Hernia
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 due
- As a result, more likely to diagnose once wall has begun to become ischemic)
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
- Abx
- Indicated for:
- Painful hernia
- Obstruction
- Peritonitis
- Cefoxitin
- Indicated for:
Disposition
- Discharge with surgery referral:
- Easily reducible hernia
- Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration)
See Also
Source
Tintinalli