is strangulation of intestines and if not repaired in time, it may lead to mortality rates as high as 10%. Uncomplicated hernias have a good prognosis if repaired appropriately [6].

Etiology

The congenital hernias are caused by small defects that occur during embryogenesis. Acquired hernias are caused by an increase in the abdominal cavity pressure that may weaken the wall and cause the protrusion. Risk factors for this include ascites, weight lifting, coughing, peritoneal dialysis and obesity [2] [3].

Epidemiology

As many as 10 to 13% of people will have a hernia at one time in their life. The most common hernia being inguinal taking up about 75% of all hernias of which 50% are indirect, 14% are umbilical, 10% are ventral and 3 to 5% femoral [4]. Inguinal hernias are more common in males, with 25% of males having one in their life time.

Sex distribution
Age distribution

Pathophysiology

  • Groin hernias are the commonest hernias of the abdominal wall. The inguinal hernia is caused by weakened musculature that usually causes a shutter effect during straining. Repeated straining that increases the intraabdominal pressure causes protrusion. Direct inguinal hernia is caused by weakness in the transversalis fascia area of the Hesselbach triangle. An indirect hernia follows the tract of the inguinal canal and it is caused by a persistent processus vaginalis.
  • Epigastric hernias are located in the midline between the umbilicus and the xiphoid process and are usually >1cm. The cause of this may be a combination of congenital and acquired factors such as muscle weakens or increased intraabdominal pressure. These are usually asymptomatic and bowel strangulation is rare.
  • Flank hernias, even being outside the anatomical abdominal wall, are still classified as such. There are two types, the superior and inferior triangle hernias. These can be acquired; usually after surgeries such as nephrectomies.
  • Umbilical hernias in adults are usually acquired and associated with obesity, ascites, and pregnancy. This may present with strangulation of intestinal contents [5].

Prevention

There is no prevention of congenital hernias. Avoidance of chronic increased intraabdominal pressure is key. Thus patients with the risk factors for this should be treated promptly and appropriately [9] [10].

Summary

There are a number of different abdominal hernias and they are classified by their anatomical locations:

  • Groin hernia is a hernia that occurs in the lower part of the abdomen where the thigh and the hip meets. There can be inguinal and femoral hernias.
  • Pelvic hernias are protrusions through the foramina of the pelvis.
  • Flank hernias protrude through weakened areas of back muscles. Included in this are the inferior and superior lumbar triangle hernias.
  • Ventral hernias occur anteriorly, such as umbilical and epigastric hernias.

The hernias may also be classified as congenital such as an indirect inguinal hernia or acquired [1].

Patient Information

Definition

The internal organs are held in a cavity with a wall (abdominal). Defects in the wall may cause protrusion of the contents of the cavity. This causes a visible bulge in the defect. There many different types of abdominal wall hernias. The most common being inguinal hernia, which are more common in men. These occur around the groin area.

Cause

They are two types; defects in the wall that you are born with, so when the pressure in the abdomen increases the contents are pushed through this defect. The second are caused by having conditions that weaken the abdominal wall and increase the pressure within, like a chronic cough, or chronic straining while urination.

Symptoms

These may present as a bulge in the trunk of the body that increases in size on coughing or straining. The protrusion may balloon out into a sac that may hold intestines. The intestines may get jammed up in the sac and swollen and compressed. This is an emergency and can be fatal.

Diagnosis

Hernias are diagnosed by your doctor just by examination, the doctor may order some scans, but this is not routinely done.

Treatment

Hernias are repaired by surgery. There are two ways this may be done. Open surgery and laparoscopic or keyhole surgery. This will depend on the size and location of the hernia. They may also use meshes to strengthen the defect in the wall to prevent it coming back again.

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References

  1. Steinke W, Zellweger R. Richter's hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview. Ann Surg 2000; 232:710.
  2. Murphy KP, O'Connor OJ, Maher MM. Adult abdominal hernias. AJR Am J Roentgenol 2014; 202:W506.
  3. Bobrow RS. The hernia. J Am Board Fam Pract. Jan-Feb 1999;12(1):95-6
  4. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol. May 15 2007;165(10):1154-61
  5. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. Apr 2008;45(4):261-312
  6. Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg. Mar 2012;147(3):277-81.
  7. Wants GE. Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994
  8. Eubanks S. Hernias. In: Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 1997
  9. Smith S. Inguinal hernia reduction. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:840-847/87
  10. Collaboration EH. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg. Jul 2000;87(7):860-7

  • A Grynfeltt hernia: report of a case - G Skrekas, VK Stafyla, VE Papalois - Hernia, 2005 - Springer
  • A Decision Support System For The Management Of Acute Abdominal Pain (user's Manual). - DG Southerland, K Fisherkeller - 1987 - archive.rubicon-foundation.org
  • Abdominal wall hernias: MDCT findings - DA Aguirre, G Casola, C Sirlin - American Journal of , 2004 - Am Roentgen Ray Soc
  • Hernias in trocar ports following abdominal laparoscopy - H Lajer, S Widecrantz - Acta obstetricia et , 1997 - Wiley Online Library
  • Abdominal pain: a surgical audit of 1190 emergency admissions - TT Irvin - British Journal of Surgery, 1989 - Wiley Online Library
  • Amyand's hernia: prospective CT diagnosis - JS Luchs, D Halpern, DS Katz - Journal of computer assisted , 2000 - journals.lww.com
  • Abdominal musculature abnormalities as a cause of groin pain in athletes Inguinal hernias and pubalgia - DC Taylor, WC Meyers, JA Moylan - The American journal , 1991 - ajs.sagepub.com
  • Abdominal hernias: CT findings. - NP Zarvan, FT Lee Jr, DR Yandow - American Journal of , 1995 - Am Roentgen Ray Soc
  • Abdominal-wall tenderness: a useful sign in the acute abdomen - H Thomson, DMA Francis - The Lancet, 1977 - Elsevier
  • Abdominal hernias: CT findings. - NP Zarvan, FT Lee Jr, DR Yandow - American Journal of , 1995 - Am Roentgen Ray Soc
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