Hernia

This page is for adult patients. For pediatric patients, see: inguinal hernia (peds)

Background

Scrotal anatomy

Anatomy of an inguinal hernia.

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

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 (due to 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)
    • May ulcerate from ascites, see Flood Syndrome
  • Spigelian
    • Also known as lateral ventral hernia
    • Nearly always acquired conditions
    • Difficult to diagnose
      • Classic presentation is abdominal pain associated with 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 with out vomiting or intestinal obstruction
    • As a result, more likely to diagnose once wall has begun to become ischemic

Clinical Features

Adult male right-sided with inguinal hernia.

• Hernia (usually) palpable on exam
  • If incarcerated, nonreducible
  • If strangulated, nonreducible and may have overlying skin changes
• +/- abdominal/groin/testicular Pain
• +/- signs/symptoms of SBO, peritonitis if strangulated

Differential Diagnosis

Testicular Diagnoses

• Scrotal cellulitis
• Epididymitis
• Fournier gangrene
• Hematocele
• Hydrocele
  • Hydrocele (peds)
• 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

Evaluation

Work-Up

• Labs
  • Not routinely necessary
  • Consider CBC, chemistry, lactate if concern for strangulation
• Imaging
  • CT, if concern for obstruction/strangulation
  • Ultrasound (only indicated to exclude other diagnoses)

Management

• 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 opioid analgesia
  • Supine and mild Trendelenburg positioning
  • Apply cold packs to hernia site to reduce swelling
  • Apply firm, steady pressure to distal part of hernia
  • If successful observe patient in ED period of time for serial abdominal exams
  • If unsuccessful after 1 or 2 attempts consult surgery
• Antibiotics (e.g. Cefoxitin) for
  • Bowel obstruction
  • Peritonitis

Disposition

• Discharge with surgery referral:
  • Easily reducible hernia
  • Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration)

See Also

• Inguinal Hernia (Peds)
• Testicular Diagnoses