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BASICS

Description

  • Areas of weakness or disruption in the abdominal wall allowing protrusion of structures.

Types of Hernia

  • Inguinal:
  • Direct: Acquired defect medial to inferior epigastric vessels through transversalis fascia.
  • Indirect: Congenital herniation lateral to inferior epigastric vessels via internal inguinal ring.
  • Pantaloon: Combined direct and indirect hernia.
  • Femoral: Herniation through femoral canal below inguinal ligament; prone to incarceration.
  • Incisional/Ventral: Through prior surgical incision site.
  • Umbilical: Through umbilical ring.
  • Epigastric: Midline above umbilicus.
  • Spigelian: Through lateral border of rectus abdominis (Spigelian line).
  • Sports Hernia: Soft tissue strain, not true hernia.
  • Others: Obturator, sciatic, perineal.

Definitions

  • Reducible: Hernia contents can be returned to abdomen.
  • Irreducible/Incarcerated: Cannot be returned.
  • Strangulated: Blood supply compromised.
  • Richter: Partial bowel circumference involved.
  • Sliding: Visceral wall forms part of hernia sac.

EPIDEMIOLOGY

  • 75-80% of groin hernias are inguinal or femoral.
  • Incidence peaks at ages 0-5 and 75-80 for inguinal hernias.
  • Lifetime risk for adult men: 6-27%.
  • Femoral hernias <10% of groin hernias; 40% present as emergencies.
  • Incisional hernias in 10-23% of abdominal surgeries; higher risk with infection.
  • Umbilical hernias: 10-20% in newborns; often close by age 5.
  • Male = female incidence ratio overall.
  • Groin hernias more common in men; femoral and umbilical more common in women.
  • Incisional hernias more common in smokers, obese patients.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Loss of tissue strength/elasticity leads to fascial defects.
  • Pediatric hernias mainly congenital (patent processus vaginalis).
  • Adult hernias usually acquired weakness.
  • No known genetic pattern.

RISK FACTORS

  • Increased intra-abdominal pressure: coughing, heavy lifting, constipation, pregnancy, ascites, prostatism, obesity.
  • Age-related tissue weakening.
  • Smoking, steroid use.
  • Low birth weight, prematurity.
  • Multiple abdominal surgeries.
  • Connective tissue disorders: Ehlers-Danlos, Marfan syndrome.
  • Other: polycystic kidney disease, osteogenesis imperfecta.

DIAGNOSIS

History

  • Noticing protrusion with straining or Valsalva.
  • Pain, nausea, vomiting, bloating indicate complications.

Physical Exam

  • Examine standing and supine with Valsalva or cough.
  • Palpate inguinal canal to differentiate direct (medial to inferior epigastric vessels) vs indirect (lateral).
  • Femoral hernia bulge below inguinal ligament, lateral to pubic tubercle.
  • Palpate umbilicus, previous incisions, epigastrium.

Differential Diagnosis

  • Lymphadenopathy, hydrocele, lipoma, varices, cryptorchidism, abscess, tumors, athletic pubalgia, pelvic fractures, adductor tears, cysts.

Diagnostic Tests

  • Imaging rarely needed unless diagnosis unclear.
  • Ultrasound: initial choice for occult inguinal hernia.
  • CT/MRI: for incisional or abdominal wall hernias.
  • Herniography no longer recommended.

TREATMENT

Elective Repair

  • Open, laparoscopic, or robotic repair.
  • Mesh preferred unless contraindicated.
  • Elective repair reduces morbidity and mortality.

Acute Setting

  • Pain management.
  • Early surgical repair for strangulated hernias.
  • Manual reduction for incarcerated hernias to allow elective repair.

Surgical Approaches

  • Lichtenstein open mesh repair (gold standard for inguinal hernia).
  • Laparoscopic: TAPP or TEP; less pain, shorter hospital stay.
  • Robotic repair: longer operative time, slightly higher early complications.
  • Pediatric laparoscopic repair effective; avoid mesh in children.
  • Incisional/ventral hernias: laparoscopic repair preferred.
  • Umbilical hernias: open suture repair in children; mesh repair in adults.

Medication

  • Antibiotics: prophylaxis not routinely recommended; indicated with mesh or infection risk.
  • Local anesthetics reduce postoperative pain; tension-free repairs can be done under local anesthesia.

ISSUES FOR REFERRAL

  • Symptoms/signs of incarceration or strangulation (acute pain, fever, bloody stools) require urgent evaluation.

ONGOING CARE

Patient Education

  • Avoid prolonged sitting and straining.
  • Maintain healthy weight and physical fitness.

PROGNOSIS

  • Pediatric groin hernias: low recurrence (<3%), some may spontaneously resolve.
  • Adult groin hernias: 1% annual risk of strangulation if untreated.
  • Postoperative recurrence: 0-10% depending on surgeon and technique.
  • Incisional hernias: 3-5% postoperative incidence; 2-17% recurrence.
  • Umbilical hernias in children mostly resolve; adults have up to 11% recurrence.
  • Epigastric hernias often progress to incarceration or strangulation if untreated.

COMPLICATIONS

  • Recurrence.
  • Seromas.
  • Postoperative pain (less with laparoscopic).
  • Wound infection.
  • Nerve injury (usually resolves).

REFERENCES

  1. Orelio CC, van Hessen C, Sanchez-Manuel FJ, et al. Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair. Cochrane Database Syst Rev. 2020;4(4):CD003769.

  2. Lockhart K, Dunn D, Teo S, et al. Mesh versus non-mesh for inguinal and femoral hernia repair. Cochrane Database Syst Rev. 2018;9(9):CD011517.

  3. Buckley FP III, Vassaur H, Monsivais S, et al. Comparison of outcomes for single-incision laparoscopic inguinal herniorrhaphy and traditional three-port laparoscopic herniorrhaphy at a single institution. Surg Endosc. 2014;28(1):30-35.

  4. Timberlake MD, Sukhu TA, Herbst KW, et al. Laparoscopic percutaneous inguinal hernia repair in children: review of technique and comparison with open surgery. J Pediatr Urol. 2015;11(5):262.e1-262.e6.

CLINICAL PEARLS

  • Direct inguinal hernia: acquired herniation medial to inferior epigastric vessels.
  • Indirect inguinal hernia: congenital herniation lateral to inferior epigastric vessels; may extend into scrotum.
  • Femoral hernias pass below the inguinal ligament; more common in women and prone to strangulation.
  • Umbilical hernias in children often close spontaneously.
  • Watchful waiting may be appropriate in asymptomatic patients with significant comorbidities.
  • Laparoscopic repair preferred in women and bilateral hernias.
  • Elective repair reduces complications; emergent surgery has higher morbidity.