Hernia: Difference between revisions
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===Types=== | ===Types=== | ||
*Inguinal (75%) | |||
**Most common type of hernia in both men and women | |||
**Presents as groin mass | |||
**Indirect (50%) | |||
***Hernia passes from inguinal ring into scrotum (d/t patent processus vaginalis) | |||
**Direct (25%) | |||
***Hernia passes directly through transversalis fascia in Hesselbach triangle | |||
*Ventral | |||
**Due to defect in anterior abdominal wall (spontaneous or acquired) | |||
**Incisional | |||
***Due to excess wall tension or inadequate wound healing / surgical wound infection | |||
**Umbilical | |||
***Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity) | |||
**Spigelian | |||
***Also known as lateral ventral hernia | |||
***Nearly always acquired conditions | |||
***Difficult to diagnose | |||
****Classic presentation is abdominal pain a/w anterior lateral abdominal wall mass | |||
****Physical exam is unreliable; imaging (US or CT) is often required | |||
*Femoral | |||
**10:1 female:male ratio | |||
**Hernia sac protrudes through femoral canal | |||
**Mass is typically below the inguinal ring | |||
**Particularly prone to complications | |||
*Obsturator | |||
**Bowel herniation through obturator canal | |||
**Nearly always presents as partial or complete bowel obstruction | |||
**High complication rate | |||
*Richter | |||
**Involves only antimesenteric border of intestine and only portion of the wall | |||
**Often presents w/o vomiting or intestinal obstruction | |||
***As a result, more likely to diagnose once wall has begun to become ischemic) | |||
==Clinical Presentation== | |||
[[File:Hernia Locations.jpeg|thumb]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Template:Testicular DDX}} | {{Template:Testicular DDX}} | ||
==Work-Up== | ==Diagnosis== | ||
===Work-Up=== | |||
*Labs | |||
**Not routinely necessary | |||
**Consider CBC, chemistry, lactate if concern for strangulation | |||
*Imaging | |||
**Abd x-ray | |||
***Only indicated if concern for obstruction | |||
**Ultrasound | |||
***Only indicated to exclude other diagnoses, exclude strangulation | |||
**CT | |||
***useful for uncommon hernia types (Spigelian, obturator) | |||
==Treatment== | ==Treatment== | ||
*Reduction for incarcerated hernia | |||
**If there is any concern for strangulation, do not attempt hernia reduction | |||
***Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis | |||
**NPO (in case reduction unsuccessful) | |||
**IV narcotic analgesia | |||
**Supine and mild Trendelenberg positioning | |||
**Apply cold packs to hernia site to reduce swelling | |||
**Apply firm, steady pressure to distal part of hernia | |||
**If successful observe pt in ED period of time for serial abd exams | |||
**If unsuccessful after 1 or 2 attempts consult surgery | |||
*Antibiotics (e.g. [[Cefoxitin]]) for | |||
**Obstruction | |||
**Peritonitis | |||
==Disposition== | ==Disposition== | ||
*Discharge with surgery referral: | |||
**Easily reducible hernia | |||
**Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration) | |||
==See Also== | ==See Also== | ||
Revision as of 00:12, 5 May 2015
Background
- Classification
- Reducible
- Hernia sac soft, easy to replace back through the hernia defect
- Incarcerated
- Hernia sac firm, often painful, nonreducible
- Strangulation
- Impairment of blood flow
- Severe pain at hernia site
- Signs of intestinal obstruction
- Skin changes overlying hernia sac may be seen
- Reducible
Types
- Inguinal (75%)
- Most common type of hernia in both men and women
- Presents as groin mass
- Indirect (50%)
- Hernia passes from inguinal ring into scrotum (d/t patent processus vaginalis)
- Direct (25%)
- Hernia passes directly through transversalis fascia in Hesselbach triangle
- Ventral
- Due to defect in anterior abdominal wall (spontaneous or acquired)
- Incisional
- Due to excess wall tension or inadequate wound healing / surgical wound infection
- Umbilical
- Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity)
- Spigelian
- Also known as lateral ventral hernia
- Nearly always acquired conditions
- Difficult to diagnose
- Classic presentation is abdominal pain a/w anterior lateral abdominal wall mass
- Physical exam is unreliable; imaging (US or CT) is often required
- Femoral
- 10:1 female:male ratio
- Hernia sac protrudes through femoral canal
- Mass is typically below the inguinal ring
- Particularly prone to complications
- Obsturator
- Bowel herniation through obturator canal
- Nearly always presents as partial or complete bowel obstruction
- High complication rate
- Richter
- Involves only antimesenteric border of intestine and only portion of the wall
- Often presents w/o vomiting or intestinal obstruction
- As a result, more likely to diagnose once wall has begun to become ischemic)
Clinical Presentation
Differential Diagnosis
Inguinal
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Diagnosis
Work-Up
- Labs
- Not routinely necessary
- Consider CBC, chemistry, lactate if concern for strangulation
- Imaging
- Abd x-ray
- Only indicated if concern for obstruction
- Ultrasound
- Only indicated to exclude other diagnoses, exclude strangulation
- CT
- useful for uncommon hernia types (Spigelian, obturator)
- Abd x-ray
Treatment
- Reduction for incarcerated hernia
- If there is any concern for strangulation, do not attempt hernia reduction
- Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
- NPO (in case reduction unsuccessful)
- IV narcotic analgesia
- Supine and mild Trendelenberg positioning
- Apply cold packs to hernia site to reduce swelling
- Apply firm, steady pressure to distal part of hernia
- If successful observe pt in ED period of time for serial abd exams
- If unsuccessful after 1 or 2 attempts consult surgery
- If there is any concern for strangulation, do not attempt hernia reduction
- Antibiotics (e.g. Cefoxitin) for
- Obstruction
- Peritonitis
Disposition
- Discharge with surgery referral:
- Easily reducible hernia
- Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration)
See Also
Source
Tintinalli