Introduction

Background
As defined in 1804 by Astley Cooper, a hernia as a protrusion of any viscus from its proper cavity. The
protruded parts are generally contained in a sac-like structure, formed by the membrane with which
the cavity is naturally lined.1
Since that time, several different types of abdominal wall hernias have been identified, along with a
larger number of associated eponyms. This article reviews the pathophysiology, evaluation, and
treatment of most of these hernias from an emergency medicine perspective. Hernias are brought to
the attention of an emergency physician either during a routine physical examination for other medical
complaints or when the patient has developed a complication associated with the hernia.

Pathophysiology
Types of Hernia - Location

Anatomic locations for various hernias.

Indirect hernia
An indirect inguinal hernia follows the tract through the inguinal canal. This results from a persistent
process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring,
located approximately midway between the pubic symphysis and the anterior iliac spine. The canal
courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric
arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the
tract of the testicle down into the scrotal sac.2,3,4
Direct hernia
A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of
the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the
inferior epigastric arteries, and medially by the conjoined tendon. 5
Femoral hernia
The femoral hernia follows the tract below the inguinal ligament through the femoral canal. The canal
lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament. Because femoral
hernias protrude through such a small defined space, they frequently become incarcerated or
strangulated.6
Umbilical hernia

The umbilical hernia occurs through the umbilical fibromuscular ring, which usually obliterates by 2
years of age. They are congenital in origin and are repaired if they persist in children older than age 24 years.2,5
Richter hernia
The Richter hernia occurs when only the antimesenteric border of the bowel herniates through the
fascial defect. The Richter hernia involves only a portion of the circumference of the bowel. As such,
the bowel may not be obstructed, even if the hernia is incarcerated or strangulated, and the patient
may not present with vomiting. The Richter hernia can occur with any of the various abdominal
hernias and is particularly dangerous, as a portion of strangulated bowel may be reduced unknowingly
into the abdominal cavity, leading to perforation and peritonitis. 6
Incisional hernia
This iatrogenic hernia occurs in 2-10% of all abdominal operations secondary to breakdown of the
fascial closure of prior surgery. Even after repair, recurrence rates approach 20-45%.
Spigelian hernia
This rare form of abdominal wall hernia occurs through a defect in the spigelian fascia, which is
defined by the lateral edge of the rectus muscle at the semilunar line (costal arch to the pubic
tubercle).7,8
Obturator hernia
This hernia passes through the obturator foramen, following the path of the obturator nerves and
muscles. Obturator hernias occur with a female-to-male ratio of 6:1, because of a gender-specific
larger canal diameter. Because of its anatomic position, this hernia presents more commonly as a
bowel obstruction than as a protrusion of bowel contents. 1
Types of Hernia - Condition

Reducible hernia: This term refers to the ability to return the contents of the hernia into the
abdominal cavity, either spontaneously or manually.

Incarcerated hernia: An incarcerated hernia is no longer reducible. The vascular supply of the
bowel is not compromised. Bowel obstruction is common.

Strangulated hernia: A strangulated hernia occurs when the vascular supply of the bowel is
compromised secondary to incarceration of hernia contents.

Frequency
United States

Over 1 million abdominal wall hernia repairs are performed each year, with inguinal hernia
repairs constituting nearly 770,000 of these cases. 9,10,11

Approximately 25% of males and 2% of females have inguinal hernias in their lifetimes; this is
the most common hernia in males and females.11,12

Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect
and one third direct.2

Indirect inguinal hernias are the most common hernias in both men and women; a right-sided
predominance exists.

Incisional and ventral hernias account for 10% of all hernias. 4

Only 3% of hernias are femoral hernias.

The incidence of inguinal hernias in children ranges up to 4.4%, while umbilical hernias occur
in approximately 1 out of every 6 children.10,2

The incidence of incarcerated or strangulated hernias in pediatric patients is 10-20%; 50% of

these occur in infants younger than 6 months.10

International

Data from developing countries is limited, therefore, an accurate occurrence value is

unavailable. Current epidemiologic assessments postulate that gender and anatomic
distribution are similar.

Mortality/Morbidity
Morbidity is secondary to missing the diagnosis of the hernia or complications associated with
management of the disease.

A hernia can lead to an incarcerated and often obstructed bowel.

The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced
strangulated bowel leads to persistent ischemia/necrosis with no clinical
improvement. Surgical intervention is required to prevent further complications such as
perforation and sepsis.

Ensuing surgery to repair the hernia or its complications may leave the patient at risk for
infection, future hernias, or intra-abdominal adhesions.

Race

Umbilical hernias occur 8 times more frequently in black infants than in white infants. 12

Sex

Approximately 90% of all inguinal hernia repairs are performed on males. 11

Reduction of hernias in females may be complicated by inclusion of the ovary in the hernia.

Femoral hernias (although rare) occur almost exclusively in women because of the
differences in the pelvic anatomy.

The female-to-male ratio of obturator hernias is 6:1. 12

Age

Indirect hernias usually present during the first year of life, but they may not appear until
middle or old age.

Indirect hernias occur more frequently in premature infants compared to term infants. Indirect
hernias develop in 13% of infants born before 32 weeks' gestation. 10

Direct hernias occur in older patients as a result of relaxation of abdominal wall musculature
and thinning of the fascia.

Umbilical hernias usually occur in infants and reach their maximal size by the first month of
life. Most hernias of this type close spontaneously by the first year of life, with only a 2-10%
incidence in children older than 1 year.13

Clinical
History
Patients with hernias present to the emergency department (ED) secondary to a complication
associated with the hernia. Hernias also may be detected in the ED on routine physical examination.
However, in relation to the chief complaint, the following clinical issues must be considered:

Asymptomatic hernia
o

Presents as a swelling or fullness at the hernia site

Aching sensation (radiates into the area of the hernia)

No true pain or tenderness upon examination

Enlarges with increasing intra-abdominal pressure and/or standing

Incarcerated hernia
o

Painful enlargement of a previous hernia or defect

Cannot be manipulated (either spontaneously or manually) through the fascial defect

Nausea, vomiting, and symptoms of bowel obstruction (possible)

Strangulated hernia
o

Symptoms of an incarcerated hernia present combined with a toxic appearance

Systemic toxicity secondary to ischemic bowel is possible

Strangulation is probable if pain and tenderness of an incarcerated hernia persist

after reduction

Suspect an alternative diagnosis in patients who have a substantial amount of pain

without evidence of incarceration or strangulation

Further anatomic considerations must be assessed in relation to the above clinical findings. The
location of the underlying hernia may provide a unique constellation of symptoms with or without
specific anatomic findings.

Femoral hernia
o

Medial thigh pain as well as groin pain are possible because of the position of this
hernia

Obturator hernia
o

Because this hernia is hidden within deeper structures, it may not present as a
swelling

The patient may complain of abdominal pain or medial thigh pain, weight loss, or
recurrent episodes of bowel or partial bowel obstruction

Pressure on the obturator nerve causes pain in the medial thigh that is relieved by
thigh flexion. This same pain may be exacerbated by extension or external rotation of
the hip (Howship-Romberg sign)

Incisional hernia
o

As these are usually asymptomatic, patients present with a bulge at the site of a
previous incision

Lesion may become larger upon standing or with increasing intra-abdominal pressure

Physical
In general, the physical examination should be performed with the patient in both the supine and
standing positions, with and without the Valsalva maneuver. The examiner should attempt to identify
the hernia sac as well as the fascial defect through which it is protruding. This allows proper direction
of pressure for reduction of hernia contents. The examiner should also identify evidence of obstruction
and strangulation.

When attempting to identify a hernia, look for a swelling or mass in the area of the fascial
defect.
o

Place a fingertip into the scrotal sac and advance up into the inguinal canal. If the
hernia is elsewhere on the abdomen, attempt to define the borders of the fascial
defect.

If the hernia comes from superolateral to inferomedial and strikes the distal tip of the
finger, it most likely is an indirect hernia.

If the hernia strikes the pad of the finger from deep to superficial, it is more consistent
with a direct hernia.

A bulge felt below the inguinal ligament is consistent with a femoral hernia.

Strangulated hernias are differentiated from incarcerated hernias by the following:

o

Pain out of proportion to examination findings

Fever or toxic appearance

Pain that persists after reduction of hernia

Causes
Any condition that increases the pressure in the intra-abdominal cavity may contribute to the formation
of a hernia, including the following:

Marked obesity

Heavy lifting

Coughing

Straining with defecation or urination

Ascites

Peritoneal dialysis

Ventriculoperitoneal shunt

Chronic obstructive pulmonary disease (COPD)

Family history of hernias14

Differential Diagnoses
Epididymitis
Hidradenitis Suppurativa
Hydrocele
Lymphogranuloma Venereum
Testicular Torsion

Other Problems to Be Considered

Groin abscess
Hematoma
Lipoma
Lymphadenitis
Pseudoaneurysm
Spermatocele
Tumor
Undescended or retracted testes
Varicocele

Workup
Laboratory Studies

Complete blood count

o

Results from CBC are nonspecific

Leukocytosis with left shift may occur with strangulation

Electrolytes, BUN, creatinine levels

o

Assess the hydration status of the patient with nausea and vomiting

These tests are rarely needed for patients with hernia except as part of a
preoperative workup

Urinalysis: This test assists with narrowing the differential diagnosis of genitourinary causes of
groin pain in the setting of associated hernias.

Imaging Studies

Imaging studies are not required in the normal workup of a hernia. 4,6

Ultrasonography can be used in differentiating masses in the groin or abdominal wall or in

differentiating testicular sources of swelling.

If an incarcerated or strangulated hernia is suspected, the following imaging studies can be

performed:

Upright chest radiograph to exclude free air (extremely rare)

Flat and upright abdominal films to diagnose a small bowel obstruction (neither
sensitive or specific) or to identify areas of bowel outside the abdominal cavity

CT scanning or ultrasonography may be necessary in the following cases:

o

To diagnose a spigelian or obturator hernia

Inability to obtain a good examination because of body habitus

Treatment
Emergency Department Care

Reduction of a hernia2,9,15
o

Provide adequate sedation and analgesia to prevent straining or pain. The patient
should be relaxed enough to not increase intra-abdominal pressure or to tighten the
involved musculature.

Place the patient supine with a pillow under his or her knees.

Place the patient in a Trendelenburg position of approximately 15-20 for inguinal

hernias.

Apply a padded cold pack to the area to reduce swelling and blood flow while
establishing appropriate analgesia.

Place the ipsilateral leg in an externally rotated and flexed position resembling a
unilateral frog leg position.

Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding
over the ring during reduction attempts.

Firm, steady pressure should be applied to the side of the hernia contents close to
the hernia opening, guiding it back through the defect.

Applying pressure at the apex, or first point, that is felt may cause the herniated
bowel to "mushroom" out over the hernia opening instead of advancing through it.

Consult with a surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use

repeated forceful attempts.

The spontaneous reduction technique requires adequate sedation/analgesia,

Trendelenburg positioning, and padded cold packs applied to the hernia for a duration
of 20-30 minutes. This can be attempted prior to manual reduction attempts.

Also see Hernia Reduction.

Consultations
Consult a surgeon for the following reasons:1,16,3

Inability to reduce the hernia

Concern for a strangulated bowel and a patient with a toxic appearance

Patients with comorbid risks for sedation should have a surgeon present for the initial
reduction attempt

Medication
For strangulated hernias, start broad-spectrum antibiotics. Antibiotics are administered routinely if
ischemic bowel is suspected.

Antibiotics
These agents are to be used if the patient has a strangulated hernia.

Cefoxitin (Mefoxin)

Multiple regimens that cover for bowel perforation and/or ischemic bowel can be used. Cover for both
aerobic and anaerobic gram-negative bacteria.

Dosing
Adult

1-2 g IV q8h
Pediatric

80 mg/kg/d IV divided into 4 equal doses q6h

Interactions
Probenecid may increase effects; aminoglycosides or furosemide may increase nephrotoxicity
(closely monitor renal function)
Contraindication
Documented hypersensitivity
Precaution
Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or
repeated treatment; caution in previously diagnosed colitis

Follow-up
Further Inpatient Care

All incarcerated or strangulated hernias demand admission and immediate surgical

evaluation.

Further Outpatient Care

Follow-up visits with the general surgeon should be scheduled within the next 1-2 weeks for
those patients with easily reducible hernias or with hernias found upon physical examination.

Discharge patients with umbilical hernias with close follow-up care if the defect is less than 2
cm in diameter and the hernia is not incarcerated or strangulated.

Educate patients to avoid those activities that increase intra-abdominal pressure.

Educate patients to return for inability to reduce hernia, increased pain, fever, and vomiting.

Deterrence/Prevention

Counsel the patient on avoidance of activities that increase intra-abdominal pressure, such as
straining at defecation or lifting heavy objects. This may require work or school-related activity
restrictions and should be clearly delineated.

Complications

If strangulation of the hernia is missed, bowel perforation and peritonitis can occur.

Hernias can reappear in the same location, even after surgical repair.

Prognosis

The prognosis depends on the type and size of hernia as well as on the ability to reduce risk
factors associated with the development of hernias.

The prognosis is good with timely diagnosis and repair.

Patient Education

Counsel the patient to avoid those activities that increase intra-abdominal pressure, such as
straining at defecation and lifting heavy objects.

Instruct the patient to apply support to the hernia. Numerous medical device companies have
developed support items to assist with this process.

Even with asymptomatic hernias, early repair (ie, before it enlarges) is preferred. Referral to a
general surgeon for discussion about type of repair is warranted as a wide variety of hernia
repair options now exist with advent of new meshes and laparoscopy.

Miscellaneous
Medicolegal Pitfalls

Failure to consider the diagnosis of hernia in patients who present with nausea and/or
vomiting

Diagnosing testicular torsion as a hernia without appropriate evaluation or imaging

considerations (puts the testicle at risk)

Reducing a strangulated bowel without recognizing it (The hernia will be reduced, but the
bowel will remain ischemic.)

Failure to provide adequate instructions for patients with reduced hernias regarding follow-up
and the need to return to the ED for worsening or persistent recurrent symptoms

Special Concerns

Pain after reduction of a hernia may indicate a strangulated hernia, requiring further
evaluation by a surgeon.