Abdominal Wall Hernias
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Introduction
A hernia is an organ protruding or bulging from its normal anatomical boundaries. Abdominal wall hernias most frequently involve the inguinal ring.
Also included in this topic are umbilical and surgical hernias.
Hernias can cause chronic pain. Initially hernias are reducible, whereby they can be returned to the abdominal cavity either spontaneously or with external palpation. Incarcerated hernias are irreducible, while strangulated hernias are ischemic and potentially necrotic. This is a severe, emergent complication.
Hernia repair is accordingly a very common and important surgery worldwide. There are a number of different approaches, involving sutures and/or mesh.
The Case of...
Types of Hernia
Inguinal hernias
Groin hernias can be:
- direct (medial to inferior epigastric vessels)
- indirect (laterial to inferior epigastric vessels, or Hesselbach's triangle)
- femoral (below the ileoinguinal ligament) least common
Umbilical hernias
Umbilical hernias are congenital. They occur via the umbilical fibromuscular ring. They usually spontaneously resolve and are rare after age 5.
Incisional hernia
Incisional hernias occur in up to 10% of abdominal operations.
- infection
- smoking
- obesity
- inherent collagen/elastin disorders (Ehlers-Dnlos, Marfan)
- poor technique
Pathophysiology
Inguinal hernias have a complex etiology. Anatomically, they can result from a defect in the processus vaginalis and/or the transversalis fascia. The shutter mechanism is normally in place, whereby the the abdominal wall musculature closes during straining or cough. A defective shutter mechanism can increase the risk of hernia.
Genetics can play a role including a patent peocessus vaginalis, as well as connective tissue disorders.
Signs and Symptoms
- history
- physical exam
History
Obturator hernias present as pain and paresthesias in the inner thigh as the obturator nerve is compressed.
Physical Exam
Physical exam for inguinal hernia...
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Lab investigations are not helpful for diagnosis of hernia
Diagnostic Imaging
Where clinical exam is limited, imaging can include
- ultrasound
- computed tomography (CT) scan
- magnetic resonance imaging (MRI)
Differential Diagnosis
Treatments
Inguinal hernias
The Bassini approach is an open, anterior repair. It involves dissection of the hernia sac and high ligation of the sac to provide reconstruction of the inguinal floor with simple inturrupted sutures. Recurrence rate was high (~10%). The Shouldice approach also used an open anterior approach to accomplish tissue repair, but with a continuous, multilayer suture.
Lichenstein uses an open anterior approach, but uses a tension-free mesh reinforcement. The recurrence rate is <1-5%.
The preperitoneal approach can be accomplished through open surgery or laparoscopy. In this way, the intraabdominal pressure is used to hold the mesh in place.
Mesh appears to reduce both pain and recurrence rate (EU trialists
It is still not known if all groin hernias need to be repaired. Up to 30% of patients are asymptomatic without surgery. Fitzgibbons et al found that watchful waiting is safe, with no risk of increased complications.
Open repair has less recurrence and is reproducible by non-specialist surgeons. It is the more preferred technique worldwide. Laproscopic repair requires more resources, skill, and time, but the return to work time is faster.
(recurrent repair, bilateral, athletes, morbid obesity
Umbilical Hernias
Umbilical hernias should be left alone in children under two years old and fixed in children above two in which they are enlarging or bothersome.
A sutured (Mayo) repair is simple but with high recurrence. An open mesh repair carries increased risk of infection, while laproscopic repair (if the skill exists) has a higher success rate and lower infectious risk.
Incisional Hernias
Incisional hernia repair has a high reccurence rate with open suture repair and high infection rate with open mesh repair.
Lumbar hernias should be fixed rarely due to their low risk of morbidity and high risk of serious complications.
Consequences and Course
Most patients with painless inguinal hernia develop symptoms over time (Chung L et al).
Consequences of surgery include:
- chronic pain; can occasionally be severe
- risk factors: severe pain pre-op, increased age; anterior surgical approach; post-op complications
- recurrence
- vas deferens injury and testicular atrophy (rare)
Acute incarcerations are a serious consequence of hernias.
Resources and References
Bisgaard T et al. 2007. Risk of recurrence...
Topic Development
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