Presentation
A detailed medical history can reveal the natural course of the disease and whether the defect is congenital or acquired. A through physical examination will also be an invaluable tool in the diagnosis. Patient may need to be examined in both upright and supine position for better results.
Hernias will initially present as a bulge in the abdomen as with ventral hernia or a bulge in the scrotal sac in the case of inguinal hernia. Palpation and probing of the hernia sac may reveal its direct or indirect nature.
Patients may present with large lumps in the ventral abdomen where the visceral organs seen may give one a clue on the herniating organ and how to manage it.
Incarcerated hernia will present with swelling, pain on palpation and the inability to manipulate the hernia sac. The associated systemic signs of fever, nausea and vomiting may be suggestive of a more urgent case of intestinal strangulation which merits immediate surgery.
Entire Body System
- Pain
Painful scar. Sometimes people experience sharp, tingling pain in a specific area near the incision after it has healed. The pain usually resolves with time. Medicine may be injected in the area if the pain continues. Injury to internal organs. [gi.surgery.ucsf.edu]
Closing the defect may, however, cause tension and pain from the abdominal wall. Instead of closing the defect, the part of the peritoneum constituting the hernia sac may be used for closing the defect. [clinicaltrials.gov]
Symptoms include pain in the abdomen, especially when lifting or straining. Treatment is with surgery, including open, laparoscopic and robotic hernia repair. [my.clevelandclinic.org]
When tissue inside the hernia becomes stuck or trapped in abdominal muscle, it can cause pain, nausea, vomiting and constipation. [ucsfhealth.org]
- Weakness
The weakness in the abdominal wall through which the intestine protrudes may be part of your body’s natural formation. [hopkinsmedicine.org]
Weakness in an area of the abdominal wall that was present at birth. Weakness in the abdominal wall caused by conditions that put strain on the wall. [my.clevelandclinic.org]
A ventral hernia is a bulge of tissues through an opening of weakness within your abdominal wall muscles. It can occur at any location on your abdominal wall. [healthline.com]
A ventral hernia is a hernia that forms in the abdominal wall, along the midline, due to a weakness in the muscles that creates a gap. Typically, with a ventral hernia, abdominal tissues or a portion of the intestines protrude into the gap. [medstarwashington.org]
- Fever
[…] inquire about and/or look for: Constipation, "narrow" or "thin" stool Lump or protrusion in the abdomen; you may be asked to stand and cough, which increases abdominal pressure and makes the hernia more pronounced and easier to diagnose Nausea, vomiting, fever [hopkinsmedicine.org]
A strangulated ventral hernia causes severe abdominal pain, fever, rapid heart rate and abdominal tenderness. Vomiting often occurs because the strangulated area blocks passage of digested material. [livestrong.com]
Other symptoms of a strangulated hernia include severe abdominal pain, profuse sweating, rapid heartbeat, severe nausea, vomiting and high fever. In many cases, a hernia can be diagnosed through a physical examination of the abdomen. [ucsfhealth.org]
Postoperative complications occurred only with rIPOM and included urinary retention, seroma, and fever. [ncbi.nlm.nih.gov]
- Wound Infection
Early wound complications included subcutaneous wound infection (18), deep wound infection (17), dehiscence (13), fistula (2), and suture sinus (2). A ventral hernia developed in 42 (4.2%) cases during follow-up. [ncbi.nlm.nih.gov]
[…] and wound infection Homeostasis Good bleeding control reduces the chance of wound infection Ratio of suture length to wound length If it is >5.1, it may result in an increased incidence of wound infection Overuse of diathermy Result in more necrotic [intechopen.com]
- Swelling
The physician may recommend a surgery, when: The swelling becomes bigger during the period of 1-2 years (age of child) The swelling does not disappear by the age of 4 years If any complication (such as tender to touch, vomiting, or severe pain) develops [dovemed.com]
It can cause severe swelling and bluish discoloration of the skin around the incision. Surgery may be necessary to open the incision and stop the bleeding. Bleeding is unusual and occurs in less than 2 percent of patients. Wound infection. [gi.surgery.ucsf.edu]
These symptoms may include: Swelling Swelling is the most common and frequently recorded sign of Hernia. The engorgement caused internally is noticeable on the surface as well. [howshealth.com]
Respiratoric
- Cough
The provider will inquire about and/or look for: Constipation, "narrow" or "thin" stool Lump or protrusion in the abdomen; you may be asked to stand and cough, which increases abdominal pressure and makes the hernia more pronounced and easier to diagnose [hopkinsmedicine.org]
For example, when an individual strains while coughing The abdominal lump may decrease in size, when gentle pressure is applied, or while lying down. [dovemed.com]
As coughing will often make a hernia expand, your doctor may ask you to cough while he or she feels the area of the suspected hernia. [dartmouth-hitchcock.org]
- Pneumonia
Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. [ncbi.nlm.nih.gov]
More serious problems include heart attack, stroke, pneumonia, and blood clots in the legs. Getting out of bed after surgery and moving as soon as the doctor allows will help reduce the risk of complications such as pneumonia and blood clots. [gi.surgery.ucsf.edu]
In the open-surgery group, patients with massive hernias required a longer length of stay and had significantly more hematomas, deep infections at the surgical site, other wound complications, and cases of pneumonia. [mdedge.com]
- Sneezing
The pain associated with a ventral hernia is usually sharp and may only be present, or worsen, during stressful activities such as physical activity, lifting heavy objects, sneezing, or coughing. [methodistsouthlake.com]
Symptoms Ventral hernia symptoms will occur in the abdominal area and generally include: Sharp pain that occurs with movement, including sneezing or coughing; jogging or running, and lifting heavy objects Constipation Vomiting Treatment A ventral hernia [westvalleycrs.com]
Hernias can develop from everyday activities such as persistent coughing, sneezing or heavy lifting. Dr. [amerra.com]
Anything that causes an increase in pressure in the abdomen can cause a hernia, including: Lifting heavy objects without stabilizing the abdominal muscles Diarrhea or constipation Persistent coughing or sneezing In addition, obesity, poor nutrition, and [webmd.com]
- Persistent Cough
When to call the office: Persistent fever over 101 F (39 C) Bleeding Increased abdominal swelling or pain Pain that is not relieved by your medications Persistent nausea or vomiting Chills Persistent cough or shortness of breath Drainage from any incision [scnv.com]
Hernias can develop from everyday activities such as persistent coughing, sneezing or heavy lifting. Dr. [amerra.com]
Persistent cough or shortness of breath Drainage from any incision Redness surrounding your incisions [utsurgery.com]
The risk of developing a ventral hernia increases if a patient is obese, has a history of hernias, has injuries to the bowel region, begins heavy work relatively early after a surgery, has persistent coughing or develops an infection at the site of a [southwestaustinsurgical.com]
Anything that causes an increase in pressure in the abdomen can cause a hernia, including: Lifting heavy objects without stabilizing the abdominal muscles Diarrhea or constipation Persistent coughing or sneezing In addition, obesity, poor nutrition, and [webmd.com]
Gastrointestinal
- Vomiting
It can also result from: Chronic coughing, severe or chronic vomiting Diabetes or other diseases Heavy lifting Injury or obesity Pregnancy Prior surgery Ventral Hernia Diagnosis To identify a ventral hernia, a health care provider may use multiple diagnostic [hopkinsmedicine.org]
Presentation Abdominal pain, nausea and vomiting. Patient Data Age: 70 years Gender: Female Loading images... Axial C+ portal venous phase A loop of ileum containing oral contrast material is seen extending into an incisional ventral hernia. [radiopaedia.org]
When tissue inside the hernia becomes stuck or trapped in abdominal muscle, it can cause pain, nausea, vomiting and constipation. [ucsfhealth.org]
[…] in the abdomen when: Exercising Lifting heavy objects Standing Coughing Straining, like when making a bowel movement Individuals who experience the following symptoms should call their doctor immediately: A visible bulge in the abdomen Nausea and/or vomiting [medstarwashington.org]
- Nausea
Presentation Abdominal pain, nausea and vomiting. Patient Data Age: 70 years Gender: Female Loading images... Axial C+ portal venous phase A loop of ileum containing oral contrast material is seen extending into an incisional ventral hernia. [radiopaedia.org]
When tissue inside the hernia becomes stuck or trapped in abdominal muscle, it can cause pain, nausea, vomiting and constipation. [ucsfhealth.org]
[…] provider will inquire about and/or look for: Constipation, "narrow" or "thin" stool Lump or protrusion in the abdomen; you may be asked to stand and cough, which increases abdominal pressure and makes the hernia more pronounced and easier to diagnose Nausea [hopkinsmedicine.org]
Nausea Incarcerated ventral hernia can cause serious bodily discomfort to the sufferer. The person may experience nausea due to this reason. Vomiting The nauseating feeling in Incarcerated hernia sufferers can also make them vomit. [primehealthchannel.com]
- Constipation
The provider will inquire about and/or look for: Constipation, "narrow" or "thin" stool Lump or protrusion in the abdomen; you may be asked to stand and cough, which increases abdominal pressure and makes the hernia more pronounced and easier to diagnose [hopkinsmedicine.org]
Vomiting and constipation may also be experienced, depending on the location of the hernia. [methodistsouthlake.com]
Here we describe a case of a man with an obstructing neoplasm of the colon within a large ventral hernia, whose constipation was initially attributed to incarceration of the hernia. [ncbi.nlm.nih.gov]
When tissue inside the hernia becomes stuck or trapped in abdominal muscle, it can cause pain, nausea, vomiting and constipation. [ucsfhealth.org]
- Abdominal Pain
Presentation Abdominal pain, nausea and vomiting. Patient Data Age: 70 years Gender: Female Loading images... Axial C+ portal venous phase A loop of ileum containing oral contrast material is seen extending into an incisional ventral hernia. [radiopaedia.org]
The chronic pain was found to be the consequence of mesh migration and erosion into the sigmoid colon from a previous supraumbilical hernia repair. Hernia repair, use of mesh, and chronic abdominal pain are discussed. [ncbi.nlm.nih.gov]
Peritonitis, infection of the lining that covers the abdominal wall and the abdominal organs, causes severe, continually worsening abdominal pain with muscle rigidity and tightness along with fever, vomiting and fast pulse. [livestrong.com]
- Severe Abdominal Pain
A 33-year-old woman, gravida 2 para 1, was admitted to our institute with severe abdominal pain and overdistended abdomen immediately after a full-term vaginal delivery. [ncbi.nlm.nih.gov]
Other symptoms of a strangulated hernia include severe abdominal pain, profuse sweating, rapid heartbeat, severe nausea, vomiting and high fever. In many cases, a hernia can be diagnosed through a physical examination of the abdomen. [ucsfhealth.org]
Peritonitis, infection of the lining that covers the abdominal wall and the abdominal organs, causes severe, continually worsening abdominal pain with muscle rigidity and tightness along with fever, vomiting and fast pulse. [livestrong.com]
Severe abdominal pain can occur if part of the intestine bulges through the abdominal wall and becomes trapped in the opening. If this happens, the trapped portion of the intestine becomes strangled, loses its blood supply and starts to die. [my.clevelandclinic.org]
Cardiovascular
- Thrombosis
Other complications included deep vein thrombosis (0.5%), pneumonia (1%), cardiac events (0.5%), and problems requiring reoperation (4.2%). At 2-year follow-up, 1.5% of the study participants had died and 5.1% had ventral hernia recurrences. [mdedge.com]
In the authors opinion, in the presence of gangrene associated with DIC, gangrene secondary to arterial thrombosis, or necrotizing fasciitis, aggressive surgical debridement is the treatment of first choice. [hindawi.com]
Perioperative deep vein thrombosis prophylaxis includes placement of compression stockings and sequential compression devices on both lower extremities. [jamanetwork.com]
- Hypotension
The shorter length of stay with TAP block was probably related to side effects of epidurals, which can include leg paresthesias, hypotension, and urinary retention, all of which get in the way of early ambulation. [mdedge.com]
He subsequently developed an acute abdomen and hypotension 7 days later. This operation revealed satisfactory hernia repair but extensive bowel ischemia and necrosis, which was not removed, and the patient died. [jamanetwork.com]
- Tachycardia
However, when strangulation of the hernia is eminent, severe, excruciating abdominal pain is noted, along with tachycardia, high grade fever, protracted vomiting and profuse sweating. [ 2, 6, 9 ] Diagnosis of Ventral Hernias A comprehensive history and [ihealthblogger.com]
Musculoskeletal
- Muscle Strain
Acquired hernias are caused by the wear and tear of living, such as childbirth, weight gain, and other muscle strain. Congenital hernias are present from birth and happen at points of weakness in the abdominal wall. [herniaclinic.co.nz]
Additional pathologies would include diastasis recti, abscess, muscle strain, seroma, wound hematoma, lymphadenopathy, soft tissue malignancy, and rectus sheath hematomas. [ncbi.nlm.nih.gov]
Skin
- Erythema
It is usually a painless application with minimal side effects such as erythema, mild burning, and itching. [dermatologyadvisor.com]
Moist gangrene is characterized by erythema which changes within 24–48 hours into blue, wet lesions [2]. Lesions can appear as small spots arranged diffusely on the body and progress rapidly into bigger crusted lesions. [hindawi.com]
It is usually asymptomatic; however 30~35% patients experience symptoms, such as pain, pressure, and erythema. [e-jmis.org]
These will usually present as erythema or drainage at one of these locations. [laparoscopy.blogs.com]
Psychiatrical
- Suggestibility
The patient who is suggested laparoscopic surgical treatment is instructed to have some lifestyle changes for faster healing of the wound. [howshealth.com]
We suggest a de-epithelialization approach prior to mesh placement for the repair of large ventral hernias as a means of achieving a completely extraperitoneal ventral herniorrhaphy. [ncbi.nlm.nih.gov]
Recent large database studies have suggested that robotic ventral hernia repair may be associated with decreased hospital length of stay. [clinicaltrials.gov]
Workup
Since the diagnosis of ventral hernia can be easily clinched by proper history taking and physical examination the need for laboratory workups may not no longer be necessary for it may only yield non-specific results.
Imaging studies like CT and MRI may only be necessary when determining the contents of the hernia sac within the abdomen or in determining the extent of the intestinal strangulation, otherwise it isn’t that necessary [7].
Laboratory workups may only be ancillary and may be used to rule out other differential causes. The urinalysis may rule out the pain of inguinal hernia against an impending urinary tract infection.
Culture from infected wound or stump may identify the pathogenic organism infecting the site. Complete blood count will not be specific but will show leukocytosis. Serum electrolytes will show the hydration status of the patients for proper management.
Treatment
The main approach in the treatment of ventral hernia is surgical reduction which may require analgesia and sedation to lower the intraabdominal pressure [8].
The Single Port Access (SPA) prosthetic repair of incisional hernia gives promising results with rare events of recurrence [9]. Surgeons ascertain initially whether the hernia is already strangulated or incarcerated which will greatly influence the methods of surgical procedures and the morbidity of the case. Ventral hernia may be approached with minimal incisions like those with laparoscopic surgical procedures but risk factors should be identified like increased Body Mass Index, history of previous repair and size of hernia to prevent any complication during the surgery [10].
Inguinal hernias will benefit from the surgical repair (Bassini repair) of the weakened wall using synthetic meshes to prevent recurrence of the hernia.
Less invasive approach for topical treatment of ventral hernias employ the use of cauterization in removing the granuloma, scarring the sac of a giant omphalocele with use of agents like povidone iodine will reduce infection, and progressive compression dressing which locally prevents further evisceration of the hernia. Postoperative patients will be regularly monitored to avert the recurrence of the ventral hernia.
Prognosis
The prognosis of all abdominal hernia is greatly influenced by the early detection and treatment of the hernia. Morbidity and mortality rate also varies directly with the size of the herniated mass and the size of the defect of the abdominal hernia.
Morbidity correlates closely with the associated complications of the ventral hernia. Neglected incarcerated hernia may lead to bowel obstruction, bowel rupture and peritonitis which are all life-threatening medical conditions. The manner and conduct of the surgical operations may also influence the prognosis of the disease where iatrogenic subcutaneous emphysema and surgical site infections can also occur and increases morbidity.
Complications
There are a number of possible complications of an abdominal hernia, the following are the most common ones:
- Incarceration or strangulation of the trapped bowel loop: When the herniated viscera is trapped within the hernia ring, bowel obstruction and infarction may occur leading to lethal consequences.
- Hernia recurrence: Even with surgical repair, hernia may recur in the same site or proximal to the site of repair. Ventral hernia usually recurs within 2 years from the first repair operation [6].
- Iatrogenic injury: Subsequent hernia repair may inadvertently injure other organs in the process like the urinary bladder, vas deferens, and the intestines.
- Wound infection: Post-operative surgical site infection is common especially with poor wound care after the patient is discharged from the hospital.
- Intestinal obstruction: Complete obstruction may lead to rupture and peritonitis while partial obstruction may cause malnutrition and growth failure.
Etiology
Incisional hernia occurs at the site of a former abdominal surgery because it is weakened by several factors. Any strain to the abdominal walls like the Valsalva in constipated defecation, chronic coughing and lifting of heavy weights can propagate the herniation in the abdominal wall.
Pregnancy can inherently stretch and aggravate the abdominal hernia. An infected surgical wound can weaken and result to evisceration if the wounds dehisce. Diabetics and chronic steroid users are prone to surgical site infection and ventral hernia.
Epidemiology
In the United States, over 1 million abdominal surgeries are performed to repair all forms of ventral hernia. More than three-fourths of these cases are inguinal type of hernia [1]. There is a male predominance for inguinal hernia with a 7:1 male to female ratio with more than half of the cases being indirect in in nature [2]. Inguinal hernia has a predisposition to the left side of the inguinal area.
Females are more prone to incisional hernia compared to men [3]. Congenital umbilical hernia often presents as ophalocele (herniated stump in navel) in the newborn. The incidence of omphalocele has currently risen with a prevalence rating of 1-2.5 cases per 5000 live births [4].
Older patients are prone to direct inguinal hernia due to the subsequent wall weakness. Premature infants born before 32 weeks of gestation have a 13% incidence of indirect hernia which are observable in the first month of life [5].
Bowel loops that protrude in the abdominal wall may be trapped and constricted causing a painful surgical emergency known as incarceration. Infants less than 6 months has twice the risk of incarcerated hernia than their older counterparts.
Pathophysiology
The pathophysiology of incisional hernia lies on the breakdown of the fascial closure of the abdominal surgical wound. The incidence of recurrence in incisional hernia is relatively high, ranging from 20-45%.
Umbilical hernia is a result of the failure of the umbilical ring to physiologically close. Children with congenital problems with collagen synthesis like Ehler-Danlos Syndrome and osteogenesis imperfecta have an increased risk for umbilical hernia.
Spigelian hernia occurs due to a defect in the spigelian fascia by the lateral edge of the rectus abdominis muscle (abdominal muscles).
The paralysis of the abdominal internal ring and the high lying abdominis aponeurosis may fail to prevent herniation of visceral organs in the inguinal ring causing the inguinal hernia.
Prevention
Ventral hernia may appear at birth which should always be given attention to prevent incarceration of the herniated organ.
Abdominal hernia may be prevented if risks are identified early in the course of the disease. Patients identified with weakness in the abdominal wall should be restricted to strain or lift heavy objects.
Constipation may be prevented with the use of laxatives and chronic coughing may be controlled with antitussive preparations.
Patient who had prior surgical hernia repair should apply proper wound care to prevent infections and wound dehiscence. A regular visit to the surgeon to monitor hernia progression can be very beneficial.
Summary
Ventral hernia is any abnormal protrusion in the abdominal wall caused by a weakened point in the muscles or tissues due to prior incisions or defect. Because of its frequent occurrence in the incisional site, it is also referred to as an incisional hernia.
Protrusion in the umbilical area is sometimes coined as an umbilical hernia, a type of ventral hernia that may not precede any abdominal surgery. Abdominal protrusions in the ventral (anterior abdomen) is oftentimes caused by an intestinal loop or any abdominal tissue that makes its way through the wall defect.
Abdominal hernia with encroachment beneath rib cage at epigastrium is called epigastric hernia while hernia which develops within the colostomy or jejunostomy stoma is known as stomal hernia. Inguinal hernia are abnormal encroachment in the inguinal area or groin which occur more commonly in men.
Patient Information
Ventral hernia is a bulging of the belly wall caused by a weakened point in the muscles or tissues.
Patients with high risk of hernia should avoid all occasions of straining like lifting of heavy loads. Medical support devices like body truss and corsets may support the abdominal wall if there are abnormal masses that herniate in the ventral abdomen.
Athletes with high risk to inguinal hernia must wear groin supporters. Any suspicious lumps in the abdominal wall should be promptly brought for surgical consultation and immediate intervention.
References
- Manthey DE. abdominal hernia reduction. In: Clinical Procedures in Emergency Medicine. Of of 2003.
- Katz DA. Evaluation and management of inguinal hernias and umbilical. Pediatr Ann. Dec. 2001, 30 (12): 729-35.
- Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. April 2008, 45 (4): 261-312.
- Scherer LR 3rd, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. Dec. 1993, 40 (6): 1121-31.
- Brandt ML. Pediatric hernias. Surg Clin North Am. February 2008, 88 (1): 27-43, vii-viii.
- Singhal V, Szeto P, VanderMeer TJ, B. Ventral hernia repair Cagir: outcomes change with long-term follow-up. JSLS. 2012; 16 (3): 373-9
- Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. April 2008, 45 (4): 261-312.
- Inguinal hernia reduction S. Smith. In:. C. King, Henretig FM, eds . Procedures Textbook of Pediatric Emergency 2nd ed Philadelphia, PA :. Lippincott Williams and Wilkins; 2008: 840-847 / 87th
- Bucher P, Pugin F, Morel P. Single-port access prosthetic repair for primary and incisional ventral hernia. toward less parietal trauma . Surg Endosc 2011; 25 (6): 1921-5 (ISSN: 1432-2218)
- Jenkins ED, Yom VH, Melman L, Pierce RA, Schuessler RB, Frisella MM, Christopher Eagon J, Michael Brunt L, Matthews BD. Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study. Surg Endosc. 2010; 24 (8): 1872-7 (ISSN: 1432-2218)