29/06/13

Hernias

Medscape Reference Reference

News Reference Education MEDLINE

Hernias
Author: Bret A Nicks, MD, MHA; Chief Editor: Steven C Dronen, MD, FAAEM more... Updated: Jun 6, 2012

Background
A hernia, as defined in 1804 by Astley Cooper, is a protrusion of any viscus from its proper cavity. The protruded parts are generally contained in a sac-like structure, formed by the membrane with which the cavity is naturally lined.[1] Since that time, many different types of abdominal wall hernias have been identified, along with a larger number of associated eponyms. This article reviews the pathophysiology, evaluation, and treatment of most of these hernias from an emergency medicine perspective. Hernias are brought to the attention of an emergency physician either during a routine physical examination for other medical complaints or when the patient has developed a complication associated with the hernia. See Medscape's Hernia Resource Center.

Pathophysiology
Types of Hernia - Location
See the image below.

Anatomic locations for various hernias.

Indirect hernia
An indirect inguinal hernia follows the tract through the inguinal canal. This results from a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately
emedicine.medscape.com/article/775630-overview 1/5

29/06/13

Hernias

midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.[2, 3, 4]

Direct hernia
A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon.[5]

Femoral hernia
The femoral hernia follows the tract below the inguinal ligament through the femoral canal. The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament. Because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated.[6]

Umbilical hernia
The umbilical hernia occurs through the umbilical fibromuscular ring, which usually obliterates by 2 years of age. They are congenital in origin and are repaired if they persist in children older than age 2-4 years.[2, 5]

Richter hernia
The Richter hernia occurs when only the antimesenteric border of the bowel herniates through the fascial defect. The Richter hernia involves only a portion of the circumference of the bowel. As such, the bowel may not be obstructed, even if the hernia is incarcerated or strangulated, and the patient may not present with vomiting. The Richter hernia can occur with any of the various abdominal hernias and is particularly dangerous, as a portion of strangulated bowel may be reduced unknowingly into the abdominal cavity, leading to perforation and peritonitis.[6]

Incisional hernia
This iatrogenic hernia occurs in 2-10% of all abdominal operations secondary to breakdown of the fascial closure of prior surgery. Even after repair, recurrence rates approach 20-45%.

Spigelian hernia
This rare form of abdominal wall hernia occurs through a defect in the spigelian fascia, which is defined by the lateral edge of the rectus muscle at the semilunar line (costal arch to the pubic tubercle) The two subtypes are interstitial and subcutaneous, which are best defined using CT and assist with optimizing the surgical approach when indicated.[7, 8, 9]

Obturator hernia
This hernia passes through the obturator foramen, following the path of the obturator nerves and muscles. Obturator hernias occur with a female-to-male ratio of 6:1, because of a gender-specific larger canal diameter and predominately in the elderly. Because of its anatomic position, this hernia presents more commonly as a bowel obstruction than as a protrusion of bowel contents.[1, 10]

Types of Hernia - Condition

Reducible hernia: This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually. Incarcerated hernia: An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised; however, bowel obstruction is common. Strangulated hernia: A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents.

Epidemiology
emedicine.medscape.com/article/775630-overview 2/5

29/06/13

Hernias

Frequency
United States Over 1 million abdominal wall hernia repairs are performed each year, with inguinal hernia repairs constituting nearly 770,000 of these cases.[11, 12, 13] Approximately 25% of males and 2% of females have inguinal hernias in their lifetimes representing the most common hernia in males and females.[13, 14] Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct.[2] Indirect inguinal hernias are the most common hernias in both men and women; a right-sided predominance exists. Incisional and ventral hernias account for 10% of all hernias.[4] Only 3% of hernias are femoral hernias. The incidence of inguinal hernias in children ranges up to 4.5%, while umbilical hernias occur in approximately 1 out of every 6 children.[12, 2] The incidence of incarcerated or strangulated hernias in pediatric patients is 10-20%; 50% of these occur in infants younger than 6 months.[12] International Data from developing countries is limited, therefore, an accurate occurrence value is unavailable. Current epidemiologic assessments postulate that gender and anatomic distribution are similar.

Mortality/Morbidity
Morbidity is secondary to missing the diagnosis of the hernia or complications associated with management of the disease. A hernia can lead to an incarcerated and often obstructed bowel. The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced strangulated bowel leads to persistent ischemia/necrosis with no clinical improvement. Surgical intervention is required to prevent further complications such as perforation and sepsis. Ensuing surgery to repair the hernia or its complications may leave the patient at risk for infection, future hernias, or intra-abdominal adhesions.

Race
Umbilical hernias occur 8 times more frequently in black infants than in white infants.[14]

Sex
Approximately 90% of all inguinal hernia repairs are performed on males.[13] Reduction of hernias in females may be complicated by inclusion of the ovary in the hernia. Femoral hernias (although rare) occur almost exclusively in women because of the differences in the pelvic anatomy. The female-to-male ratio of obturator hernias is 6:1.[14]

Age
Indirect hernias usually present during the first year of life, but they may not appear until middle or old age. Indirect hernias occur more frequently in premature infants compared to term infants. Indirect hernias develop in 13% of infants born before 32 weeks' gestation.[12] Direct hernias occur in older patients as a result of relaxation of abdominal wall musculature and thinning of the fascia. Umbilical hernias usually occur in infants and reach their maximal size by the first month of life. Most hernias of this type close spontaneously by the first year of life, with only a 2-10% incidence in children older than 1 year.[15] Obturator hernias occur predominately in the elderly.
emedicine.medscape.com/article/775630-overview 3/5

29/06/13

Hernias

Contributor Information and Disclosures

Author Bret A Nicks, MD, MHA Assistant Dean of Global Health, Assistant Professor, Medical Director, ED Clinical Operations, Department of Emergency Medicine, Wake Forest University School of Medicine Bret A Nicks, MD, MHA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Christian Medical & Dental Society, Society for Academic Emergency Medicine, and Wilderness Medical Society Disclosure: Nothing to disclose. Coauthor(s) Kim Askew, MD Assistant Professor, Director of Undergraduate Medical Education, Department of Emergency Medicine, Wake Forest University School of Medicine Disclosure: Nothing to disclose. Specialty Editor Board Richard Lavely, MD, JD, MS, MPH Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center Disclosure: Nothing to disclose. John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Chief Editor Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine Disclosure: Nothing to disclose.

References
1. Eubanks S. Hernias. In: Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 1997. 2. Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann. Dec
emedicine.medscape.com/article/775630-overview 4/5

29/06/13

Hernias

2001;30(12):729-35. [Medline]. 3. Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med. May-Jun 1999;17(3):515-6. [Medline]. 4. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. Apr 2008;45(4):261-312. [Medline]. 5. Scherer LR 3d, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. Dec 1993;40(6):1121-31. [Medline]. 6. Bobrow RS. The hernia. J Am Board Fam Pract. Jan-Feb 1999;12(1):95-6. [Medline]. 7. Wants GE. Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994. 8. Mensching JJ, Musielewicz AJ. Abdominal wall hernias. Emerg Med Clin North Am. Nov 1996;14(4):73956. [Medline]. 9. Martin M, Paquette B, Badet N, Sheppard F, Aubry S, Delabrousse E. Spigelian hernia: CT findings and clinical relevance. Abdom Imaging. Apr 3 2012;[Medline]. 10. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia--a condition seldom thought of and hence seldom sought. Int J Colorectal Dis . Feb 2012;27(2):133-41. [Medline]. 11. Manthey DE. Abdominal hernia reduction. In: Clinical Procedures in Emergency Medicine. 2003. 12. Brandt ML. Pediatric hernias. Surg Clin North Am. Feb 2008;88(1):27-43, vii-viii. [Medline]. 13. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. Jun 1993;73(3):413-26. [Medline]. 14. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am. Dec 1998;78(6):941-51, v-vi. [Medline]. 15. Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. Aug 1998;45(4):773-89. [Medline]. 16. Akbulut S, Cakabay B, Sezgin A. A familial tendency for developing inguinal hernias: study of a single family. Hernia. Aug 29 2009;[Medline]. 17. 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. 18. Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med. Feb 2006;30(2):155-7. [Medline]. 19. Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg. Mar 2012;147(3):277-81. [Medline]. Medscape Reference 2011 WebMD, LLC

emedicine.medscape.com/article/775630-overview

5/5