Hernias
From Medical-Wiki
Hernias are an opening where there should not be an opening—a widening where there should not be a widening. There are a variety of abdominal wall hernias.
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Types of hernias
An indirect hernia is one that follows the developmental tract through the inguinal canal. It basically represents a persistent process vaginalis. The hernia follows the tract of the testicle as it descends into the scrotum, from the internal inguinal ring along the inguinal ligament to the external ring.
A direct hernia occurs when there is a defect or weakness in the transversalis fascia in a triangle defined by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon. This is called the Hesselbach triangle.
A femoral hernia follows the tract through the femoral canal—below the inguinal ligament. This course lies lateral to the lacunar ligament and medial to the femoral vein.
Umbilical hernias occur when the umbilical fibromuscular ring does not obliterate. It should do so by the age of 2.
A Spigelian hernia occurs through the Spiogelian fascia, an area defined by the lateral edge of the rectus muscle at the semilunar line.
An obturator hernia is one that follows the obturator bundle of nerves and vessels. It traverses the obturator foramen.
An incisional hernia occurs when there is a failure of fascial closure at a surgical incision. The rate of occurrence of this hernia is surprisingly high—estimated to be between 2% and 10%. [1]
A sportsman’s hernia has been described as being caused by a dilated superficial inguinal ring. It presents as chronic pain, near the pubic tubercle. It is usually worse on the evening of maximal exercise or the following morning. It is worsened by any activity that increases abdominal pressure. It is technically not a true hernia. Findings may reveal laxity of the transversalis fascia, abnormalities of the insertion of the abnominus, insertion avulsions of the internal oblique, or entrapment of the ilioinguinal or genitofemoral nerves.
Configurations of hernia
In addition to various sites of hernia, there are also a variety of hernia configurations. A reducible hernia is one where the hernia contents can be placed back into their proper configuration—either spontaneously or manually. An incarcerated hernia cannot be reduced but the vascular supply of the bowel is not compromised. However, bowel obstruction is common. A strangulated hernia is one where the vascular supply of the bowel is compromised. A Richter hernia involved only a part of the bowel. This means that even if the bowel is strangulated or incarcerated, it may not necessarily be obstructed. This is a potentially devastating circumstance because strangulated bowel may unwittingly be reduced. [2]
Clinical Presentation
Hernias of different nature present with different symptoms. Asymptomatic hernias may appear as a swelling or fullness at the hernia site with some mild aching but little tenderness on exam. Exam does, however, show enlargement with increased abdominal straining or standing.
An incarcerated hernia usually appears as a painful enlargement of a previous asymptomatic hernia. It cannot be reduced. Signs of bowel obstruction may be present.
A strangulated hernia appears like an incarcerated hernia but with additional signs of toxicity. The possibility of strangulation increases if the tenderness of an incarcerated persists following reduction.
A femoral hernia typically presents as medial thigh pain of groin pain.
There may be no pain associated with an obturator hernia because it is located within deep structures. An obturator hernia may present as undifferentiated abdominal pain. There may be intermettant episodes of abdominal pain as well as bowel obstruction.
Incisional hernias are usually asymptomatic but obvious on examination. [3]
Diagnosis
Physical findings
Physical examination reveals dilation of the superficial inguinal ring with or without herniation. There may often be a point of maximum tenderness on the ipsilateral pubic tubercle. Sit-ups and valsalva will increase pain and a patient’s gait will show weakness of adduction.
Radiological findings
Diagnosis is primarily made on a clinical basis. In some cases, upright abdominal films may be of help checking for signs of bowel obstruction. MRIs and CT scans are sometimes used when diagnosing Spigelian hernias.
Treatment
Even though conservative management will decrease pain, surgical intervention is required to clear the problem. [4]
A rule of thumb regarding treatment of hernias is that they should all be surgically repaired because the risk of surgical complication is exceeded by the risk of allowing a hernia to persist and runs the possibility of becoming incarcerated or strangulated.
