Hernias

Gregory P. McLennan II, MS3 St. Louis University School of Medicine

Definitions
Hernia A general term referring to a protrusion of a tissue through the wall of the cavity in which it is normally contained Incarceration the contents of the hernia cannot be returned to the cavity from which they came Strangulation The blood supply to the herniated tissue is disrupted causing ischemia and tissue death

Groin Hernias
96% Inguinal 9:1 M:F 4% Femoral 4:1 F:M Lifetime risk approximately 25% in males and <5% in females 700,000 repairs each year

Case 1
14 y/o male with no significant PMHx presents to the ED with scrotal swelling that he noticed after helping his father carry a couch. He has never noticed this swelling before, but it now causes him some discomfort when he stands from a sitting position. The patient states that it seems to mainly be on the right side of the scrotum. He denies severe pain, N/V, fevers, and says that the bulge does not seem to go away when he is supine.

Differential Diagnosis
Acute Conditions Testicluar Torsion Epididymitis Nonacute Conditions Hydrocele Varicocele Spermatocele Epdidiymal Cyst Testicular Tumor

Important Anatomical Relationships

Inguinal Ligament Hesselbachs Triangle Inferior Epigastric Vessels

http://feedbus.com/wikis/wikipedia.php?title=Inferior_epigastric_artery

Testicular Descent
Ventromedial aspect of urogenital ridge Descend through coelomic cavity pulled by gubernaculum testis Processus vaginalis forms at internal ring and precedes testicles into scrotum Processus Vaginalis obliterates

http://caltest.vet.upenn.edu/repropath/MReview/normdiag/picture.htm#Testicular%20Descent

Indirect Inguinal Hernia Track

Lateral to inferior epigastric vessels Through deep inguinal ring and canal Through external inguinal ring
Often into scrotum

Hernial sac formed by processus vaginalis Hernia is w/in the coverings of the spermatic cord
http://www.aafp.org/afp/990101ap/143.html

Indirect Inguinal Hernia

Most common groin hernias in men and women 20x more common in males Most are congenital due to defective obliteration of the processus vaginalis and lack of closure of internal inguinal ring Sx
Bulge medial to pubic tubercle and into the scrotum Heaviness or dull discomfort more pronounced with lifting or straining Pain with straining or standing Severe pain and/or peritoneal signs with strangulation, fevers, N/V

PE
Reducible versus non-reducible Can be mildly tender to exquisitely tender (strangulated)

Hernia Complications
Incarceration
14 to 31% of inguinal hernias, usually in infants < 1y/o Swelling due to decreased venous and arterial flow Outright pain, irritability and crying in children Bowel obstruction (N/V/colicky abdominal pain/distention) Tender, edematous, erythematous

Strangulation
Severe pain secondary to bowel ischemia Bowel obstruction Swelling, erythema, tenderness, peritoneal signs, fever, N/V Study of 439 patients showed probability of strangulation was 2.8% at three months, 4.5% at two years for groin hernias

Direct Inguinal Hernia

Common in older males, rare in women Occur as a result of weakness in the floor of the abdominal wall medial to the inferior epigastric arteries
Inborn Defect Smoking Chronic steroid use Collagen disorders Some studies have shown a correlation with heavy lifting

Sx
Similar to Indirect hernias without extension of the hernia into the scrotum

PE
Symptoms similar to indirect inguinal hernias Often more easily reducible than indirect hernias

Hernia Track
Bulges through Hesselbachs Triangle in hernial sac formed by transversalis fascia Traverses the medial portion of the inguinal canal Emerges around conjoint tendon to reach the superficial inguinal ring Gains an outer covering of http://www.hernia.net.au/hernia_inguinal.html external spermatic fascia

Inguinal Hernia Treatment

Medical Management
Watchful Waiting Trial with 720 men >18 y/o and asymp/minimal sx; easily reducible
Open tension free repair versus Waitful Watching
23% and 31% of WW group had surgery at 2 and 4 years

Truss use is not supported in the literature

Incarceration/Strangulation
Only true indications for repair Emergent reduction Bowel can be saved in most patients if operation occurs within four to six hours

Tx Contd
Operative Repair
Only definitive repair Recurrence in .5 to 15% depending on type of repair Open Repair versus Laparoscopic repair
Lap with less post op pain and faster return to work Increase risk of complications with longer surgery, higher risk of nerve, vascular, bowel, and bladder injury

Mesh versus suture repair

Mesh repair creates less tension but very few studies to compare the techniques One meta-analysis of 26000 hernia repairs found mesh repairs with a lower reoperation rate

Complications include recurrence, infection, seromas, pain and neuralgia

Case 2
57 y/o G5P5 female with PMHx of HTN presents to clinic with a two hour history of a nonreducible bulge on her upper thigh. She reports severe pain, some fevers, N/V. She reports that she has had this same bulge intermittently for about a month. However, it has never hurt like it does at the time of presentation. Physical exam shows an exquisitely tender, erythematous bulge on the upper anterior thigh below the inguinal ligament. It is non-reducible.

Femoral Hernia
40% present with emergencies (incarceration/strangulation) Most commonly in females, especially older women
Less bulky musculature Weakness of pelvic floor muscles 2/2 childbirth Pelvic floor muscle atrophy 2/2 age Prior inguinal hernia repair is a RF

http://herniaplasty.med.nyu.edu/strangulatedhernia.html

Hernia Track
Hernia protrudes through medial aspect of femoral canal/sheath Below the inguinal ligament medial to the femoral vein Below and lateral to the pubic tubercle through the femoral ring Becomes more pronounced when it passes through the saphenous opening
http://www.aafp.org/afp/990101ap/143.html

Incisional Hernia
Due to failure of fascial tissues to heal and close Promoted by inhibition of wound healing 10-15% of abdominal incisions Highest incidence with midline incisions

RCT with vertical versus transverse incisions for AAA

Incisional hernia more likely with vertical incision (37 pt)

Incisional Hernia
Sx
Bulge of abdominal wall deep to skin scar Cosmetic concern versus discomfort Worsened with coughing or straining Incarceration
<1cm, >7-8 cm unlikely to incarcerate

Tx
Most should be repaired (unlike groin hernias) Suture versus mesh repair
Suture repair in one European study showed 60% recurrence with mesh recurrence at 30%

Umbilical Hernia
Congenital
Opening in linea alba when umbilical scar fails to heal at birth More common in AA children Most close in first 12-18 months of life Repair rarely recommended prior to 3 y/o

Acquired
3:1 F:M Men more likely have incarceration Associated with increased intra-abdominal pressure
Obesity Ascites Abdominal distention Pregnancy
http://medicine.ucsd.edu/clinicalimg/abdomen-incarcerated-umbo.html

Spigelian
Lateral ventral hernia

Hernias

Junction of vertical semilunar line and horizontal semicircular line (arcuate line)

90% located 0 - 6 cm above anterior superior iliac spine

Sharp pain, swelling, easily reducible 20% present with incarceration median age = 50 years more common in males and on (R) Rare

PE
Difficult to diagnose Below EAO U/S or CT can aid in diagnosis
http://herniaplasty.med.nyu.edu/spigelianhernia.html

Richters

- Hernia where only a portion of the bowel wall circumference incarcerates

or strangulates

Littres
Any groin hernia that involves a Meckels Diverticulum Usually incarcerated or strangulated

Armands
Any hernia that contains the appendix Can cause symptoms of Appendicitis

Pantaloon Hernia
Simultaneous Direct and Indirect Inguinal Hernias Two bulges straddle the inferior epigastric vessels

Take Home Points

Hernias can involve the small bowel, appendix, a Meckels diverticulum, ureter

Incarceration with frank pain or strangulation are operative emergencies and bowel can be saved if done within 4-6 hours
An attempt at reduction should be made with a hernia, but operative reduction is the only definitive treatment Femoral hernias have a high rate of incarceration and should be repaired, but other inguinal hernias may be watched if asymptomatic With abdominal incisions, try not to put excessive tension or damage the suture in any way as it can promote incisional hernias