Abdominal and groin hernias

Definition:

• the protrusion of an organ or any other body structure outside the wall of its normal containing cavity

Classification:

• hernias can be classified by:
  • their anatomical location
  • whether they are congenital or acquired
  • structures involved
• several subclassification systems exist for groin hernias

Risk factors:

• age
• male sex
• obesity
• chronic cough
• heavy lifting
• prostatism
• chronic constipation

Clinical presentation:

• patients may present with symptomatic or asymptomatic hernias

Alarm features?

• assessment should rule out incarceration or strangulation as these are surgical emergencies requiring urgent referral
• signs and symptoms of strangulation include:
  • irreducible mass which is firm, painful, and tender (erythema over mass in later stages)
  • signs of bowel obstruction
  • fever
  • raised white blood cell (WBC) count
  If these alarm symptoms are present >> Refer urgently to
  surgeon
  

  Clinical presentation

  These can present as different hernia types including:
  

  • Richter's hernia:
    • only a portion of the circumference of the bowel is included in the sac, hence strangulation without obstruction may occur
    • reduction of an unrecognised Richter's hernia is potentially dangerous as it could lead to perforation and peritonitis
    • they are most common in femoral hernias 
  • Littre's hernia: 
    • Meckel's diverticulum within hernial sac
    • may be associated with delayed small bowel obstruction symptoms and signs 
  • Sliding hernia:
    • also known as hernie-en-glissade
    • retroperitoneal structures and posterior parietal peritoneum slip through the hernial orifice
    • no attempt to dissect the hernia from the sac should be made as blood supply to the viscera may be compromised
    

     

    Epigastric hernia

    Epigastric hernia is a hernia through the linea alba between the xiphisternum and umbilicus (commonly midway between the two):
    

    • hernia content is usually extraperitoneal fat 
    • the hernial neck may be narrow and can strangulate
    • this hernia may lead to symptoms quite out of proportion to its size
    • differential diagnosis of divarication of the recti muscles and intra-abdominal pathology must be ruled out
    • repaired by excision or reduction of the protruding extraperitoneal fat and/or peritoneal sac
    • the defect is closed with a simple or Mayo technique with a non-absorbable suture or mesh repair
    • repair may also involve resection of ischaemic tissue

    Incisional hernia

    • incisional hernias develop at a point of weakness in a previous abdominal wound
    • pain is usually located over the abdominal wall defect which may be exacerbated by straining maneuvers
    • patients may describe changes in bowel habits
    • early surgical referral is recommended for hernias at increased risk or incarceration or strangulation

    Epidemiology:
    

    • estimated occurrence is 3-13% following primary abdominal incisions
    • recurrence rate is high (25-50%)
    • incidence of port site incisional hernias is between 1-6%
    • improved trocars and methods of suturing port sites have reduced the chance of herniation

    Risk factors:
    

    • obesity
    • wound infection
    • smoking
    • diabetes
    • poor nutritional state
    • previous poor surgical closure

    Reducible or irreducible non-tender

    Refer to surgery

    Irreducible and tender and/or obstructed and/or strangulated

    Urgent referral to surgery

    Surgical repair

    
    

    • there are various methods of repairing incisional hernias
    • hernias less than 3cm may be repaired by primary tissue approximation
    • larger hernias will require the use of a prosthetic mesh for tension free repair
    • mesh application includes:
      • onlay
      • inlay
      • preperitoneal (sublay) - the preferred location for mesh placement
      • intraperitoneal
    • tissue release techniques, such as component separation, use of tissue flaps, and the application of tissue expansion techniques may obviate the need for prosthetic repair
    • consider laparoscopic repair (intraperitoneal mesh often with an anti-adhesive layer incorporated)

    Umbilical or para-umbilical hernia

    • umbilical hernia in children:
      • a congenital hernia defect caused by the incomplete closure of the umbilical ring (muscle)
      • often asymptomatic but can lead to obstruction and/or strangulation
      • rare in children over age 3 years
      • more common in Afro-Caribbean children
      • more than 90% resolve spontaneously as the abdominal wall matures

      Under age 3 years

      • the majority of umbilical hernias close spontaneously by age 3 or 4 years

      Asymptomatic
      Review at age 3 years

      
      

      Symptomatic (reducible)

      
      

      • a hernia that reduces spontaneously or with encouragement from the examiner or patient

      Refer to paediatric surgery

      Symptomatic (tender and/or irreducible)

      
      

      • irreducible (also described as incarcerated):
        • sac contents do not return to abdominal cavity
      • signs and symptoms of intestinal obstruction:
        • colicky abdominal pain
        • vomiting
        • abdominal distension
        • absolute constipation

        Over age 3 years

        • the majority of umbilical hernias should have closed spontaneously by age 3 or 4 years

        Refer to paediatric surgery
        
        
    • para-umbilical hernia in adults:
      • para-umbilical hernias do not occur through the umbilical scar but rather above, or less frequently below, the umbilicus
      • tend to increase in size if untreated
      • obese patients should be encouraged to lose weight
      • a narrow hernia neck is prone to obstruction or strangulation

      Reducible or irreducible non-tender

       Refer to surgery

      Obstructed and/or strangulated

      Refer urgently to surgery

      Inguinal hernia

    • protrusion of a peritoneal sac through the anterior abdominal wall in the groin
    • patients may present with complications of groin hernias, such as incarceration or strangulation of the bowel
    • associated with vague groin pain exacerbated by straining and physical activity
    • surgical referral is recommended

    Classification:

    • indirect:
      • originate lateral to the inferior epigastric artery and follow the path of the spermatic cord (or round ligament in females) through the internal inguinal ring, and along the inguinal canal into the scrotum passing above and medial to the pubic tubercle through the external inguinal ring (in males)
    • direct:
      • originate medial to the inferior epigastric artery and push through a weakness in the posterior wall of the inguinal canal rather than down the canal itself

    Epidemiology:

    • approximately 0.14% of the population in England was estimated to be affected in 2001-2002
    • this resulted in 70,000 surgical repairs - 62,969 were primary repairs while 4939 were recurrent repairs
    • 4.8% of primary repairs present as an emergency with a complication compared to 8.6% of recurrent hernias
    • more common in males

    Risk factors:

    • age
    • male gender
    • obesity
    • chronic cough
    • heavy lifting
    • prostatism
    • chronic constipation

    Clinical presentation:

    • patients may present with symptomatic or asymptomatic hernias
    • symptoms may be mild including abdominal or groin pain and a mass or bulge
    • examination of the patient is to assess whether the hernia can be reduced and whether it is inguinal or femoral
    • it is unnecessary to differentiate between direct or indirect inguinal hernias as the management is the same
    • assessment should rule out incarceration or strangulation as these are surgical emergencies requiring urgent referral
    • signs and symptoms of strangulation include:
      • irreducible mass which is firm, painful, and tender (erythema over mass in later stages)
      • signs of bowel obstruction
      • fever
      • raised white blood cell (WBC) count

      Reducible

    a hernia that reduces spontaneously or with encouragement from the examiner or patient 

    Conservative management

    • repair of easily reducible direct hernias is not mandatory, especially in the elderly
    • a cross over study of surgical repair compared with truss wearing shows a truss is a poor alternative
    • obese patients should be encouraged to lose weight
    • optimise or treat:
      • prostatism
      • chronic cough
      • constipation 

      Consider referral to surgery

      Irreducible and non-tender

    • irreducible (also described as incarcerated):
      • sac contents do not return to abdominal cavity
      • commonly due to adhesions, secondary to a long standing hernia
      • no evidence of bowel ischaemia or obstruction
      • there is a higher risk of strangulation in irreducible hernias
    • the high incidence of complications and their associated postoperative mortality all point to the importance of prompt elective repair
    • elective repair will depend on whether the patients is fit and well, or at high risk of anaesthetic complications

    Consider referal to surgery

    • recent irreducibility with no signs of obstruction or strangulation needs surgical referral within 2-8 weeks
    • long standing irreducibility with no signs of obstruction or strangulation that has previously been assessed by a surgeon needs a surgical opinion within 3 months

    Irreducible and tender and/or obstructed and/or strangulated

    • these patients may be acutely ill
    • obstructed:
      • irreducible hernia containing bowel but with no interference to blood supply
    • strangulated:
      • obstructed bowel with interference to blood supply
      • often erythema over hernia
      • less than 10% of strangulated hernias occur with no previous history of hernia
      • the policy of elective repairs has possibly reduced the incidence of strangulated hernias, but does not result in gain in life expectancy
    • signs and symptoms of obstruction:
      • colicky abdominal pain
      • vomiting
      • abdominal distension
      • absolute constipation
    • on examination:
      • tender, inflamed irreducible hernia
      • absent cough impulse
    • treat as surgical emergency:
      • nil by mouth
      • intravenous (IV) fluids
      • prepare for theatre

      Refer urgently to surgery

    Emergency operation with resection of any ischaemic sac contents

    Refer to surgery

     Assess hernia type

    Unilateral inguinal hernia

    
    

    • suitable for surgery if medically fit
    • the three basic approaches to repair are:
      • open suture repair (using patient's own tissue)
      • open mesh repair (tension free or Lichtenstein repair)
      • laparoscopic repair (requires a general anaesthetic)

    Open suture repair:
    

    • less effective than open mesh repair or laparoscopic repair in improving clinical outcomes

    Open mesh repair:
    

    • reduced recurrence rate compared to open suture repair

    Laparoscopic repair:
    

    • two types - totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP)
    • both associated with reduced pain and time taken to return to normal activity compared with open repair

    Inguino-scrotal hernia

    
    

    • suitable for surgery if medically fit
    • warn of risk of testicular atrophy
    • the three basic approaches to repair are:
      • open suture repair (using patient's own tissue)
      • open mesh repair (tension free or Lichtenstein repair)
      • laparoscopic repair (requires a general anaesthetic)

    Open suture repair:
    

    • less effective than open mesh repair or laparoscopic repair in improving clinical outcomes

    Open mesh repair:
    

    • reduced recurrence rate compared to open suture repair

    Laparoscopic repair:
    

    • two types - totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP)
    • both associated with reduced pain and time taken to return to normal activity compared with open repair

    
    

    Bilateral inguinal hernia

    
    

    • suitable for surgery if medically fit
    • simultaneous repair of bilateral hernias may:
      • reduce operating time
      • save two inpatient hospital days; and
      • allow the patient to return to normal activity earlier
    • not associated with any increase in wound complications or postoperative respiratory problems, but increased chance of postoperative urinary retention
    • the three basic approaches to repair are:
      • open suture repair (using patient's own tissue)
      • open mesh repair (tension free)
      • laparoscopic repair (requires a general anaesthetic)

    Open suture repair:
    

    • may be less effective than open mesh repair or laparoscopic repair in improving clinical outcomes

    Open mesh repair:
    

    • may be associated with reduced length of stay compared to open suture repair

    Laparoscopic repair:
    

    • two types - totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP)
    • both are associated with reduced pain and time taken to return to normal activity compared with open repair

    Recurrent inguinal hernia

    
    

    • primary inguinal hernia repair should have a recurrence rate of less than 0.5% at 5 years
    • warn that there is a risk of testicular atrophy
    • the three basic approaches to repair are:
      • open suture repair (using patient's own tissue)
      • open mesh repair (tension free or Lichtenstein repair)
      • laparoscopic repair (requires a general anaesthetic)

    Open suture repair:
    

    • may be less effective than open mesh repair or transabdominal preperitoneal laparoscopic repair in improving clinical outcomes

    Open mesh repair:
    

    • may be associated with reduced length of stay compared to open suture repair

    Laparoscopic repair:
    

    • if the primary surgery was done as an open procedure the laparoscopic approach has the advantage of relatively undisturbed tissue planes
    • two types - totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP)
    • both may be associated with reduced time taken to return to normal activity compared with open repai

    
    

    Femoral hernia

    • a protrusion of peritoneum into the potential space of the femoral canal medial to the femoral vessels
    • the hernia occurs below and lateral to the pubic tubercle
    • third most common hernia, making up 10% of groin hernias but accounting for 35-50% of emergency presentations, secondary to incarceration or strangulation
    • this hernia occurs more frequently in females than males (4:1)
    • difficult to diagnose in elderly or obese people
    • not normally associated with a visible or palpable cough impulse
    • early surgical referral is recommended for suspected femoral hernias because of the increased risk of incarceration or strangulation

    Reducible

    
    

    • a hernia that reduces spontaneously or with encouragement from the examiner or patient 

    Consider referral to surgery

    Irreducible and/or obstructed and/or strangulated

    • Richter's hernia are relatively common in the femoral sac, as:
      • they do not contain bowel lumen - symptoms of obstruction will not occur, but bowel wall ischaemia and perforation may

      Refer urgently to surgery:

      Surgical repair

    • all patients with femoral hernias should be considered for surgical repair because of the high incidence of bowel strangulation
    • urgent repair is indicated for patients with signs of incarceration or strangulation
    • repair may be carried out under general, regional, or local anaesthetic 
    • the three basic approaches to repair are:
      • open repair (using patient's own tissue) - three approaches:
        • low (Lockwood)
        • inguinal (Lotheissen)
        • high (McEvedy)
      • open tension free repair (using a mesh)
      • laparoscopic repair (requires a general anaesthetic)

    Lumbar hernia

    • may appear spontaneously through one or two anatomical points of weakness within the lumbar region:
      • the lumbar triangle of Petit (bounded by the iliac crest, posterior edge of external oblique and anterior edge of latissimus dorsi)
      • the superior quadrilateral lumbar space (bounded by the twelfth rib, the lower border of serratus posterior inferior, the anterior border of erector spinae and the internal oblique)
    • predisposing factors include:
      • renal operations
      • lumbar abscess 
      • paralysis of the lateral lumbar muscles, ie. by poliomyelitis or spina bifida 
    • the neck of the hernial sac is wide and therefore rarely requires surgery

    Spigelian hernia

    • represent less than 1% of all abdominal hernias
    • occurs through the linea semilunaris at the outer border of the rectus abdominis muscle
    • occurs below the umbilicus and is more frequent in women than men (1.5:1)
    • liable to strangulate
    • can be clinically difficult to diagnose but ultrasound, CT scan, or magnetic resonance imaging (MRI) of the abdominal wall aid in the diagnosis
    • open repair of the hernia is by excision of the peritoneal sac and closure of the aponeurotic defect
    • laparoscopic surgery may be diagnostic as well as therapeutic

    Parastomal hernia

    • parastomal hernias are a common complication of an ileostomy or colostomy 
    • symptoms include intermittent bowel obstruction if the hernia contains a segment of bowel proximal to the stoma
    • rate of occurrence is higher in end ileostomies (1.8-28.3%) compared to loop ileostomies (0-6.2%)
    • rate of occurrence following colostomies is estimated to be between 4-48.1% (end colostomies) and 0-30.8% (loop colostomies)
    • there is limited evidence that mesh repair is associated with a lower recurrence rate compared to direct tissue repair or stoma relocation