hernia presentation

• Inguinal hernia

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When to see a doctor, risk factors, complications.

An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object. However, many hernias do not cause pain.

Inguinal hernias occur when part of the membrane lining the abdominal cavity (omentum) or intestine protrudes through a weak spot in the abdomen — often along the inguinal canal, which carries the spermatic cord in men.

An inguinal hernia isn't necessarily dangerous. It doesn't improve on its own, however, and can lead to life-threatening complications. Your doctor is likely to recommend surgery to fix an inguinal hernia that's painful or enlarging. Inguinal hernia repair is a common surgical procedure.

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Inguinal hernia signs and symptoms include:

• A bulge in the area on either side of your pubic bone, which becomes more obvious when you're upright, especially if you cough or strain
• A burning or aching sensation at the bulge
• Pain or discomfort in your groin, especially when bending over, coughing or lifting
• A heavy or dragging sensation in your groin
• Weakness or pressure in your groin
• Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

Signs and symptoms in children

Inguinal hernias in newborns and children result from a weakness in the abdominal wall that's present at birth. Sometimes the hernia will be visible only when an infant is crying, coughing or straining during a bowel movement. He or she might be irritable and have less appetite than usual.

In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period.

Signs of trouble

If you aren't able to push the hernia in, the contents of the hernia may be trapped (incarcerated) in the abdominal wall. An incarcerated hernia can become strangulated, which cuts off the blood flow to the tissue that's trapped. A strangulated hernia can be life-threatening if it isn't treated.

Signs and symptoms of a strangulated hernia include:

• Nausea, vomiting or both
• Sudden pain that quickly intensifies
• A hernia bulge that turns red, purple or dark
• Inability to move your bowels or pass gas

Seek immediate care if a hernia bulge turns red, purple or dark or if you notice any other signs or symptoms of a strangulated hernia.

See your doctor if you have a painful or noticeable bulge in your groin on either side of your pubic bone. The bulge is likely to be more noticeable when you're standing, and you usually can feel it if you put your hand directly over the affected area.

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Some inguinal hernias have no apparent cause. Others might occur as a result of:

• Increased pressure within the abdomen
• A preexisting weak spot in the abdominal wall
• Straining during bowel movements or urination
• Strenuous activity
• Chronic coughing or sneezing

In many people, the abdominal wall weakness that leads to an inguinal hernia occurs prior to birth when a weakness in the abdominal wall muscle doesn't close properly. Other inguinal hernias develop later in life when muscles weaken or deteriorate due to aging, strenuous physical activity or coughing that accompanies smoking.

Weaknesses can also occur in the abdominal wall later in life, especially after an injury or abdominal surgery.

In men, the weak spot usually occurs in the inguinal canal, where the spermatic cord enters the scrotum. In women, the inguinal canal carries a ligament that helps hold the uterus in place, and hernias sometimes occur where connective tissue from the uterus attaches to tissue surrounding the pubic bone.

Factors that contribute to developing an inguinal hernia include:

• Being male. Men are eight times more likely to develop an inguinal hernia than are women.
• Being older. Muscles weaken as you age.
• Being white.
• Family history. You have a close relative, such as a parent or sibling, who has the condition.
• Chronic cough, such as from smoking.
• Chronic constipation. Constipation causes straining during bowel movements.
• Pregnancy. Being pregnant can weaken the abdominal muscles and cause increased pressure inside your abdomen.
• Premature birth and low birth weight. Inguinal hernias are more common in babies who are born prematurely or with a low birth weight.
• Previous inguinal hernia or hernia repair. Even if your previous hernia occurred in childhood, you're at higher risk of developing another inguinal hernia.

Complications of an inguinal hernia include:

• Pressure on surrounding tissues. Most inguinal hernias enlarge over time if not repaired surgically. In men, large hernias can extend into the scrotum, causing pain and swelling.
• Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, the contents can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas.
• Strangulation. An incarcerated hernia can cut off blood flow to part of your intestine. Strangulation can lead to the death of the affected bowel tissue. A strangulated hernia is life-threatening and requires immediate surgery.

You can't prevent the congenital defect that makes you susceptible to an inguinal hernia. You can, however, reduce strain on your abdominal muscles and tissues. For example:

• Maintain a healthy weight. Talk to your doctor about the best exercise and diet plan for you.
• Emphasize high-fiber foods. Fruits, vegetables and whole grains contain fiber that can help prevent constipation and straining.
• Lift heavy objects carefully or avoid heavy lifting. If you must lift something heavy, always bend from your knees — not your waist.
• Stop smoking. Besides its role in many serious diseases, smoking often causes a chronic cough that can lead to or aggravate an inguinal hernia.

Apr 24, 2021

• Brooks DC, et al. Classification, clinical features and diagnosis of inguinal and femoral hernias in adults. https://www.uptodate.com/contents/search. Accessed Feb. 12, 2021.
• Ramsook C. Overview of inguinal hernia in children. https://www.uptodate.com/contents/search. Accessed Feb. 12, 2021.
• AskMayoExpert. Inguinal hernia (child). Mayo Clinic; 2020.
• Inguinal hernia. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/inguinal-hernia. Accessed Feb. 12, 2021.
• Townsend CM Jr, et al. Hernias. In: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier; 2017. https://www.clinicalkey.com. Accessed Feb. 15, 2021.
• Pearson DG (expert opinion). Mayo Clinic. Feb. 26, 2021.
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Last updated: November 2, 2023 Revisions: 58

• 1.1 Classification
• 2 Risk Factors
• 3.1 Differentiation of Inguinal Hernia
• 4 Differential Diagnosis
• 5 Investigations
• 6.1 Emergency Presentation of a Hernia
• 6.2 Surgical Intervention
• 7 Complications
• 8 Key Points

Introduction

An  inguinal hernia  occurs when abdominal cavity contents  enter the inguinal canal .

They are the  most common type of hernia  and account for around 75% of all anterior abdominal wall hernias, with a prevalence of 4% in those over 45 years.

In this article, we shall look at the classification, clinical features and management of inguinal hernia.

Figure 1 – Sagittal view of the inguinal canal, showing the borders

Classification

A hernia is defined as the protrusion of part or whole of an organ or tissue through the wall of the cavity that normally contains it. Inguinal herniae involve abdominal contents passing into the inguinal canal (and can continue into the scrotum)

The two main subtypes that can occur:

• They occur more commonly in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
• In younger patients, they arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin

These two types of inguinal hernia can only be reliably differentiated at the time of surgery by identifying the  inferior epigastric vessels – indirect hernias will be lateral to the vessels whilst direct hernias will be medial to the vessels. In paediatric cases , they are nearly always indirect inguinal hernias

*Hesselbach’s triangle is bordered medially by the lateral border of the rectus abdominis muscle, superiorly by the inferior epigastric vessels, and inferiorly by the inguinal ligament

Figure 2 – An Indirect Inguinal Hernia, with abdominal contents entering the canal via the internal (deep) ring

Risk Factors

The main factors that increase the risk of developing an inguinal hernia:

• Male  gender
• Increasing age
• Raised intra-abdominal pressure , from chronic cough, heavy lifting, or chronic constipation

Clinical Features

The most common presenting symptom is a  lump in the groin , which (for reducible herniae) will initially disappear with minimal pressure or when the patient lies down. There may be mild to moderate discomfort, which can worsen with activity or standing.

If the hernia becomes  incarcerated , it can become painful and the lump cannot be reduced. The patient may also present with clinical features of bowel obstruction  if the bowel lumen becomes blocked, or with features of strangulation *   if the blood supply becomes compromised.

When  examining any groin lump , specific features to note for any suspected inguinal hernia include:

• Cough impulse – remember that an irreducible hernia may not have a cough impulse
• Location  – inguinal herniae appear superomedial to the pubic tubercle* (whilst femoral herniae appear inferolateral to the pubic tubercle)
• Reducible  – On lying down or with gentle pressure
• If it enters the scrotum , can you get above it / is it separate from the testis

*This is not always clear on examination, especially if large and tender

Figure 3 – A right sided inguinal hernia

Differentiation of Inguinal Hernia

Theoretically, to differentiate a direct from an indirect inguinal hernia, the examiner must reduce the hernia and then place pressure over the deep inguinal ring (located at the mid-point of the inguinal ligament), before asking the patient to cough.

If the hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia, whereas if the hernia does not protrude, this indicates an indirect hernia.

This assessment is often seen as unreliable and the only definite method to differentiate them is at the time of surgery.

Differential Diagnosis

There are several differential diagnoses for a lump in the groin. These include femoral hernia , saphena varix , inguinal lymphadenopathy , lipoma , or groin abscess . If the mass extends into the scrotum, consider a hydrocoele , varicocoele , or a testicular malignancy .

Investigations

A hernia is typically a  clinical diagnosis . Current  Royal College of Surgeons Guidelines  state that imaging should only be considered in patients if there is diagnostic uncertainty or to exclude other pathology.

If necessary, an  ultrasound scan is recommended as first line imaging in the outpatient setting (Fig. 4). For patients with features of obstruction or strangulation, CT imaging will be required.

Figure 4 – Ultrasound of inguinal hernia, demonstrating moving intestinal loops within inguinal canal with respiration

Any patient with a  symptomatic inguinal hernia (significant mass or discomfort) should be offered surgical intervention (see below).

The  risk of strangulation is no more than about 2% per year with an inguinal hernia. Any patients presenting with evidence of strangulation (such as pain out of proportion to clinical features or deranged biochemical results) nearly always require urgent surgical exploration .

A third of patients with an inguinal hernia will never experience any symptoms (especially those identified incidentally on imaging). Discussions should take place around the likelihood of future surgical intervention and the symptoms of potential strangulation .

Emergency Presentation of a Hernia

The complications that can occur with any hernia are:

• Irreducible / incarcerated – the contents of the hernia are unable to return to their original cavity
• Obstruction – the bowel lumen has become obstructed, leading to the clinical features of bowel obstruction
• Strangulation – compression of the hernia has compromised the blood supply, leading to the bowel becoming ischaemic

An abdominal wall hernia that has strangulated will present as an irreducible and tender lump, the pain often being out of proportion to clinical signs. A strangulated hernia is a surgical emergency and requires an urgent operation.

Surgical Intervention

Hernia repairs can be performed via  open repair or laparoscopic repair *; laparoscopic repairs are associated with longer operating times but quicker post-operative recovery, fewer complications, and less post-operative pain:

• Lichtenstein technique (with a mesh) is the most commonly technique used, whilst repair options without mesh include the Bassini or Shouldice methods
• The two main types of laparoscopic repair are total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP) repair

*A TAPP repairs involves establishing pneumoperitoneum, before accessing the preperitoneal space by incising the parietal peritoneum from the inside, whilst a TEP repair involves the entire operation being carried out within the preperitoneal space, without entering the peritoneal cavity, and a balloon dissector is used to expand and create room

Figure 5 – Suggested inguinal hernia treatment algorithm

Complications

The  main complications  of an inguinal hernia are  incarceration , strangulation , and  obstruction .

Potential complications following elective inguinal hernia repair include haemoatoma or seroma formation, recurrence (around 1% by 5years), chronic pain , or damage to vas deferens or testicular vessels (leading to ischaemic orchitis, and potentially sub-fertility)

• An inguinal hernia can be classified as direct or indirect
• The diagnosis is a clinical one and only warrants further investigation if there is diagnostic uncertainty or features of complication
• Most cases are repaired via open approach

These two types of inguinal hernia can only be reliably differentiated at the time of surgery by identifying the  inferior epigastric vessels - indirect hernias will be lateral to the vessels whilst direct hernias will be medial to the vessels. In paediatric cases , they are nearly always indirect inguinal hernias

• Cough impulse - remember that an irreducible hernia may not have a cough impulse
• Location  - inguinal herniae appear superomedial to the pubic tubercle* (whilst femoral herniae appear inferolateral to the pubic tubercle)
• Reducible  - On lying down or with gentle pressure

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Hernias of the Abdominal Wall

• Classification of Abdominal Hernias |
• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Prognosis |

A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become incarcerated or strangulated, causing pain and requiring immediate surgery. Diagnosis is clinical. Treatment is surgical repair.

(See also Acute Abdominal Pain .)

Abdominal hernias are extremely common. For example, approximately 600,000 ventral hernia repair operations are performed each year in the United States ( 1 ).

General reference

1. Schlosser KA, Renshaw SM, Tamer RM, Strassels SA, Poulose BK . Ventral hernia repair: an increasing burden affecting abdominal core health.  Hernia . 2023;27(2):415-421. doi:10.1007/s10029-022-02707-6

Classification of Abdominal Hernias

Approximately 75% of all abdominal wall hernias are inguinal ( 1 ). Incisional (ventral) and umbilical hernias comprise another 10 to 15%. Femoral and unusual hernias account for the remaining 10 to 15%.

Strangulated hernias are ischemic because of physical constriction of their blood supply. Strangulation can result in bowel infarction, perforation , and peritonitis .

Abdominal wall hernias

Abdominal wall hernias include

Inguinal hernias

Incisional (ventral) hernias

Umbilical hernias

Femoral hernias

Epigastric hernias

Spigelian hernias

Inguinal hernias occur above the inguinal ligament. Indirect inguinal hernias traverse the internal inguinal ring into the inguinal canal, and direct inguinal hernias extend directly forward and do not pass through the inguinal canal. (See also Inguinal hernia in neonates .)

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Incisional hernias occur through an incision from previous abdominal surgery.

Umbilical hernias (protrusions through the umbilical ring) are mostly congenital, but some are acquired in adulthood secondary to obesity, ascites, pregnancy, or chronic peritoneal dialysis.

Femoral hernias occur below the inguinal ligament and go into the femoral canal.

Epigastric hernias occur through the linea alba.

Spigelian hernias occur through defects in the transversus abdominis muscle lateral to the rectus sheath, usually below the level of the umbilicus.

Sports hernias

A sports hernia is not a true hernia because there is no abdominal wall defect through which abdominal contents protrude. Instead, the disorder involves a tear of one or more muscles, tendons, or ligaments in the lower abdomen or groin, particularly where they attach to the pubic bone. It is more appropriately termed athletic pubalgia.

1. Dabbas N, Adams K, Pearson K, Royle G . Frequency of abdominal wall hernias: is classical teaching out of date?.  JRSM Short Rep . 2011;2(1):5. Published 2011 Jan 19. doi:10.1258/shorts.2010.010071

Symptoms and Signs of Abdominal Wall Hernias

Most patients have only a visible bulge, which may cause vague discomfort or be asymptomatic. They can often reduce the hernia by pushing it back through the abdominal wall defect.

A strangulated hernia causes steady, gradually increasing pain, typically with nausea and vomiting. The hernia itself is tender, and the overlying skin may be erythematous; peritonitis may develop depending on location, with diffuse tenderness, guarding, and rebound.

Diagnosis of Abdominal Wall Hernias

Clinical evaluation

The diagnosis of an abdominal hernia is clinical. Because the hernia may be apparent only when abdominal pressure is increased, the patient should be examined in a standing position. If no hernia is palpable, the patient should cough or perform a Valsalva maneuver as the examiner palpates the abdominal wall. Examination is focused on the umbilicus, the inguinal area (with a finger in the inguinal canal in males), the femoral triangle, and any incisions that are present.

Most hernias, even large ones, can be manually reduced with persistent gentle pressure; placing the patient in the Trendelenburg position may help. An incarcerated hernia cannot be reduced and can be the cause of a bowel obstruction.

Inguinal masses that resemble hernias may be the result of adenopathy (infectious or malignant), an ectopic testis, or lipoma. These masses are solid and are not reducible. A scrotal mass may be a varicocele , hydrocele , or testicular tumor .

Ultrasound may be done if physical examination is equivocal.

Treatment of Abdominal Wall Hernias

Surgical repair

Groin hernias typically should be repaired electively because of the risk of strangulation, which results in higher morbidity (and possible mortality in older patients).

Asymptomatic inguinal hernias in men can be observed; if symptoms develop, they can be repaired electively. Repair may be through a standard incision or a laparoscope

An incarcerated or strangulated hernia of any kind requires urgent surgical repair.

Prognosis for Abdominal Wall Hernias

Congenital umbilical hernias rarely strangulate and are not treated; most resolve spontaneously within several years. Very large defects may be repaired electively after age 2 years.

Umbilical hernias in adults cause cosmetic concerns and can be electively repaired; strangulation and incarceration are unusual but can happen and usually contain omentum rather than intestine.

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

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• Abdominal Hernias
• Author: Assar A Rather, MBBS, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
• Sections Abdominal Hernias
• Practice Essentials
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Approach Considerations
• Laboratory Studies
• Radiography
• Computed Tomography
• Ultrasonography
• Histologic Findings
• Hernia Reduction
• Topical Therapy
• Surgical Repair of Inguinal Hernia
• Surgical Repair of Other Hernia Types
• Surgical Repair of Gastroschisis, Omphalocele, and Other Defects
• Long-Term Monitoring
• Medication Summary
• Antibiotics
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Abdominal wall hernias are among the most common of all surgical problems. Knowledge of these hernias (usual and unusual) and of protrusions that mimic them is an essential component of the armamentarium of the general and pediatric surgeon. More than 1 million abdominal wall hernia repairs are performed each year in the United States, with inguinal hernia repairs constituting nearly 770,000 of these cases; approximately 90% of all inguinal hernia repairs are performed on males. [ 1 , 2 , 3 ] See the image below.

Signs and symptoms

Hernias may be detected on routine physical examination, or patients with hernias may present because of a complication associated with the hernia.

Characteristics of asymptomatic hernias are as follows:

• 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

Characteristics of incarcerated hernias are as follows:

• 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)

Characteristics of strangulated hernias are as follows:

• Patients have symptoms of an incarcerated hernia
• 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

When attempting to identify a hernia, look for a swelling or mass in the area of the fascial defect, as follows:

• For inguinal hernias, 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

Characteristics of various hernia types include the following:

• Inguinal hernia - Bulge in the inguinal region or scrotum, sometimes intermittent; may be accompanied by a dull ache or burning pain, which often worsens with exercise or straining (eg, coughing)
• Spigelian hernia - Local pain and signs of obstruction from incarceration; pain increases with contraction of the abdominal musculature
• Interparietal hernia - Similar to spigelian hernia; occurs most frequently in previous incisions
• Internal supravesical hernias - Symptoms of gastrointestinal (GI) obstruction or symptoms resembling a urinary tract infection
• Lumbar hernia - Vague flank discomfort combined with an enlarging mass in the flank; progressive protrusion through lumbar triangles, more commonly through the superior (Grynfeltt-Lesshaft) triangle than through the inferior (Petit); not prone to incarceration
• Obturator hernia - Intermittent, acute, and severe hyperesthesia or pain in the medial thigh or in the region of the greater trochanter, usually relieved by thigh flexion and worsened by medial rotation, adduction, or extension at the hip
• Sciatic hernia - Tender mass in the gluteal area that is increasing in size; sciatic neuropathy and symptoms of intestinal or ureteral obstruction can also occur
• Perineal hernias - Perineal mass with discomfort on sitting and occasionally obstructive symptoms with incarceration
• Umbilical hernia - Central, midabdominal bulge
• Epigastric hernia - Small lumps along the linea alba reflecting openings through which preperitoneal fat can protrude; may be adjacent to the umbilicus (umbilical hernia) or more cephalad (ventral hernia [epiplocele])

See Presentation for more detail.

History and physical examination remain the best means of diagnosing hernias. The review of systems should carefully seek out associated conditions, such as ascites, constipation, obstructive uropathy, chronic obstructive pulmonary disease, and cough.

Laboratory studies include the following:

• Stain or culture of nodal tissue
• Complete blood count (CBC)
• Electrolytes, blood urea nitrogen (BUN), and creatinine

Imaging studies are not required in the normal workup of a hernia. However, they may be useful in certain scenarios, as follows:

• Ultrasonography (US) 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, upright chest films or flat and upright abdominal films may be obtained
• Computed tomography (CT) or ultrasonography may be necessary if a good examination cannot be obtained, because of the patient’s body habitus, or in order to diagnose a spigelian or obturator hernia

See Workup for more detail.

Nonoperative therapeutic measures include the following:

• Binders or corsets
• Hernia reduction [ 1 ]
• Topical therapy
• Compression dressings

Surgical options depend on type and location of hernia. Basic types of inguinal hernia repair include the following:

• Bassini repair
• Shouldice repair
• Cooper repair
• Simple inguinal hernia repair in children

Surgical approaches to other hernia types may vary, as follows:

• Umbilical hernia - After exposure of the umbilical sac, a plane is created to encircle the sac at the level of the fascial ring, and the defect is closed transversely with interrupted sutures; if the defect is very large (>2 cm), mesh may be required
• Epigastric hernia - A small vertical incision directly over the defect is carried to the linea alba, and incarcerated preperitoneal fat is either excised or returned to the properitoneum; the defect is closed transversely with interrupted sutures
• Spigelian hernia - A transverse incision over the hernia to the sac allows dissection to the neck, and clean approximation of the internal oblique muscle and the transversus abdominis followed by closure of the external oblique aponeurosis completes the repair
• Interparietal hernia - Large interparietal hernias require mesh or component separation technique
• Supravesical hernia - The standard techniques for inguinal and femoral hernias are used, usually via a paramedian or midline incision
• Lumbar hernia - A skin-line oblique incision is made from the 12th rib to the iliac crest; a layered closure or mesh onlay for large defects is successful
• Obturator hernia - Generally approached abdominally and often amenable to laparoscopic repair; mesh closure is necessary for a tension-free repair
• Sciatic hernia - A transperitoneal approach is used in the event of incarceration; a transgluteal repair can be used if the diagnosis is established and the intestine is clearly viable
• Perineal hernia - A transabdominal approach with prosthetic closure is preferred; a combined transabdominal-perineal approach can also be used
• Gastroschisis and omphalocele - Primary closure of fascia and skin is usually best; nonoperative management of gastroschisis (plastic closure) is an alternative to conventional primary operative closure or staged silo closure
• Femoral hernia - A standard Cooper ligament repair, a preperitoneal approach, or a laparoscopic approach may be used; the procedure includes dissection and reduction of the hernia sac and obliteration of the defect in the femoral canal by approximating the iliopubic tract to the pectineal (Cooper) ligament or by using a mesh

See Treatment and Medication for more detail.

Uncommon in other animals, abdominal wall hernias are among the most common of all surgical problems. They are a leading cause of work loss and disability and are sometimes lethal. Knowledge of hernias of the abdominal wall (usual and unusual) and of the protrusions that mimic hernias is an essential component of the armamentarium of the general and pediatric surgeon.

Abdominal wall hernias are commonly described in terms of their anatomic location. Four of the most common types are shown in the image below.

Operative management of hernias, despite being described since antiquity and constituting an essential part of the general surgeon’s repertoire of operations, remains controversial. By definition, a hernia is an abnormal protrusion from one anatomic space to another, with the protruded parts generally contained in a saclike structure formed by the membrane that naturally lines the cavity.

Variants on the definition of hernia exist with regard to congenital abdominal wall defects. An omphalocele is characterized by extension of viscera from the abdominal cavity into the umbilical stalk, with the contents covered by a translucent, bilaminar sac consisting of fused amnion and peritoneum. On occasion, the sac tears prenatally or during delivery, thus becoming harder to identify. The underlying abdominal wall defect exceeds 4 cm. The umbilical vessels insert onto the sac and travel along its left superior aspect to the abdominal wall.

On the other hand, gastroschisis is present when midgut viscera protrude through a central abdominal fascial defect and are not covered by a sac. In this case, the extracorporeal viscera are exposed to the amniotic fluid in utero or to the atmosphere postnatally. The responsible fascial defect is usually less than 4 cm and is almost always immediately to the right and inferior to the umbilicus.

Anterior abdominal wall

The anterior abdominal wall is composed of multilaminar mirror-image muscles, the associated aponeuroses, fasciae, fat, and skin. Laterally, three muscle layers with fascicles run obliquely in relation to each other. Each inserts into a flat white tendon, known as an aponeurosis.

The paired rectus abdominis muscles originate on the pubis inferiorly and insert on the ribs superiorly. The muscle has four transversely oriented tendinous bands, variably spaced. At the lateral margin of the rectus abdominis muscles is the linea semilunaris, where the aponeurosis serves as an insertion for the lateral musculature. The lower edge of the posterior sheath, midway between the umbilicus and the pubis with its concavity oriented toward the pubis, defines the semicircular line.

Above this line, anterior and posterior laminae form from division of the internal oblique aponeurosis. The posterior lamina joins the transversus abdominis aponeurosis and forms the posterior rectus sheath. The anterior rectus sheath results from fusion of the anterior lamina and the external oblique aponeurosis. The external oblique aponeurosis forms the external lamina of the anterior sheath below the semicircular line. Fusion of the internal oblique and transversus abdominis aponeuroses forms the internal lamina of the anterior sheath.

The posterior surface of the rectus muscles is covered with transversalis fascia below the semicircular line. The midline linea alba represents a decussation of these fibers from the different aponeurotic layers.

The external oblique muscle originates on the lower eight ribs, with obliquely and inferiorly directed fascicles inserting into its aponeurosis. Deep to the external oblique muscle is the internal oblique muscle, with obliquely and superiorly oriented fascicles arising from the iliac fascia deep to the lateral half of the inguinal ligament, the anterior two thirds of the iliac crest, and the lumbodorsal fascia. The internal oblique muscle inserts into its aponeurosis, the rectus sheath, and the lower ribs and cartilages superiorly.

The transversus abdominis is the most internal of the lateral abdominal wall muscles. The fascicles generally are transversely oriented. The transversus abdominis arises from the lateral iliopubic tract, the iliac crest, the lumbodorsal fascia, and the caudad six ribs. It inserts principally into its aponeurosis and fuses with the internal oblique aponeurosis to become the posterior rectus sheath.

The caudad margin curves to form the transversus abdominis aponeurotic arch as the upper edge of the internal ring and above the medial floor of the inguinal canal. In 3% of cases, this arch may combine with the internal oblique aponeurosis to form the conjoined tendon.

The innominate fascia overlies the external oblique muscle. The transversalis fascia forms an investing fascial envelope of the abdominal cavity. A variable layer of preperitoneal fat separates the peritoneum from the transversalis fascia.

Posterolateral region

In the posterolateral (lumbar) region, the quadratus originates from the iliac crest and the iliolumbar ligament from between the iliac crest and the fifth lumbar transverse process. It then inserts along the 12th rib. The psoas arises from vertebrae T12-L5 and passes downward under the inguinal ligament to insert on the lesser trochanter.

The serratus posterior inferior originates from the lumbodorsal fascia and inserts along the four lowest ribs. The sacrospinalis runs along the spinous processes for the entire length of the spine.

The latissimus dorsi originates on the posterior third of the iliac crest, the spinous processes of the sacral and lumbar vertebrae, and the lumbodorsal fascia. From this wide origin, the muscle inserts as a tendon into the intertubercular groove of the humerus.

The superior lumbar triangle of Grynfeltt-Lesshaft is bounded superiorly by the 12th rib, the posterior lumbocostal ligament, and the serratus posterior inferior; inferiorly by the superior border of the internal oblique muscle; and posteriorly by the lateral border of the sacrospinalis. The deep margin of the superior lumbar triangle is the transversus abdominis, and the superficial margin is the latissimus dorsi. Spontaneous lumbar hernias occur more commonly because the potential space is larger and more constant than the inferior lumbar triangle.

The inferior lumbar triangle of Petit is bounded posteriorly by the latissimus dorsi, anteriorly by the external oblique muscle, and inferiorly by the iliac crest.

Inguinal region

Vessels regularly found during inguinal hernia repairs are the superficial circumflex iliac, superficial epigastric, and external pudendal arteries, which arise from the proximal femoral artery and course superiorly. The inferior epigastric artery and vein run medially and cephalad in the preperitoneal fat near the caudad margin of the internal inguinal ring.

The external iliac vessels pass posterior to the inguinal ligament and iliopubic tract and anterior to the pectineal ligament to enter the femoral sheath. The external spermatic artery arises from the inferior epigastric artery just caudad to the internal inguinal ring to supply the cremaster muscle.

The inguinal ligament bridges the space between the pubic tubercle and the anterior superior iliac spine and rotates posteriorly and then superiorly to form a shelving edge. It is the caudad edge of the external oblique aponeurosis. This ligament revolves medially to create the lacunar ligament, which inserts on the pubis and courses medially and superiorly toward the midline. The external oblique aponeurosis has a triangular opening with a superior apex, through which the cord enters the inguinal canal.

The transversus abdominis is the predominant abdominal wall layer for the prevention of inguinal hernias. The transversus abdominis aponeurotic arch inserts inferiorly on the Cooper ligament and contributes to the anterior rectus sheath medially.

The pectineal ligament courses from the superior part of the superior pubic ramus periosteum. The components incorporate fibers from the lacunar ligament, the transversus abdominis aponeurosis, and the pectineus.

An aponeurotic band from the caudad portion of the transversus abdominis creates the iliopubic tract. It is the anterior margin of the femoral sheath and the caudad border of the internal ring. The course is from the superior pubic ramus medially to the iliopectineal arch and iliopsoas fascia, anterior to the femoral vessels, and then laterally to the anterior superior iliac spine.

The iliacus fascia thickens as it exits the pelvis to form the iliopectineal arch. The fascia curves forward, lateral to the external iliac vessels, and combines with fibers from the inguinal ligament, from the internal oblique muscle and the transversus abdominis, and from part of the ligament lateral attachment of the iliopubic tract. The external iliac vessels pass beneath the inguinal ligament and iliopubic tract but anterior to the pectineal ligament to enter the femoral sheath.

The femoral sheath, with contributions from the transversalis, pectineus, psoas, and iliacus fasciae, has three compartments. A femoral hernia most often occurs in the most medial compartment. The femoral canal is bounded laterally by the femoral vein. The medial margin is the transversus abdominis aponeurosis insertion and transversalis fascia. The femoral canal holds lymphatic channels and lymph nodes.

The superolateral border of the Hesselbach triangle is the inferior epigastric vessels. The inguinal ligament constitutes the inferolateral side. The lateral edge of the rectus sheath is the medial side.

The internal ring is bordered by the transversalis fascia circumferentially and deep, the arch of the internal oblique and transversus abdominis muscles superomedially, and the iliopubic tract inferolaterally. The course of the spermatic cord or round ligament through the abdominal wall defines the inguinal canal. Transversus abdominis aponeurosis and transversalis fascia combine to make the floor of the inguinal canal in 75% of persons (a minority have only transversalis fascia). The external oblique aponeurosis is anterior, and the inguinal ligament is inferior.

The vas deferens and the testicular artery and vein constitute the spermatic cord. The innominate fascia extends onto the cord as the external spermatic fascia. The cremasteric fascia and the cremaster muscle extend from internal oblique muscle and its aponeurosis to provide the most external investment of the cord. The next layer, the internal spermatic fascia, is an extension of the transversalis fascia and contains the cord structures and tunica vaginalis (or an indirect hernial sac, when present).

The inferior epigastric artery, which arises from the external iliac artery and courses with its companion vein vertically in the preperitoneal fat, is the anatomic point differentiating indirect inguinal hernias from direct inguinal hernias. Hernias presenting superolateral to the inferior epigastric vessels are indirect inguinal hernias, whereas those arising inferomedial to these vessels are direct inguinal hernias.

The iliohypogastric and ilioinguinal nerves originate principally from the first lumbar nerve root and have contributions from the 12th thoracic root. The nerves traverse the transversus abdominis in the middle of the iliac crest, are deep to the internal oblique muscle until the anterior superior iliac spine, and then become superficial just beneath the external oblique aponeurosis.

The ilioinguinal nerve then runs anterior to the spermatic cord in the canal to receive sensation from the pubis and the upper scrotum (labium majus). The genital branch of the genitofemoral nerve, which arises from the first and second lumbar nerve roots, becomes superficial near the internal ring to supply motor fibers of the cremaster muscle and sensation for the scrotum and the medial aspect of the upper thigh.

The intraperitoneal view has the medial umbilical ligament as the lateral border of the bladder, and the lateral umbilical ligament helps identify the inferior epigastric vessels.

The internal inguinal ring is the apex of a triangle formed medially by the ductus deferens and laterally by the testicular vessels. The base of the triangle contains the external iliac vessels, which may be injured during laparoscopic hernia repair. The pubic tubercle, the iliopubic tract, the transversus abdominis muscular arch, the lacunar ligament, the pectineal ligament, and the lateral border of the rectus abdominis usually are easily visualized.

The obturator internus arises from the margins of the obturator foramen and the obturator membrane. The muscle fascicles exit the pelvis at the lesser sciatic foramen and have a tendinous insertion on the medial surface of the greater trochanter of the femur. The obturator vessels and nerve pass through the obturator canal, which is superior in the obturator foramen.

The obturator canal runs obliquely in the medial thigh between the pectineus, obturator externus, and adductor longus. The anterior surface of sacral vertebrae 2-4 gives rise to the piriformis to have a tendon traversing the greater sciatic foramen. Above and below this tendon, in the greater sciatic foramen, are the suprapiriform and infrapiriform foramina. The superior gluteal vessels and nerves exit through the suprapiriform foramen; the sciatic nerve, perineal nerves, and pelvic vessels pass through the infrapiriform foramen.

Inguinal hernia

The pinchcock action of the internal ring musculature during abdominal muscular straining prohibits protrusion of the intestine into a patent processus. Muscle paralysis or injury can disable the shutter effect. In addition, the transversus abdominis aponeurosis flattens during tensing, thus reinforcing the inguinal floor. A congenitally high position of the aponeurotic arch may preclude the buttressing effect. Neurapraxic or neurolytic sequelae of appendectomy or femoral vascular procedures may increase the incidence of hernia in these patients.

Clinical presentations suggest repetitive stress as a factor in hernia development. Increased intra-abdominal pressure is seen in a variety of disease states and seems to contribute to hernia formation in these populations. Elevated intra-abdominal pressure is associated with chronic cough, ascites, increased peritoneal fluid from biliary atresia, peritoneal dialysis or ventriculoperitoneal shunts, intraperitoneal masses or organomegaly, and obstipation. (See the images below.)

Other conditions associated with an increased incidence of inguinal hernias are exstrophy of bladder, neonatal intraventricular hemorrhage, myelomeningocele, and undescended testes. A high incidence (16-25%) of inguinal hernias occurs in premature infants; this incidence is inversely related to weight.

The rectus sheath adjacent to groin hernias is thinner than normal. The rate of fibroblast proliferation is less than normal, and the rate of collagenolysis appears increased. Sailors who developed scurvy had an increased incidence of hernia. Aberrant collagen states (eg, Ehlers-Danlos, fetal hydantoin, Freeman-Sheldon, Hunter-Hurler, Kniest, Marfan, and Morquio syndromes), have increased rates of hernia formation, as do osteogenesis imperfecta, pseudo-Hurler polydystrophy, and Scheie syndrome.

Acquired elastase deficiency also can lead to increased hernia formation. In 1981, Cannon and Read found that the increased serum elastase and decreased alpha 1 -antitrypsin levels associated with smoking contribute to an increased rate of hernia in heavy smokers. The contribution of biochemical or metabolic factors to the creation of inguinal hernias remains a matter for speculation.

Inguinal hernias are commonly classified as either direct or indirect. A direct inguinal hernia usually occurs as a consequence of 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. [ 4 ]

An indirect inguinal hernia follows the tract through the inguinal canal. It results from a persistent processus vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal ring, approximately midway between the pubic symphysis and the anterior superior iliac spine, and courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. The hernia contents then follow the tract of the testicle down into the scrotal sac. [ 5 , 6 , 7 ]

Femoral hernia

A 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. [ 8 ] Perihernial fasciae or muscles may be malformed. [ 9 ]

Umbilical hernia

An umbilical hernia occurs through the umbilical fibromuscular ring, which is usually obliterated by age 2 years. (See the image below.) They are congenital in origin and are repaired if they persist in children older than 2-4 years. [ 5 , 4 ]

Although umbilical hernias in children arise from failed closure of the umbilical ring, only one in 10 adults with umbilical hernias had this defect as a child. Adult umbilical hernias occur through a canal bordered anteriorly by the linea alba, posteriorly by the umbilical fascia, and laterally by the rectus sheath. Proof that umbilical hernias persist from childhood to present in adulthood is only hinted at by an increased incidence among black Americans. Multiparity, increased abdominal pressure, and a single midline decussation are associated with umbilical hernias.

Congenital hypothyroidism, fetal hydantoin syndrome, Freeman-Sheldon syndrome, Beckwith-Wiedemann syndrome, and disorders of collagen and polysaccharide metabolism (such as Hunter-Hurler syndrome, osteogenesis imperfecta, and Ehlers-Danlos syndrome), should be considered as possibilities in children with large umbilical hernias.

Richter hernia

A Richter hernia occurs when only the antimesenteric border of the bowel herniates through the fascial defect. This hernia involves only a portion of the circumference of the bowel. Thus, the bowel may not be obstructed, even if the hernia is incarcerated or strangulated, and the patient may not present with vomiting. A Richter hernia can occur with any of the abdominal hernias and is particularly dangerous in that a portion of strangulated bowel may inadvertently be reduced into the abdominal cavity, leading to perforation and peritonitis. [ 10 ]

Incisional hernia

An incisional hernia is an iatrogenic condition that occurs in 2-10% of all abdominal operations secondary to breakdown of the fascial closure of a surgical procedure. (See Guidelines .) Even after repair, recurrence rates approach 20-45%.

Spigelian hernia

A spigelian hernia occurs through a defect in the spigelian fascia, defined by the lateral edge of the rectus abdominis at the semilunar line (from costal arch to pubic tubercle). Abnormal orientation of the semilunar and semicircular lines, along with obesity, increased intra-abdominal pressure, aging, and rapid weight loss, leads to the production of spigelian hernias.

There are two subtypes of spigelian hernia, interstitial and subcutaneous. Distinguishing between these subtypes helps optimize the surgical approach (when indicated) and is best done by means of computed tomography (CT). [ 11 , 12 , 13 ]

Obturator hernia

An obturator hernia passes through the obturator foramen, following the path of the obturator nerves and muscles. There is a strong female preponderance (female-to-male ratio, 6:1), because of a gender-specific larger canal diameter; this hernia is also much more likely to occur in the elderly. Because of its anatomic position, an obturator hernia more commonly presents as a bowel obstruction than as a protrusion of bowel contents. [ 14 , 10 ]

Other hernias

Aberrant formation of the decussations of the linea alba, leading to a midline pattern of single anterior and posterior lines, predisposes to the formation of epigastric hernias (epiploceles). Internal supravesical hernias probably arise from a congenital fascial deficiency. Perihernial fasciae or muscles may be malformed in lumbar hernias. Interparietal hernias are often a product of ectopic testicular descent. Multiparity and age produce laxity of the pelvic floor to cause perineal hernias.

Congenital abdominal wall defects

The underlying embryogenic factor in omphalocele and gastroschisis is deficient closure of the developing anterior wall at the umbilical stalk. Variations in lateral fold migration can result in both of these defects. [ 15 ] In addition, most children with omphalocele and all children with gastroschisis have intestinal malrotation; their extracoelomic location precludes normal attachment of the intestines to the posterior peritoneum.

Improper development of other portions of the abdominal wall leads to specific anomalies. In 1967, Duhamel proposed that maldevelopment of the superior (cephalad) fold of the abdominal wall leads to the thoracic, sternal and diaphragmatic, and abdominal wall defects that make up the upper midline syndrome (pentalogy of Cantrell). This syndrome includes a bifid sternal cleft, an anterior diaphragmatic defect, an anterior pericardial defect, an epigastric omphalocele, and congenital cardiac defects.

Maldevelopment of the inferior (caudal) fold produces pelvic, hindgut, sacral, genital, and bladder defects. Lower midline syndrome includes a hypogastric omphalocele, exstrophy of the bladder or cloaca, vesicointestinal fissure, colonic atresia, imperforate anus, sacral vertebral defects, and often meningoceles.

Lateral fold maldevelopment results in omphalocele (see the image below), as well as gastroschisis. It has been postulated that an omphalocele results from persistence of the umbilical stalk in the somatopleure. Approximately 20% of infants with omphaloceles have an associated chromosomal abnormality (eg, trisomy 13, trisomy 18, trisomy 21, or Klinefelter syndrome).

An omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex is characterized by a combination of omphalocele, exstrophy of the bladder, an imperforate anus, and spinal defects. [ 16 ] More than 50% of infants with omphaloceles have associated neurologic, urinary tract, cardiac, and skeletal anomalies. The liver is present in the omphalocele sac in 35% of patients. In small omphaloceles, there is a high coincidence of Meckel diverticulum.

Maternal smoking is associated with an increased prevalence of omphalocele and gastroschisis. An increased incidence of abdominal wall defects is related to surface water atrazine and nitrate levels. [ 17 ]

Gastroschisis is thought to be the result of a failure of the umbilical coelom to develop to an appropriate size. The intestine then ruptures out of the body wall to the right of the umbilicus, where a slight weakness exists secondary to resorption of the right umbilical vein early in gestation (see the image below). Gastroschisis is associated with intestinal atresias in 10-15% of cases, probably as a consequence of interruption of the vascular supply to the intestine.

Experimentally, administration of the insecticide methylparathion has produced gastroschisis. Transplacental transmission of such teratogens helps explain gastroschisis in siblings with different fathers.

The etiology of indirect hernias is largely explainable in terms of the embryology of the groin and of testicular descent. An indirect inguinal hernia is a congenital hernia, regardless of the patient’s age. It occurs because of protrusion of an abdominal viscus into an open processus vaginalis. The following terms are employed:

• If the processus contains viscera, the patient has an indirect inguinal hernia
• If peritoneal fluid fluxes between the space and the peritoneum, the patient has a communicating hydrocele
• If fluid accumulates in the scrotum or spermatic cord without exchange of fluid with the peritoneum, the patient has a noncommunicating scrotal hydrocele or a hydrocele of the cord; in a girl, fluid accumulation in the processus results in a hydrocele of the canal of Nuck

The inguinal canal forms by mesenchyme condensation around the gubernaculum. During the first trimester, the gubernaculum extends from the testis to the labioscrotal fold, and the processus vaginalis and its fascial coverings form. A bilateral oblique defect in the abdominal wall develops during week 6 or 7 of gestation as the muscular wall develops around the gubernaculum. The processus vaginalis protrudes from the peritoneal cavity and lies anteriorly, laterally, and medially to the gubernaculum by week 8 of gestation.

Beginning at week 8 of gestation, the testis produces many male hormones. At the beginning of month 7, the gubernaculum begins a marked swelling influenced by a nonandrogenic hormone, probably a müllerian inhibiting substance. This results in expansion of the inguinal canal and the labioscrotal fold, forming the scrotum. The genitofemoral nerve also influences migration of the testis and gubernaculum into the scrotum under androgenic control.

The female inguinal canal and processus are much less developed than their male equivalents. The inferior aspect of the gubernaculum is converted to the round ligament. The cephalad part of the female gubernaculum becomes the ovarian ligament.

Gonads develop on the medial aspect of the mesonephros during week 5 of gestation. The kidney then moves cephalad, leaving the gonad to reside in the pelvis until month 7 of gestation. During this time, it retains a ligamentous attachment to the proximal gubernaculum.

The gonads then migrate along the processus vaginalis, with the ovary descending into the pelvis and the testis being wrapped within the distal processus (tunica vaginalis). The processus fails to close adequately at birth in 40-50% of boys. Therefore, other factors play a role in the development of a clinical indirect hernia. A familial tendency exists, with 11.5% of patients having a family history. The relative risk of inguinal hernia is 5.8 for brothers of male cases, 4.3 for brothers of female cases, 3.7 for sisters of male cases, and 17.8 for sisters of female cases.

More generally, 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
• Straining with defecation or urination
• Peritoneal dialysis
• Ventriculoperitoneal shunt
• Chronic obstructive pulmonary disease (COPD)
• Family history of hernias [ 18 ]

United States statistics

As much as 10% of the population develops some type of hernia during life. [ 19 ] More than 1 million abdominal hernia repairs are performed each year, with inguinal hernia repairs constituting nearly 770,000 of these cases. [ 1 , 2 , 3 ] Frequencies of various types of hernias are as follows:

• Approximately 75% of all hernias are inguinal; of these, 50% are indirect (male-to-female ratio, 7:1), with a right-side predominance, and 25% are direct [ 5 ] ; 3% of inguinal hernias have a sliding component, most often on the left side (left-to-right ratio, 4.5:1)
• About 14% of hernias are umbilical
• About 10% of hernias are incisional or ventral (female-to-male ratio, 2:1) [ 7 ]
• Only 3-5% of hernias are femoral
• Interparietal, supravesical, lumbar, sciatic, and perineal hernias are rare; interparietal hernias are on the right side in 70% of cases, and a similar percentage of cases involve testicular maldescent (Denis-Browne pouch)

In the case of congenital abdominal wall defects, the incidence of omphalocele has increased only slightly over the past few decades, to a current level of about 1-2.5 in 5000 live births. In contrast, the incidence of gastroschisis has increased markedly over the past 25 years, to a current level of 1 in 3600 live births. In some areas, the prevalence of gastroschisis has increased by as much as 400% over the past two decades.

International statistics

Data from developing countries are limited. Consequently, accurate determinations of incidence and prevalence are unavailable. Current epidemiologic assessments suggest that gender distribution and anatomic distribution are similar to those in more developed countries.

Age-related demographics

The prevalence of all varieties of hernias increases with age.

The incidence of inguinal hernias in children is as high as 4.5%. Indirect hernias usually present during the first year of life, but they may not appear until middle or old age. Indirect hernias are more common in premature infants than in term infants; they develop in 13% of infants born before 32 weeks’ gestation. [ 2 ] Direct hernias occur in older patients as a result of relaxation of abdominal wall musculature and thinning of the fascia.

Umbilical hernias occur in approximately one of every six children. [ 2 , 5 ] They usually develop 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; the incidence in children older than 1 year is only 2-10%. [ 20 ]

Spigelian hernias are rare and typically occur around the age of 50 years; no sex or side predilection is reported. Primary perineal hernias occur most often in elderly multiparous women. Obturator hernias occur most often in thin, elderly women and are more common on the right side. Richter hernias present late in life, most often in women with femoral hernias. Littre hernias have a much broader spectrum of hernia site and occur across all ages.

The incidence of incarcerated or strangulated hernias in pediatric patients is 10-20%; 50% of these occur in infants younger than 6 months. [ 2 ]

Sex-related demographics

Inguinal hernias are the most common type in both males and females; approximately 25% of males and 2% of females have an inguinal hernia over the course of their lifetime. [ 3 , 21 ] The male-to-female ratio for indirect inguinal hernia is 7:1.

Sliding hernias are much more common in men than in women, and the predominance increases with age. Female infants have a high incidence of sliding tube, ovary, or broad ligament hernias.

Femoral hernias (though rare overall) occur more frequently in women because of the differences in the pelvic anatomy (female-to-male ratio, 1.8:1). Umbilical hernias are equally common in male and female children but are 3 times more frequent in female adults than in male adults (overall female-to-male ratio, 1.7:1). Incisional or ventral hernias are also more common in females (female-to-male ratio, 2:1), as are obturator hernias (female-to-male ratio, 6:1). [ 21 ]

Epigastric hernias have a prevalence of 0.5% and are more common in males (male-to-female ratio, 3:1). Reports of internal supravesical hernias are limited, but the literature suggests that they occur more often in men and in elderly people.

Race-related demographics

Umbilical hernias are much more common in persons of African ethnicity. [ 22 ] With respect to the pediatric population, umbilical hernias occur eight times more frequently in black infants than in white infants. [ 21 ]

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. As a rule, the prognosis is good with timely diagnosis and repair. Morbidity typically is secondary either to missing the diagnosis of the hernia or to complications associated with management of the disease.

A hernia can lead to an incarcerated and often obstructed bowel, or even to a strangulated bowel with a compromised blood supply, which, if missed, can result in bowel perforation and peritonitis. Reduction of the strangulated bowel leads to persistent ischemia or necrosis with no clinical improvement. Surgical intervention is required to prevent further complications (eg, perforation and sepsis.

In general, patients with uncomplicated inguinal and abdominal wall hernias do well. However, mortality is 10% for those who have hernias with associated strangulation. It should be kept in mind that surgery to repair the hernia or manage its complications may leave the patient at risk for infection or intra-abdominal adhesions. In addition, hernias can reappear in the same location, even after surgical repair.

In a study investigating complications during and after 780 laparoscopic inguinal herniorrhaphies in 569 patients, Coelho et al found that hernias recurred in 14 patients (2.5%) and that intraoperative complications occurred in 28 (4.9%), with extensive subcutaneous emphysema being the most common complication. [ 23 ]

Postoperative complications developed in 35 patients (6.2%). Small bowel perforation occurred in one patient, and bladder perforation occurred in another. [ 23 ] One cohort member developed an extensive, preperitoneal Mycobacterium massiliense infection. No cohort members died. The authors concluded that despite having a low mortality, laparoscopic inguinal herniorrhaphy can result in life-threatening complications.

Potential complications of inguinal hernia repair include the following:

• Hernia recurrence
• Infarcted testis or ovary with subsequent atrophy (see the images below)
• Wound infection
• Bladder injury
• Iatrogenic orchiectomy or vasectomy
• Intestinal injury

Postoperative death is usually related either to complications (eg, strangulated bowel) or to preexisting risk factors. [ 24 ] A postoperative hydrocele results from fluid accumulation in the distal sac. This usually resolves spontaneously but sometimes must be aspirated.

A femoral hernia as a sequela of inguinal hernia repair may have been overlooked initially. Unilateral transection of the vas deferens can cause infertility through antibody production. Iatrogenic cryptorchidism can occur in children (1.3%) if the testicle is not placed in the scrotum at the end of the operation; orchiopexy is required for correction. Iliohypogastric and ilioinguinal neuralgia may develop but usually will regress within months; in refractory cases, nerve blocks or neurectomy may be employed.

Most recurrences develop within 5 years after the operation. They are often associated with incarcerated hernias, concurrent orchiopexy, sliding hernias (in girls), or emergency operations. The recurrence rate is higher in children younger than 1 year and in the elderly. It is also higher in patients with ongoing increased intra-abdominal pressure, growth failure and malnutrition, prematurity, seizure disorder, or chronic respiratory problems.

Technical factors that increase the likelihood of recurrence include the following:

• Unrecognized tear in the sac
• Failure to repair a large internal inguinal ring
• Damage to the floor of the inguinal canal
• Infection or other postoperative complications

In some cases, a direct hernia may result from vigorous dissection; in others, it may be a simultaneous hernia that was initially unrecognized.

Other hernia types

Recurrence, bleeding, infection, and persisting pain are potential complications for the other types of abdominal wall hernia. The rate of recurrence for incisional hernias may be as high as 30%. The addition of mesh to most abdominal wall hernia repairs is decreasing the incidence of recurrence.

Gastroschisis and omphalocele

Infants with uncomplicated gastroschisis and omphalocele generally fare well, with a mortality of less than 5%. [ 25 ] Complications arising from the prolonged time required to reduce the contents into the abdomen include the following:

• Dislodgment of the prosthesis
• Prolonged mechanical ventilation
• Intestinal obstruction
• Budd-Chiari syndrome (due to kinking of the suprahepatic inferior vena cava)

However, mortality among infants with gastroschisis or omphalocele who have intestinal atresia or severe associated anomalies is substantially higher, in the range of 15-50%.

Intestinal atresias occur in about 20% of infants with gastroschisis. Massive atresias present infrequently with their attendant sequela of short gut syndrome. Maximal bowel preservation, achieved by means of “second-look” operations 24-48 hours after initial management, may be warranted. Infants with gastroschisis are at risk for necrotizing enterocolitis after the initiation of feeding. This is managed by bowel rest and broad-spectrum antibiotics; surgery is seldom necessary.

An increased incidence of gastroesophageal reflux after closure of gastroschisis and omphalocele often necessitates the administration of antireflux medication. Severe reflux and hiatal hernias require operative correction. Adhesive small bowel obstruction is a frequent occurrence in the first year following treatment of congenital abdominal wall defects, with previous sepsis and fascial dehiscence as predictive factors. [ 26 ]

Long-term follow-up shows function equal to that reported in age-related groups.

Patients should be counseled to avoid those activities that increase intra-abdominal pressure (eg, straining at defecation and lifting heavy objects). This may require restrictions on work or school-related activities, which should be clearly delineated. Patients should also receive instruction regarding ways of applying support to the hernia. Numerous medical device companies have developed support items that can assist with this process.

Even with asymptomatic hernias, repair at an early stage (ie, before the hernia enlarges) is preferred. Referral to a general surgeon for discussion of the available types of hernia repair is warranted; with the advent of new meshes and laparoscopic approaches, the range of repair options is now wider than ever.

Fitch MT, Manthey DE. Abdominal hernia reduction. Roberts JR, Custalow CB, Thomsen TW, Chanmugam AS, Chudnofsky CR, DeBlieux PMC, et al, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine . 7th ed. Philadelphia: Elsevier; 2019. 897-903.

Brandt ML. Pediatric hernias. Surg Clin North Am . 2008 Feb. 88 (1):27-43, vii-viii. [QxMD MEDLINE Link] .

Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am . 1993 Jun. 73 (3):413-26. [QxMD MEDLINE Link] .

Scherer LR 3rd, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am . 1993 Dec. 40 (6):1121-31. [QxMD MEDLINE Link] .

Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann . 2001 Dec. 30 (12):729-35. [QxMD MEDLINE Link] .

Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med . 1999 May-Jun. 17 (3):515-6. [QxMD MEDLINE Link] .

Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg . 2008 Apr. 45 (4):261-312. [QxMD MEDLINE Link] .

Bobrow RS. The hernia. J Am Board Fam Pract . 1999 Jan-Feb. 12 (1):95-6. [QxMD MEDLINE Link] .

Chen J, Lv Y, Shen Y, Liu S, Wang M. A prospective comparison of preperitoneal tension-free open herniorrhaphy with mesh plug herniorrhaphy for the treatment of femoral hernias. Surgery . 2010 Nov. 148 (5):976-81. [QxMD MEDLINE Link] .

Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia--a condition seldom thought of and hence seldom sought. Int J Colorectal Dis . 2012 Feb. 27 (2):133-41. [QxMD MEDLINE Link] .

Wantz GE. Abdominal wall hernias. Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery . 6th ed. 1994.

Mensching JJ, Musielewicz AJ. Abdominal wall hernias. Emerg Med Clin North Am . 1996 Nov. 14 (4):739-56. [QxMD MEDLINE Link] .

Martin M, Paquette B, Badet N, Sheppard F, Aubry S, Delabrousse E. Spigelian hernia: CT findings and clinical relevance. Abdom Imaging . 2013 Apr. 38 (2):260-4. [QxMD MEDLINE Link] .

Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med . 2006 Feb. 30 (2):155-7. [QxMD MEDLINE Link] .

deVries PA. The pathogenesis of gastroschisis and omphalocele. J Pediatr Surg . 1980 Jun. 15 (3):245-51. [QxMD MEDLINE Link] .

Chen CP. Syndromes and disorders associated with omphalocele (II): OEIS complex and Pentalogy of Cantrell. Taiwan J Obstet Gynecol . 2007 Jun. 46(2):103-10. [QxMD MEDLINE Link] .

Mattix KD, Winchester PD, Scherer LR. Incidence of abdominal wall defects is related to surface water atrazine and nitrate levels. J Pediatr Surg . 2007 Jun. 42 (6):947-9. [QxMD MEDLINE Link] .

Akbulut S, Cakabay B, Sezgin A. A familial tendency for developing inguinal hernias: study of a single family. Hernia . 2010 Aug. 14 (4):431-4. [QxMD MEDLINE Link] .

Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol . 2007 May 15. 165 (10):1154-61. [QxMD MEDLINE Link] .

Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am . 1998 Aug. 45 (4):773-89. [QxMD MEDLINE Link] .

Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am . 1998 Dec. 78 (6):941-51, v-vi. [QxMD MEDLINE Link] .

Walker SH. The natural history of umbilical hernia. A six-year follow up of 314 Negro children with this defect. Clin Pediatr (Phila) . 1967 Jan. 6 (1):29-32. [QxMD MEDLINE Link] .

Coelho JC, Claus CM, Michelotto JC, Fernandes FM, Valle CL, Andriguetto LD, et al. Complications of laparoscopic inguinal herniorrhaphy including one case of atypical mycobacterial infection. Surg Endosc . 2010 Nov. 24 (11):2708-12. [QxMD MEDLINE Link] .

Anthony T, Bergen PC, Kim LT, Henderson M, Fahey T, Rege RV, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg . 2000 Jan. 24 (1):95-100;discussion 101. [QxMD MEDLINE Link] .

Henrich K, Huemmer HP, Reingruber B, Weber PG. Gastroschisis and omphalocele: treatments and long-term outcomes. Pediatr Surg Int . 2008 Feb. 24 (2):167-73. [QxMD MEDLINE Link] .

van Eijck FC, Wijnen RM, van Goor H. The incidence and morbidity of adhesions after treatment of neonates with gastroschisis and omphalocele: a 30-year review. J Pediatr Surg . 2008 Mar. 43 (3):479-83. [QxMD MEDLINE Link] .

Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg . 2012 Mar. 147 (3):277-81. [QxMD MEDLINE Link] .

Hamlin JA, Kahn AM. Herniography: a review of 333 herniograms. Am Surg . 1998 Oct. 64 (10):965-9. [QxMD MEDLINE Link] .

Toms AP, Dixon AK, Murphy JM, Jamieson NV. Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg . 1999 Oct. 86 (10):1243-9. [QxMD MEDLINE Link] .

Hernias. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice . 21st ed. Philadelphia: Elsevier; 2022. Chap 45.

London JA, Utter GH, Sena MJ, Chen SL, Romano PS. Lack of Insurance is Associated With Increased Risk for Hernia Complications. Ann Surg . 2009 Aug. 250 (2):331-7. [QxMD MEDLINE Link] .

Abi-Haidar Y, Sanchez V, Itani KM. Risk factors and outcomes of acute versus elective groin hernia surgery. J Am Coll Surg . 2011 Sep. 213 (3):363-9. [QxMD MEDLINE Link] .

Smith S. Inguinal hernia reduction. King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures . 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. 840-847/87.

Pavlin DJ, Horvath KD, Pavlin EG, Sima K. Preincisional treatment to prevent pain after ambulatory hernia surgery. Anesth Analg . 2003 Dec. 97 (6):1627-32. [QxMD MEDLINE Link] .

EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg . 2000 Jul. 87 (7):860-7. [QxMD MEDLINE Link] .

Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg . 2006 Jun. 41 (6):1081-4. [QxMD MEDLINE Link] .

Martin DF, Williams RF, Mulrooney T, Voeller GR. Ventralex mesh in umbilical/epigastric hernia repairs: clinical outcomes and complications. Hernia . 2008 Aug. 12 (4):379-83. [QxMD MEDLINE Link] .

Liang MK, Berger RL, Li LT, Davila JA, Hicks SC, Kao LS. Outcomes of laparoscopic vs open repair of primary ventral hernias. JAMA Surg . 2013 Nov. 148 (11):1043-8. [QxMD MEDLINE Link] .

Sarosi GA Jr. Laparoscopic umbilical and epigastric hernia repair: the procedure of choice?. JAMA Surg . 2013 Nov. 148 (11):1049. [QxMD MEDLINE Link] .

Manoharan S, Samarakkody U, Kulkarni M, Blakelock R, Brown S. Evidence-based change of practice in the management of unilateral inguinal hernia. J Pediatr Surg . 2005 Jul. 40 (7):1163-6. [QxMD MEDLINE Link] .

Ballantyne A, Jawaheer G, Munro FD. Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia. Br J Surg . 2001 May. 88 (5):720-3. [QxMD MEDLINE Link] .

Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia following unilateral repair in a pediatric hospital. J Pediatr Surg . 1989 Oct. 24 (10):963-5. [QxMD MEDLINE Link] .

Holcomb GW 3rd. Diagnostic laparoscopy for contralateral patent processus vaginalis and nonpalpable testes. Semin Pediatr Surg . 1998 Nov. 7 (4):232-8. [QxMD MEDLINE Link] .

Bell C, Dubose R, Seashore J, Touloukian R, Rosen C, Oh TH, et al. Infant apnea detection after herniorrhaphy. J Clin Anesth . 1995 May. 7 (3):219-23. [QxMD MEDLINE Link] .

Parelkar SV, Oak S, Gupta R, Sanghvi B, Shimoga PH, Kaltari D, et al. Laparoscopic inguinal hernia repair in the pediatric age group--experience with 437 children. J Pediatr Surg . 2010 Apr. 45 (4):789-92. [QxMD MEDLINE Link] .

Esposito C, Montinaro L, Alicchio F, Savanelli A, Armenise T, Settimi A. Laparoscopic treatment of inguinal hernia in the first year of life. J Laparoendosc Adv Surg Tech A . 2010 Jun. 20 (5):473-6. [QxMD MEDLINE Link] .

Niyogi A, Tahim AS, Sherwood WJ, De Caluwe D, Madden NP, Abel RM, et al. A comparative study examining open inguinal herniotomy with and without hernioscopy to laparoscopic inguinal hernia repair in a pediatric population. Pediatr Surg Int . 2010 Apr. 26 (4):387-92. [QxMD MEDLINE Link] .

Bonnard A, Zamakhshary M, de Silva N, Gerstle JT. Non-operative management of gastroschisis: a case-matched study. Pediatr Surg Int . 2008 Jul. 24 (7):767-71. [QxMD MEDLINE Link] .

Carlson GW, Elwood E, Losken A, Galloway JR. The role of tissue expansion in abdominal wall reconstruction. Ann Plast Surg . 2000 Feb. 44 (2):147-53. [QxMD MEDLINE Link] .

[Guideline] Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, et al. Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B. Surg Endosc . 2019 Nov. 33 (11):3511-3549. [QxMD MEDLINE Link] . [Full Text] .

Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT, Kao LS, et al. Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA Surg . 2014 May. 149 (5):415-21. [QxMD MEDLINE Link] .

Timmermans L, de Goede B, van Dijk SM, Kleinrensink GJ, Jeekel J, Lange JF. Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery. Am J Surg . 2014 Jun. 207 (6):980-8. [QxMD MEDLINE Link] .

• Large right inguinal hernia in 3-month-old girl.
• In this baby with gastroschisis, bowel is uncovered and presents to right inferior aspect of cord.
• Hernia of umbilical cord.
• Note translucent sac in baby with large omphalocele. Umbilical vessels attach to sac.
• Hernia content balloons over external ring when reduction is attempted.
• Hernia can be reduced by medial pressure applied first.
• Infant with Silon chimney placed in treatment of gastroschisis.
• Atrophy of right testis after hernia repair. Note adult-type incision.
• Iatrogenic cryptorchid testis in child. Taking care to position testis in scrotum is integral part of completion of hernia repair in boys.
• Erythematous edematous left scrotum in 2-month-old boy with history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
• Testis at operation in 2-month-old boy with history of irritability and vomiting for 36 hours. Capsulotomy was performed, but atrophy occurred. Patient also required bowel resection.
• Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy.
• Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy. Abdominal radiograph shows incarcerated shunt within communicating hydrocele. Repair of hydrocele relieved increased intracranial pressure.
• Bassini-type repair approximating transversus abdominis aponeurosis and transversalis fascia to iliopubic tract and inguinal ligament.
• Anatomic locations for various hernias.

Contributor Information and Disclosures

Assar A Rather, MBBS, MD, FACS Minimally Invasive General and Colorectal Surgeon, Bayhealth Kent General Hospital Assar A Rather, MBBS, MD, FACS is a member of the following medical societies: American College of Surgeons , American Medical Association , American Society of Colon and Rectal Surgeons , Society of American Gastrointestinal and Endoscopic Surgeons Disclosure: Nothing to disclose.

Bret A Nicks, MD, MHA, FACEP Professor and EVC, Department of Emergency Medicine, Davie Medical Center, Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine Bret A Nicks, MD, MHA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine , American College of Emergency Physicians , Christian Medical and Dental Associations , International Federation for Emergency Medicine , Society for Academic Emergency Medicine Disclosure: Nothing to disclose.

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association , American Physiological Society , American Society of Nephrology , Association for Academic Surgery , International Society of Nephrology , New York Academy of Sciences , Society for Surgery of the Alimentary Tract Disclosure: Nothing to disclose.

Kim Askew, MD Assistant Professor, Director of Undergraduate Medical Education, Department of Emergency Medicine, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Kimberly M Erickson, MD Assistant Professor, Division of Pediatric Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Pediatric Trauma, NC Children's Hospital

Kimberly M Erickson, MD is a member of the following medical societies: American Academy of Pediatrics , American College of Surgeons , and Children's Oncology Group

Eustace Stevers Golladay, MD Emeritus Clinical Professor of Pediatric Surgery, University of Michigan Medical Center; Consulting Staff, Department of Pediatric Surgery, Mott Children's Hospital

Eustace Stevers Golladay, MD is a member of the following medical societies: American Academy of Pediatrics , American Medical Association , American Pediatric Surgical Association , Central Surgical Association , Johns Hopkins Medical and Surgical Association , Southeastern Surgical Congress , and Southern Medical Association

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Richard Lavely, MD, JD, MS, MPH Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine

Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians , American College of Legal Medicine , and American Medical Association

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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What Is a Hernia?

A Tear in Weakened Muscle That Allows an Organ or Tissue to Protrude

A hernia is a tear in a muscle or other tissue that lets part of an internal organ bulge through it. Often, it's the intestines. This sounds like it would cause noticeable symptoms—and sometimes it does. However, many don't have any hernia symptoms at all, or they simply notice a bump or bulge.

Hernias can produce a bulge that is constant or that may come and go, depending on your position or what you’re doing.

Hernia surgery may be needed in some cases, but not all. Learn more about treatment decisions are made, the types of hernia that exist, how they are diagnosed, and what you can do to prevent a hernia.

Click Play to Learn All About Hernias

This video has been medically reviewed by Kashif J. Piracha, MD

Types of Hernia

Most hernias occur in the abdominal area, between your chest and hip bones. Hernias that can be pushed back into place are called reducible hernias. Those that can’t be popped back into position are termed irreducible or incarcerated.

If you can feel the hernia on the outside of your body (you might notice a bump), you have an external hernia. Those that can’t be felt are labeled internal hernias.

Hernias are further classified by the body region where they occur. '

Inguinal Hernias

Inguinal hernias typically occur in the inguinal canals, which are located on either side of the groin.

Inguinal hernias are one of the most common types of hernia, affecting 27% of men and 3% of women.

Umbilical Hernias

Umbilical hernias occur when tissue or parts of the intestine push through a weak area near the navel. They account for 6-14% of adult abdominal hernias, making them the second most common type.  

Up to 20% of newborns have this hernia. If not closed by age 5, it needs to be closed surgically.

Hiatal Hernias

Hiatal hernias occur when parts of the stomach or other organs break through an opening in the diaphragm.

Hiatal hernias are very common and the overwhelming majority are what’s known as “sliding” hiatal hernias, meaning they can move in and out of place.

Femoral Hernias

Femoral hernias are found in the lower groin area, near the upper thigh. Women, because of their wider pelvises, are four times more likely than men to develop femoral hernias.

Incisional Hernias

The cutting (incision) and sewing of surgery can weaken a muscle wall, making it more likely an incisional hernia will develop. Roughly 15% of people will develop an incisional hernia after surgery involving the abdominal wall.

Hernia Symptoms

Laura Porter / Verywell

Most hernias can be felt. You might notice a bump or bulge (it may be hard or soft) in an area of your body. Not all hernias produce discomfort, but when they do you might experience:

• Digestive issues like heartburn or gastroesophageal reflux disease (GERD)

The discomfort may be more intense when you strain (for example, while having a bowel movement or lifting a heavy object) or tighten your abdominal muscles (when you’re coughing, sneezing or exercising, for instance).

Complications

Get immediate medical attention if you have:

• Pain around the hernia that’s sudden or severe
• Nausea and vomiting along with the pain

These could be signs that an organ or tissue is dangerously stuck within the torn area or that its blood supply is being cut off (called a strangulated hernia). This is a medical emergency.

What Causes a Hernia?

Hernias occur when pressure is put on a weak or injured muscle.

Hernias can happen to anyone—male or female, young or old. Sometimes you’re born with a weakening in muscle walls that can make you prone to a hernia, and other times it develops over time.

Some risk factors for hernia development include: 

• Sex : Males have hernias about twice as often as females . When a fetus' testicles descend from the abdomen, the opening doesn’t always close properly. That increases hernia risk.
• Having excess weight or obesity : Extra weight increases pressure on muscles and organs, weakening the structures that hold things in place.
• Pregnancy, especially multiple pregnancies : As a fetus grows, so, too, does the strain on your abdominal wall . 
• Age : Muscles become weaker as you age.
• Prior surgery : Surgery in the abdominal or groin area can weaken the muscles.
• Performing activities that can strain abdominal muscles : This includes heavy lifting.
• Persistent coughing : Coughing places pressure on the chest and abdomen.
• Tobacco use : This can lead to chronic coughing.
• Family history of hernias : Males with a family history of inguinal hernias are eight times more likely to develop one than other males.
• Constipation : This can result in straining during a bowel movement, placing pressure on the abdomen.

To diagnose a hernia, your healthcare provider will perform a physical exam, feeling for a hernia while you sit, stand or even cough. They may also order imaging tests like an ultrasound or computed tomography (CT) scan.

Your provider may also perform an endoscopy , which uses a flexible scope equipped with a light and camera to examine the inside of your esophagus and your stomach.

What Can Be Mistaken for a Hernia?

There are times when someone is diagnosed with a hernia when they really have something else.

Some conditions that can be mistaken for a hernia include:

• Pubic and inguinal venous collaterals
• Acute vasitis (inflammation of the vas deferens, which is a duct that carries sperm from the testicle to the urethra)
• Spermatic cord lipomas (fatty tumors on the cord-like structure formed by the vas deferens and the tissue around it)
• Spermatic cord cancer
• Appendicitis
• Diverticulitis (inflammation of the colon)
• Hip problems
• Inflammatory bowel disease
• Lumbar disc diseases
• Prostatitis (prostate inflammation)
• Urinary tract infection

Likewise, as your doctor evaluates you, they may consider and work to rule out these issues.

Hernia Treatment

How your hernia is treated depends on a number of factors, including where the hernia is located, its size, whether it’s growing and if it’s causing you discomfort.

Even anatomy plays a role. Inguinal hernias in those born female may be treated more aggressively than in those born male.  

In general, for hernias that are small and asymptomatic, your doctor may advise simply watching the hernia. For hernias that are large, causing pain or impacting your quality of life, surgery may be recommended. Types of hernia surgery include open surgery, laparoscopic surgery, and robotic surgery.

Open Surgery

In open surgery, the surgeon cuts through the body where the hernia is located. The bulging parts are put back into place and the tear is stitched.

Instead of sutures, a doctor might use a mesh panel (usually made of plastic or animal tissues) to provide added support. Those who have their inguinal and femoral hernias repaired with a mesh appear to have a reduced risk of hernia recurrence.  

Laparoscopic Surgery

Using small incisions through which surgical tools (usually a flexible tube with a camera and light that guides the surgeon), the organs/tissues are moved back to where they belong and the hole is repaired. This is considered minimally invasive surgery and has a quicker recovery time than open surgery. 

Robotic-Assisted Surgery

Robotic-assisted surgery is similar to laparoscopic surgery, but the surgeon operates the tools from a console.

Other than the umbilical hernias that affect newborns, a hernia will not go away on its own. See your doctor if you notice a bulge. If you have any of the risk factors for a hernia, make sure your doctor is checking for them at your physical exams.

To keep hernias at bay, stay on top of your health game:

• Maintain a healthy weight.
• Stay hydrated and eat a diet rich in fruits, whole grains and vegetables to avoid constipation.
• Don’t lift more than you’re able.
• Don’t smoke.

A Word From Verywell

Finding a bump or bulge on your body can be scary, and your first step is to get it checked out by a doctor. But if you’re diagnosed with a hernia, rest assured that you’re not alone.

Hernias are quite common, and the surgeries that are often used to treat them are some of the most frequently performed surgeries in the U.S.   More than 20 million hernias are repaired every year, worldwide, with 700,000 of those in the U.S. alone.  

While there are risks with any surgery, hernia surgery is considered safe and effective. Recovery will depend on your overall health and the type of surgery performed, but many people are back to their regular routines in just a couple of weeks.

American Academy of Family Physicians: familydoctor.org. Hernia .

Cleveland Clinic. Hernia .

Öberg S, Andresen K, Rosenberg J. Etiology of inguinal hernias: A comprehensive review .  Front Surg . 2017;4:52. doi:10.3389/fsurg.2017.00052

National Institutes of Health, National Library of Medicine: StatPearls. Umbilical hernia .

Sfara Alice, Dumitrascu DL. The management of hiatal hernia: an update on diagnosis and treatment . Medicine and Pharmacy Reports. 2019;92(4):321–325. doi:10.15386/mpr-1323

Kouchupapy RT, Ranganan Dias S, Shanahan D. Aetiology of femoral hernias revisited: bilateral femoral hernia in a young male (two cases) . Annals of the Royal College of Surgeons England . 2013;95(1):e14–e16. doi:10.1308/003588413X13511609955733

National Institutes of Health, National Library of Medicine: InformedHealth.org. Hernias: Overview .

Iqbal MN, Akhter S, Irfan M. Prevalence of hernia in relation to various risk factors in Narowal, Pakistan . Science Letters. 2015.3(1):29-32

Lau H, Fang C, Yuen WK, Patil NG. Risk factors for inguinal hernia in adult males: a case-control study . Surgery . 2007;141(2):262-6. doi:10.1016/j.surg.2006.04.014

Oldhafer F, Alten T, Klempnauer J, Emmanouilidis N. Pubic and inguinal venous collaterals mimic inguinal hernia .  J Surg Case Rep . 2017;2017(8):rjx113. Published 2017 Aug 22. doi:10.1093/jscr/rjx113

Dall C, Lim K, Khludenev G, Venkatesan K. A case of acute vasitis mimicking an incarcerated inguinal hernia with subtle imaging findings .  Can J Urol . 2020;27(6):10496-10499.

Cabarrus MC, Yeh BM, Phelps AS, Ou JJ, Behr SC. From inguinal hernias to spermatic cord lipomas: Pearls, pitfalls, and mimics of abdominal and pelvic hernias .  Radiographics . 2017;37(7):2063-2082. doi:10.1148/rg.2017170070

Valeshabad AK, Walsh A, Lloyd GL. An important mimic of inguinal hernia .  Urology . 2016;97:e11. doi:10.1016/j.urology.2016.08.001

LeBlanc KE, LeBlanc LL, LeBlanc KA. Inguinal hernias: diagnosis and management .  Am Fam Physician . 2013;87(12):844-848.

Berger D. Evidence-based hernia treatment in adults .  Dtsch Arztebl Int . 2016;113(9):150-158. doi:10.3238/arztebl.2016.0150

Kathleen Lockhart, Kathleen, Dunn, Douglas, Teo, Shawn, Ng, Jessica Y, Dhillon, Manvinder, Teo, Edward, van Driel, Mieke, L. Mesh versus non-mesh for inguinal and femoral hernia repair . 2018. 9(9):CD011517. doi: 10.1002/14651858.CD011517.pub2

Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT, Kao LS, Liang MK. Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis . JAMA Surg . 2014;149(5):415-21. doi:10.1001/jamasurg.2013.5014

Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? .  JRSM Short Rep . 2011;2(1):5. doi:10.1258/shorts.2010.010071

By Donna Christiano Campisano Christiano is a Florida-based freelance writer who specializes in women's and children's health issues.

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Introduction

Hernias are one of the most common general surgical conditions but are often poorly understood. Getting to grips with the underlying anatomy of different hernias will hopefully enable you to identify them with confidence and understand the principles of their management.

This article will cover  groin hernias  (inguinal, femoral and obturator) and  abdominal wall or “ventral” hernias  (umbilical, epigastric, Spigelian and incisional).

We will also briefly discuss other hernia types and key differential diagnoses .

What is a hernia?

The often-recited surgical definition of a hernia is “the protrusion of a viscus into an abnormal space” .

In simple terms, a hernia is an organ or piece of tissue that passes through a hole and ends up somewhere it isn’t supposed to be . Herniation most commonly affects abdominopelvic organs but can also involve other parts of the body such as the intervertebral discs of the spine, the lung, or the brain.

Before we dive into the different types, it is important to unpick some of the surgical terminology used to describe hernias (e.g. “a 56-year-old male with a strangulated inguinal hernia” ):

• “Reducible” – the contents of the hernia can be manipulated back into their original position through the defect from which they have emerged. These hernias are either left alone or repaired electively.
• “Incarcerated” or “Irreducible” – the contents of the hernia are stuck and cannot be pushed back into their original position. This can be due to sudden constriction of the hernia at the level of the fascial defect resulting in painful swelling of the tissues. Acutely incarcerated hernias should be repaired urgently . Other hernias can gradually become adherent to the surrounding tissues over time without causing any constriction of the contents. Chronically incarcerated hernias are usually repaired electively unless they are very painful or at high risk of obstruction or strangulation.
• “Obstructed” – the contents of a hernia containing bowel are compressed to the extent that the bowel lumen is no longer patent, leading to obstruction. The cardinal features of intestinal obstruction are colicky abdominal pain , distension , vomiting and absolute constipation . These hernias generally require emergency surgery unless they can be reduced very quickly.
• “Strangulated” – compression of the contents of the hernia by the fascial defect prevents blood flow into the tissues, causing ischaemia which may lead to infarction and necrosis. This typically presents with disproportionately severe constant pain , systemic illness and sepsis . These hernias are the most serious and require emergency surgery as soon as possible to salvage or resect their contents.

An abdominal hernia passes through an existing anatomical opening or an acquired fascial defect . Its contents are usually contained within a sac of parietal peritoneum . The opening it emerges from is called the hernia neck . This may be wide or narrow , and its edges may consist of fascial tissue , ligament or bone . The neck is important as it dictates the risk of complications – a loop of bowel trapped in a narrow defect with solid edges is much more likely to become obstructed or strangulated.

What causes a hernia?

Generally speaking, hernias are caused by increased intra-abdominal pressure , weak or damaged tissues , or a combination of both.

Increased intra-abdominal pressure may be due to:

• Chronic cough:  COPD , long-term smoking, bronchiectasis , cystic fibrosis
• Abdominal distension: pregnancy, ascites, peritoneal dialysis, obesity (ventral hernias)
• Straining: chronic constipation, prostatism, heavy lifting during work or exercise
• Kyphoscoliosis

Weakened tissues may result from:

• Congenital defects: patent processus vaginalis, patent umbilical ring
• Collagen disorders: Ehlers-Danlos syndrome, vitamin C deficiency, family history of hernias
• Trauma: including surgery
• Chronic malnutrition
• Long-term corticosteroid use

Inguinal hernia

Inguinal hernias are by far the most common type of hernia. They account for over 70% of all hernias, and around 70,000 of them are repaired in England every year.

An inguinal hernia is an abnormal protrusion of abdominopelvic contents through the superficial inguinal ring into the groin.

The inguinal ligament runs between the anterior superior iliac spine (ASIS) and the pubic tubercle (PT). Just above this ligament runs a structure known as the inguinal canal . The function of the inguinal canal is to provide a passageway between the peritoneal cavity and the external genitalia. In men , it transmits the spermatic cord to the testis , and in women , it contains the round ligament . In both sexes, it also carries the ilioinguinal nerve and the genital branch of the genitofemoral nerve .

As shown in the diagram below, the inguinal canal is best visualised as a tube or tunnel with an entry point from the abdominal cavity (the deep inguinal ring ) and an exit point into the groin (the superficial inguinal ring ). The location of these two openings is clinically important and is a common exam question. The deep ring is located just above the mid-point of the inguinal ligament . The superficial ring lies just above and lateral to the pubic tubercle .

Direct inguinal hernia

A direct inguinal hernia is caused by a weakness in the posterior wall of the inguinal canal in an area known as Hesselbach’s triangle . Abdominal contents (usually just fatty tissue, sometimes bowel) are forced “directly” through this defect into the inguinal canal. The hernia enters the canal medial to the deep ring and exits via the superficial ring, as shown below.

Indirect inguinal hernia

An indirect inguinal hernia follows a different trajectory. Instead of piercing the posterior wall, the abdominal contents enter the deep ring , pass along the length of the inguinal canal and exit via the superficial ring, as shown below.

Differences between indirect and direct inguinal hernias

Both types of inguinal hernia exit via the superficial ring and can sometimes enter the scrotum . This is known as an inguinoscrotal hernia . It is much more common for indirect hernias to do this as the path through both anatomical inguinal rings offers less resistance to the passage of hernia contents.

An appreciation of the anatomical differences can help to distinguish between direct and indirect hernias on clinical examination of the hernia . The principle of this is that if you place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament), then you can control an indirect inguinal hernia which has been reduced. If when you press the deep ring , the hernia still protrudes , then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore, a direct hernia .

It is useful to understand this clinical test as it helps remember the difference between the two. However, the clinical application of this kind of assessment is limited as it is not very reliable and doesn’t change management.

Aetiology and risk factors

Inguinal hernias are much more common in men due to the anatomy of their inguinal canals. The incidence in adults peaks at age 70 . Interestingly, studies have shown that a low BMI appears to be a risk factor for inguinal hernias, whilst obesity appears to be protective . This may be due to the presence of more intra-abdominal fatty tissue which covers and protects the deep inguinal ring.

Clinical features

Patients often present with a lump in the groin that comes and goes and has slowly increased in size over time. Alternatively, the lump may have popped out suddenly, for example after heavy lifting.

Many inguinal hernias are otherwise asymptomatic . Symptomatic hernias often present with groin pain or discomfort , particularly after coughing, bending over or standing for long periods. Some patients may also report pain or altered sensation over the scrotum or inner thigh due to compression of the ilioinguinal nerve . A small proportion may develop changes in bowel habit or urinary symptoms depending on the contents of the hernia.

Incarcerated, obstructed or strangulated inguinal hernias are a fairly common presentation to emergency departments or surgical assessment units.

The majority of inguinal hernias can be accurately diagnosed on clinical examination as a palpable swelling located above and medial to the pubic tubercle . Larger hernias may extend down into the scrotum . Where there is diagnostic uncertainty, an ultrasound scan of the groin can help differentiate between other possible causes such as enlarged lymph nodes, fatty lumps, or vascular pathology.

The tissues around the inguinal canal are soft and stretchy , and inguinal hernias carry a relatively low risk of obstruction or strangulation of about 2% per year . If the hernia is small and asymptomatic , the patient may wish to leave it alone. However, hernias do tend to gradually increase in size over time and become more bothersome, so most of them will eventually need to be repaired. Patients with larger or symptomatic hernias should be offered surgery to relieve their symptoms and prevent complications.

Mesh repair is the gold standard for inguinal hernias. Direct and indirect inguinal hernias are managed in the same way. The main decision is whether to fix the hernia via open or laparoscopic surgery.

Open repair

Open repair involves directly exploring the inguinal canal via a groin incision, identifying and protecting important structures (including the spermatic cord and ilioinguinal nerve), reducing the contents of the hernia back into the abdominal cavity, and placing a mesh to strengthen the deep inguinal ring and the posterior wall. It is a simple operation with excellent results and can be done under either general or local anaesthetic. This approach is preferred for large inguinoscrotal hernias .

Laparoscopic repair

Laparoscopic repair is also very successful in experienced hands. It has the added benefits of decreased post-operative pain and a faster recovery. The operation involves visualising the anatomy from within the abdominal cavity, opening the peritoneum, pulling the contents of the hernia back inside, and placing a mesh in the preperitoneal space to cover the defect. This approach is preferred for recurrent or bilateral inguinal hernias .

Research has not shown either technique to be superior, so current guidelines recommend an individualised approach tailored to the characteristics of the hernia, the surgeon’s experience and the patient’s preference.

Femoral hernia

Femoral hernias are a less common type of groin hernia, accounting for 3-5% of all hernias. They frequently present with bowel obstruction, but the diagnosis is often missed in clinical practice.

A femoral hernia is an abnormal protrusion of abdominopelvic contents through the femoral canal into the medial upper thigh.

Passing beneath the inguinal ligament are some important structures travelling to the upper leg. Most notably these include the femoral artery , the femoral vein and the femoral nerve . The order in which these structures lie is easy to remember using the ‘NAVY VAN’ mnemonic. With the ‘Y’ signifying the creases of the groin, this illustrates how the structures lie from lateral to medial (nerve, artery, vein).

The femoral artery and vein are enclosed within the femoral sheath . Lying medial to the femoral vein is a space known as the femoral canal . The function of this space is to allow expansion of the femoral vein to increase venous return from the lower limb. The femoral canal normally contains just a small amount of fatty tissue and a lymph node known as the lymph node of Cloquet .

It is important to note that the femoral canal is a narrow space bordered medially by the sharp edge of the lacunar ligament . Femoral hernias are therefore at very high risk of obstruction or strangulation .

Femoral hernias are much more common in women . Their incidence increases with age , and they are most likely to affect people over 50 . As with inguinal hernias, a low BMI is a risk factor. This is because weight loss diminishes the amount of fatty tissue within the femoral canal, creating a space where hernias can enter.

Interestingly, having a previous laparoscopic inguinal hernia repair is protective against a femoral hernia, as the preperitoneal mesh should also cover the femoral canal.

Femoral hernias may present with a lump in the groin similar to an inguinal hernia. The two can often be differentiated clinically as inguinal hernias are situated above and medial to the pubic tubercle , whereas femoral hernias are located below and lateral to the pubic tubercle . Femoral hernias are usually quite small and are not always easily palpable, especially in overweight patients.  Ultrasound can also be used to confirm the diagnosis.

A significant proportion of femoral hernias present as an emergency with symptoms of bowel obstruction or strangulation , but the diagnosis is often missed due to inadequate clinical examination or inadequate imaging. These patients often become very unwell, and the bowel may perforate due to the diagnostic delay. This is why you should always check the groins as part of an abdominal examination .

Due to the high risk of complications, femoral hernias should always be repaired . There are many different ways to do this, but current guidelines advocate laparoscopic mesh repair as the best method.

Obturator hernia

Obturator hernias are very rare, constituting less than 1% of all hernias. Due to their anatomical location, they are difficult to diagnose clinically. This often results in a missed or delayed diagnosis which leads to considerably increased morbidity and mortality for patients.

An obturator hernia is an abnormal protrusion of abdominopelvic contents through the obturator foramen of the bony pelvis into the medial upper thigh.

The obturator foramen is an anterior opening formed by the rami of the pubis and ischium on either side of the pelvis. It is roughly 3.5cm x 5cm in size and is the largest foramen in the human skeleton. Men tend to have a smooth, oval-shaped obturator foramen, whilst women’s are smaller and more triangular .

“Obturator” means “blocked off” in Latin, reflecting that in life the obturator foramen is almost completely occluded by a layer of fibrous tissue known as the obturator membrane . The obturator internus and obturator externus muscles lie on either side of this membrane, creating a muscular sandwich which further strengthens the seal covering the hole. The obturator artery, vein and nerve form a neurovascular bundle which enters a small gap in the upper edge of the obturator membrane just beneath the superior pubic ramus. These structures then leave the pelvis and pass obliquely through the obturator canal , a short tunnel 2-3cm long and about 1cm wide, to enter the medial compartment of the thigh .

Obturator hernias have been nicknamed the “little old lady hernia”. They overwhelmingly affect elderly multiparous women , and like femoral hernias, they are especially common in people who are very thin or have recently lost weight .

The female pelvis and pelvic floor muscles undergo marked changes during pregnancy and as part of normal ageing, creating wider gaps covered by laxer tissues which are easier for things to herniate through. The sharp pointy angles of the female obturator foramen also mean that structures that herniate through it are much more likely to get stuck there.

More than 90% of obturator hernias present as an emergency with an acute abdomen and clinical features of bowel obstruction and/or strangulation . This usually occurs suddenly, but some patients may report self-limiting episodes of subacute obstruction at home previously. These are characterised by attacks of colicky abdominal pain, bloating and nausea/vomiting which resolved within a few hours.

The deep position of the hernia means there is hardly ever a lump to feel on clinical examination. In addition to abdominal symptoms, up to 50% of patients present with pain and altered sensation along the inner thigh due to compression of the obturator nerve by the hernia, which is relieved by flexing the hip and worsened by internally rotating it. This is known as the Howship-Romberg sign and is pathognomonic for an obturator hernia. The Hannington-Kiff sign describes an absent adductor reflex on the affected side, but this can be hard to confidently elicit and is probably not worth relying upon as a diagnostic tool.

The gold-standard diagnostic test for an undifferentiated acute abdomen is a CT scan of the abdomen and pelvis with portal venous contrast, which should accurately identify an obturator hernia. They are also sometimes diagnosed using ultrasound or picked up unexpectedly on MRI scans.

Obturator hernias generally require emergency surgery to relieve mechanical obstruction and deal with any compromised bowel segments.

As they are so rare, there are no standardised recommendations for their treatment. Open surgery via a lower midline laparotomy remains the standard, especially if bowel resection is required, but a laparoscopic approach offers better visualisation and access to deep structures within the pelvis with improved patient outcomes. Simple suture repair is the fastest and safest way to close the hernia defect in an acutely unwell patient but has a much higher risk of recurrence than a mesh repair.

In the elective setting , obturator hernias can either be repaired laparoscopically or via a groin incision.

Umbilical hernia

Umbilical hernias are the most common ventral hernia . They account for at least 15% of all hernias and are estimated to affect 25% of the general population.

An umbilical hernia is an abnormal protrusion of intra-abdominal contents through a fascial defect in or around the umbilical ring .

The umbilicus is a dimpled structure on the midline of the anterior abdominal wall at the level of the L3/L4 intervertebral disc .

It is an embryological remnant of the attachment of the umbilical cord which carried the fetal-maternal circulation from the placenta. During fetal development, the umbilical opening provides an entry point for the umbilical arteries and vein . After birth, the umbilical cord detaches and the blood vessels fibrose into a dense stalk of scar tissue known as the cicatrix , which is a crucial landmark for initial port insertion during laparoscopic surgery.

The residual umbilical opening is located in the centre of the cicatrix and is known as the umbilical ring . This gradually fuses with the surrounding midline fascia and normally closes completely within the first 5 years of life.  

A true (or direct) umbilical hernia is a congenital problem which occurs when the umbilical ring fails to close , resulting in herniation of intra-abdominal contents into the middle of the cicatrix . This is extremely common, especially in children, and is why so many people have an “outie” belly button. A paraumbilical (or indirect umbilical) hernia is associated with an acquired fascial defect in the linea alba located within 3cm of the umbilical ring  and results in a hernia which lies separate from the cicatrix . Umbilical hernias vary considerably, ranging from a few millimetres to a football.

Umbilical hernias are more likely to affect women , especially during or after pregnancy , however, they are more likely to cause problems which ultimately require surgery in men. Down’s syndrome and Beckwith-Wiedemann syndrome have been associated with umbilical hernias in children.

Chronically raised intra-abdominal pressure due to obesity or ascites is a major risk factor. Up to 20% of patients with cirrhosis will develop an umbilical hernia secondary to ascites. Umbilical hernias can be lethal to these patients, as they often develop large hernias containing bowel and do not have the physiological reserve to survive an acute complication.

Umbilical hernias are usually asymptomatic . Symptomatic patients usually report a longstanding lump in their belly button which may be causing them varying amounts of bother. Due to their central position in the abdomen, symptomatic umbilical hernias may contain extraperitoneal fat , omentum , small bowel or transverse colon . Hernias containing bowel are at risk of obstruction or strangulation as most have fairly small fascial defects, and the umbilical ring is made from thick fibrous tissue. As many as 20% of umbilical hernias will present with acute complications.

On examination, there will be a palpable swelling in or around the umbilicus . The umbilicus itself may be everted or distorted by the hernia. It is important to note the condition of the overlying skin , which can become stretched and thin and may start to break down, posing a risk of infection.

An umbilical hernia is usually a clinical diagnosis . An ultrasound or CT scan can clarify the anatomy of larger hernias or rule out other pathology if there is any diagnostic uncertainty.  

Asymptomatic umbilical hernias have a low risk of complications and can safely be managed conservatively . These patients should be safety-netted about worrying symptoms to look out for and when to seek further medical advice.

International guidelines recommend that the majority of symptomatic umbilical hernias should undergo open repair with a mesh to reduce the risk of recurrence.

Very small hernias less than 1cm in size or women who plan to become pregnant in the future can be treated with simple suture repair instead. Large umbilical hernias more than 4cm in size or patients at high risk of wound infection are better managed with a laparoscopic approach .

Epigastric hernia

Epigastric hernias are a less common type of midline ventral hernia, which account for about 5% of all hernias. They have a relatively low risk of serious complications.

An epigastric hernia is an abnormal protrusion of intra-abdominal contents through a fascial defect in the linea alba between the umbilicus and the xiphoid process of the sternum.

The linea alba is a dense fibrous band which runs down the midline of the anterior abdominal wall from the xiphoid process to the pubic bone. It is formed by a complex interweaving and decussation of the fibres of the external oblique, internal oblique and transversus abdominis aponeuroses between the two rectus abdominis muscles. Epigastric hernias occur through a congenital or acquired defect in the upper part of the linea alba . These defects are often tiny, and the majority are less than 2cm in size.

Epigastric hernias are more common in men and people aged 20-50 . As with umbilical hernias, central obesity is a key risk factor as it increases intra-abdominal pressure and weakens the linea alba.

Epigastric hernias are usually asymptomatic . Symptomatic patients commonly present with an upper abdominal lump that comes and goes and may be uncomfortable . Epigastric hernias are unlikely to cause bowel obstruction or ischaemia as most of them only contain extraperitoneal fat . However, this fatty tissue can still strangulate , resulting in acute pain and inflammation around the hernia.

On examination, there will be a palpable swelling in the midline above the umbilicus . In most cases, it will be possible to gently reduce the hernia and feel the fascial defect with your fingers.

Like umbilical hernias, epigastric hernias are usually a clinical diagnosis .

The treatment guidelines for epigastric hernias are the same as for umbilical hernias .

Spigelian hernia

Spigelian hernias are rare , representing 1-2% of all hernias. They are often hard to detect clinically due to their small size and unusual position. This hernia is named after Adriaan van den Spiegel , who described the anatomy of the semilunar line in 1627. However, it should be named after Josef Thaddeus Klinkosch, who first described the hernia in 1764.

A Spigelian hernia is a lateral ventral hernia characterised by the abnormal protrusion of abdominal contents through a defect in the fascial layers lateral to the rectus sheath .

The semilunar line is a curved tendinous intersection located at the point where the transversus abdominis muscle transitions into its aponeurosis . It forms a visible landmark which runs lateral to the rectus abdominis muscle from the ninth costal cartilage to the pubic tubercle on either side.

The Spigelian fascia is the portion of the transversus abdominis aponeurosis located between the semilunar line and the rectus sheath .

Spigelian hernias occur when a small defect develops in this layer and allows extraperitoneal fat or abdominal contents to escape. They are usually less than 2cm in size and are most likely to occur at or below the level of the arcuate line . This is located roughly halfway between the umbilicus and the pubis and is the point at which the posterior rectus sheath becomes deficient .

The Spigelian fascia also becomes wider here and is pierced by the inferior epigastric vessels. The overlying external oblique aponeurosis is strong and often remains intact, forcing the hernia to spread out within the abdominal wall muscle compartment rather than popping out under the skin. This is known as an interparietal hernia and is another reason Spigelian hernias can be so tricky to spot.

Spigelian hernias are slightly more common in women  and more likely to affect people aged 40-60 .

Spigelian hernias are surrounded by tight fascial layers , making obstruction or strangulation of the contents much more likely. Around 25% of cases present as an emergency with acute complications.

Pain is the most common symptom, and patients often describe a feeling of localised stretching or tightness in the abdominal wall. The hernia may be palpable as a lump lateral to the rectus abdominis muscle , usually located below the umbilicus . However, Spigelian hernias are undetectable clinically in up to 50% of cases , and abdominal tenderness may be the only positive finding on examination.

An ultrasound scan of the symptomatic area can identify a small impalpable Spigelian hernia, but its accuracy may be limited in people with large body habitus. Some are diagnosed with a CT scan , or a diagnostic laparoscopy to investigate unexplained acute abdominal pain.

Spigelian hernias should be repaired as they carry a high risk of complications . As they are rare, there is insufficient evidence to support standardised recommendations for their management. Recent guidelines suggest a laparoscopic approach to aid the identification of the fascial defect and advise using mesh .

Incisional hernia

Incisional hernias are a diverse group of conditions ranging from tiny port site hernias to total abdominal wall failure. They will complicate around 15% of all abdominal operations and have become increasingly common as more and more patients are undergoing surgery at some point in their lives.

An incisional hernia is a ventral hernia characterised by the protrusion of intra-abdominal contents through the site of a previous surgical incision .

A midline laparotomy through the linea alba is the most frequently used abdominal incision. There is only one fascial layer to open and close, so this technique is easy, fast and provides excellent access without damaging muscles. However, it involves one of the thinnest parts of the abdominal wall , and there is no backup available if the single fascial suture line fails. It is therefore unsurprising that incisional hernias most commonly occur in the midline , especially after an upper midline laparotomy.

Transverse or lateral incisions  access specific structures such as the liver, gallbladder, appendix, uterus or retroperitoneal vessels. These involve several fascial layers and require the surgeon to split or cut muscles on the way down. They are more time-consuming to perform, but the fascial closure is stronger as it involves multiple suture lines and is reinforced by extra layers of tissue .

Laparoscopic and robotic surgery involves making multiple small incisions to insert instrument ports. These are known as port sites . The first port is most commonly located above or below the umbilicus , and other ports are then positioned according to the procedure performed. Laparoscopic ports have diameters of 5-12mm , so the incisions are small. However, a fascial defect 1cm in size can still cause a hernia if it is not closed properly, and port site hernias have a high risk of obstruction or strangulation if a loop of bowel manages to get stuck in the tiny hole.

A parastomal hernia is an incisional hernia related to a stoma site . Stoma formation involves the creation of a tunnel through the rectus sheath and rectus abdominis muscle to bring the bowel out onto the skin. This leaves a residual fascial defect which often allows other intra-abdominal contents to escape over time. Parastomal hernias are more likely to occur with a colostomy than with an ileostomy or urostomy.

Incisional hernias occur because the fascial closure of the abdominal wall failed to heal properly . Wound healing depends upon the direct approximation of healthy tissue edges with minimal tension , no  contamination or infection, a good blood supply , and adequate nutrition . There are numerous factors which may compromise adequate wound healing after abdominal surgery.

Technical factors

The surgeon’s fascial closure may have been suboptimal . For example, they may have used the wrong suture material, failed to approximate the correct fascial layers, left gaps between suture bites, tied loose knots, pulled the suture line overly tight or made a stoma opening too big.

Patient factors

Raised intra-abdominal pressure due to obesity , coughing , vomiting or a post-operative ileus will put additional tension on the fascial closure while it is trying to heal.

Smoking , peripheral arterial disease, diabetes and radiotherapy damage the capillary microcirculation and impair the blood supply to the tissues.

Chronic illnesses such as kidney disease , liver disease and intestinal disorders may result in malnutrition with inadequate protein levels available for building strong scar tissue.

Corticosteroids , immunosuppressant medications and chemotherapy increase the risk of infection and also dampen the inflammatory response to injury, directly impairing wound healing.

Disease-related factors

These include the need for emergency surgery , tissue damage or  contamination , inflammatory processes (such as Crohn’s disease) or malignancy , and post-operative wound infections .

Many incisional hernias are asymptomatic . Patients with symptomatic hernias tend to present with a lump which has gradually increased in size since their surgery. Incisional hernias tend to be more painful than primary hernias, with up to 50% of patients experiencing pain or discomfort. Large incisional hernias can also be functionally debilitating as they impair the patient’s core muscle strength and stability. Up to 15% of incisional hernias will present acutely with obstruction or strangulation .

In most cases, there will be a palpable lump close to a previous surgical scar or stoma site. However, it may be difficult to feel the hernia due to scarring or the patient’s body habitus.

Ultrasound can help diagnose small defects, such as port site hernias. Larger hernias and those associated with open incisions should be investigated with a CT scan to facilitate surgical planning. This will allow full characterisation of the anatomy of the fascial defect and hernia contents as well as identification of any other hernias which may have been missed on examination.

Asymptomatic incisional hernias can safely be managed conservatively .

The consensus is that symptomatic incisional hernias should be treated with a mesh repair . There are many open and laparoscopic techniques available, but you don’t need to worry about learning these (unless you’re studying for FRCS!). Symptomatic parastomal hernias can be treated by either reversing the stoma (if possible), performing a mesh repair around the stoma, or moving the stoma to another site on the abdominal wall. 

Incisional hernia repairs can be technically challenging as many patients will have scarring and tissue damage from their previous surgery. The risk of recurrence is more than 10% and can be much higher for large hernias. It is important to remember that not all patients will meaningfully benefit from surgery, and there is a chance that a major abdominal wall reconstruction could leave some patients worse off than they were before.

The optimal strategy depends on numerous factors including the patient’s symptoms and quality of life, the nature of their previous operation(s), the anatomy of the fascial defect(s), the likelihood of obstruction or strangulation, the patient’s fitness to undergo further surgery and their risk of postoperative complications. The decision-making process is complex and should be specifically tailored to each case .

Other types of hernia

Richter’s hernia.

A Richter’s hernia involves the partial herniation of just one edge of the bowel wall , usually the antimesenteric border of the small intestine , as opposed to its entire circumference.

It is named after August Gottlich Richter, who first described it in 1785. This is not a separate anatomical type of hernia, but a term used to describe a pathological phenomenon which can affect any hernia . It most commonly occurs in femoral hernias, inguinal hernias and ventral hernias with small fascial defects that won’t admit a whole loop of bowel (such as laparoscopic port site hernias). It can result in serious complications, as the herniated portion of the bowel wall can rapidly become strangulated and ischaemic, leading to necrosis, perforation and sepsis .

Patients often present with fairly vague symptoms and clinicians may be falsely reassured by the absence of features of intestinal obstruction . If the compromised bowel is manually reduced back into the abdominal cavity, the patient may develop generalised peritonitis when it perforates.

It is estimated that at least 10% of hernias requiring emergency surgery are Richter’s hernias. When assessing a patient with an acutely painful hernia, it is essential to take any abnormal findings seriously to avoid missing the diagnosis of bowel ischaemia. Red flags include skin changes over the hernia (erythema, cellulitis, bruising or dark discolouration), anxiety, fever, tachycardia, tachypnoea, raised inflammatory markers, acute kidney injury or elevated lactate . Patients with a piece of dead gut inside them also “don’t look right” from the end of the bed – once you’ve seen it, you won’t forget it.

Internal hernia

Unlike external hernias which end up outside the abdomen or pelvis, internal hernias occur when bowel loops remain within the peritoneal cavity but pass through an opening in the peritoneum  or the mesentery .

There are numerous congenital types, of which paraduodenal hernias are the most common. Internal hernias are also an important complication of abdominal surgery . Adhesions formed by scar tissue can create tight bands between adjacent structures which tangle up bits of bowel. Any procedure involving a Roux-en-Y reconstruction of the upper gastrointestinal tract – such as oesophagectomy, total gastrectomy, Whipple’s procedure, liver transplants and gastric bypass surgery – creates at least two new mesenteric spaces which small bowel loops can accidentally wander off into.

In addition, weight loss following bariatric surgery considerably increases the risk of herniation due to the rapid loss of intra-abdominal fatty tissue.

Internal hernias can be devastating  as a large amount of bowel can end up in the wrong place and suddenly develop closed-loop obstruction or  strangulation . Any patient with unexplained abdominal pain and a history of gastric bypass surgery should have an urgent CT scan to rule out an internal hernia.

Hiatus hernia

A hiatus hernia (also known as a hiatal hernia ) is characterised by the herniation of abdominal contents into the chest through the oesophageal hiatus of the diaphragm .

The sliding type is extremely common and usually only involves a small part of the top of the stomach slipping upwards. This impairs the function of the lower oesophageal sphincter, leading to heartburn and reflux symptoms. Patients are often told they have these after having a tiny defect noted during a routine endoscopy and can become preoccupied with their diagnosis of a “hernia”.

In contrast, the para-oesophageal type can involve the stomach and multiple other abdominal organs herniating up around the oesophagus en masse. These may result in life-threatening complications and can be very challenging to repair.

Diaphragmatic hernia

Unlike hiatus hernias, which pass through an existing anatomical opening, true diaphragmatic hernias are caused by the herniation of abdominal contents through a pathological defect in the diaphragm muscle . They may be congenital – these include Bochdalek (posterolateral), Morgagni (anteromedial) and central hernias – or acquired , usually following surgical mishaps or blunt or penetrating thoracoabdominal trauma. It is important to maintain a high index of suspicion for a diaphragmatic injury in patients with stab wounds to the junctional zone around the lower chest and upper abdomen.

Subxiphoid hernia

This is a high ventral hernia in the upper abdomen less than 5cm from the xiphoid process or costal margin . It usually develops as an incisional hernia following a median sternotomy, upper midline laparotomy or rooftop incision. It is unusual for these to contain bowel unless they are very large, as the left lobe of the liver covers the fascial defect in most cases. They are usually asymptomatic.

Suprapubic hernia

This is a low ventral hernia occurring in the suprapubic region less than 4cm above the pubic symphysis . It usually develops as an incisional hernia following a lower midline laparotomy or Caesarean section . These can be challenging to repair, especially in obese patients, as the lower posterior rectus sheath is relatively weak and the hernia is close to the bladder and important neurovascular structures . A piece of mesh often has to be anchored directly onto the pubic bone to adequately cover the fascial defect.

Lumbar hernia

This is another rare lateral ventral hernia in which abdominal contents herniate posteriorly through the muscles of the superior or inferior lumbar triangle into the soft tissues of the back . It can occur spontaneously or as a result of surgery or torso trauma.

Sciatic hernia

This is an extremely rare pelvic hernia in which abdominopelvic contents herniate through the greater or lesser sciatic foramen into the gluteal region . It may be mistaken for a buttock abscess.

Perineal hernia

This involves the herniation of abdominopelvic contents through the muscles of the pelvic floor into the perineum . It occurs more frequently as an incisional hernia following radical pelvic surgery , such as abdominoperineal resection of the rectum or pelvic exenteration. It is therefore important for these patients to have their perineal wounds checked at follow-up appointments.

Burst abdomen

A burst abdomen (also known as full-thickness wound dehiscence) involves the failure of the fascial closure of the abdominal wall in the early postoperative period . It can be dramatic and requires a trip to the emergency theatre to put the bowel back where it should be and close everything up again.

Traumatic hernia

Traumatic hernias are thankfully rare. They occur as a result of high-energy blunt trauma to the abdominal wall with a sudden increase in intra-abdominal pressure which disrupts muscle and fascial layers , such as a seatbelt injury , handlebar injury or crush injury .

These mechanisms are associated with severe blunt polytrauma and patients may be critically unwell. There are often direct injuries to the underlying bowel with extensive soft tissue destruction leading to large and complex wounds.

Eponymous hernias

As well as Spigelian and Richter’s hernias, there are many other eponymously named hernias. The ones you are most likely to hear mentioned are named after a surgeon of yore who found an interesting internal organ inside a hernia. Some examples we have encountered in clinical practice include Amyand’s hernia (appendix in an inguinal hernia), de Garengeot’s hernia (appendix in a femoral hernia), and Littre’s hernia (Meckel’s diverticulum in any hernia).

Differential diagnoses – things that aren’t hernias

Sportsman’s hernia.

The helpfully named “sportsman’s hernia” (also known as inguinal disruption, Gilmore’s groin, or athletic pubalgia) is not a hernia . It is a poorly understood group of conditions but is generally accepted to be a sprain or tear of the soft tissues in the groin which causes pain around the inguinal ligament and pubic tubercle.

Patients may experience abnormal tension in the inguinal canal due to damage to surrounding structures, and some develop chronic pain. An MRI scan will identify any soft tissue abnormalities. Surgery is only indicated if conservative treatment and physiotherapy are unsuccessful.

Divarication of the recti

Divarication of the recti (also known as rectus diastasis) occurs when the rectus abdominis muscles separate , leading to stretching and thinning of the linea alba to a width of more than 2cm . This causes a bulge in the midline , which can look striking on clinical examination but isn’t a hernia as there is no underlying fascial defect . It is often cosmetically unappealing to patients, especially women who develop it during pregnancy and also can lead to core weakness and instability.

Intensive physiotherapy and exercise programmes are first-line treatments as they can effectively bring the muscles back together again in addition to improving core strength. Surgery is reserved for large symptomatic divarications of more than 5cm and those associated with an umbilical or epigastric hernia.

Pseudohernia

A pseudohernia is a soft tissue bulge resulting from localised muscle paralysis secondary to trauma, nerve root compression by an intervertebral disc prolapse, peripheral neuropathy or infections such as shingles (herpes zoster). This may also be mistaken for a hernia on clinical examination.

Reference texts

• Birindelli, A., Sartelli, M., Di Saverio, S. et al.2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg  12 , 37 (2017).
• Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011 Jan 19;2(1):5. 
• Seker G, Kulacoglu H, Öztuna D, Topgül K, Akyol C, Çakmak A, Karateke F, Özdoğan M, Ersoy E, Gürer A, Zerbaliyev E, Seker D, Yorgancı K, Pergel A, Aydın I, Ensari C, Bilecik T, Kahraman İ, Reis E, Kalaycı M, Canda AE, Demirağ A, Kesicioğlu T, Malazgirt Z, Gündoğdu H, Terzi C. Changes in the frequencies of abdominal wall hernias and the preferences for their repair: a multicenter national study from Turkey. Int Surg. 2014 Sep-Oct;99(5):534-42.
• Hemberg, A., Montgomery, A., Holmberg, H. et al.Waist Circumference is not Superior to Body Mass Index in Predicting Groin Hernia Repair in Either Men or Women. World J Surg  46 , 401–408 (2022).
• HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018 Feb;22(1):1-165.
• NICE Technology appraisal guidance [TA83]: Laparoscopic surgery for inguinal hernia repair. National Institute for Health and Care Excellence 2004. Available from: [ LINK ]
• Bedewi MA, El-Sharkawy MS, Al Boukai AA, Al-Nakshabandi N. Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study. Hernia. 2012 Feb;16(1):59-62.
• Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Simons MP; European and Americas Hernia Societies (EHS and AHS). Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg. 2020 Feb;107(3):171-190.
• Henriksen NA, Kaufmann R, Simons MP, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Montgomery A; on behalf of the European Hernia Society and the Americas Hernia Society. EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances. BJS Open. 2020 Apr;4(2):342-353.
• Rennie, S.R., Eliopoulos, C. & Gonzalez, S. Evaluation of the obturator foramen as a sex assessment trait. Forensic Sci Med Pathol(2022).
• Li, Z., Gu, C., Wei, M. et al.Diagnosis and treatment of obturator hernia: retrospective analysis of 86 clinical cases at a single institution. BMC Surg  21 , 124 (2021).
• Park, Jinyoung MD, PhD. Obturator hernia: Clinical analysis of 11 patients and review of the literature. Medicine: August 21, 2020 – Volume 99 – Issue 34 – p e21701
• Schizas, D., Apostolou, K., Hasemaki, N. et al.Obturator hernias: a systematic review of the literature. Hernia  25 , 193–204 (2021).
• Ponten, J.E.H., Somers, K.Y.A. & Nienhuijs, S.W. Pathogenesis of the epigastric hernia. Hernia 16 , 627–633 (2012).
• Hertzer NR, Montie JE. Spigelian hernia: a review of the literature and report of three cases. Cleveland Clinic Journal of Medicine Jan 1971, 38 (1) 13-18. Available from: [ LINK ]
• Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, Chowbey PK. Diagnosis and management of Spigelian hernia: A review of literature and our experience. J Minim Access Surg. 2008 Oct;4(4):95-8.
• Hanzalova, I., Schäfer, M., Demartines, N. et al.Spigelian hernia: current approaches to surgical treatment—a review. Hernia (2021). 
• Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RK, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A. Classification of primary and incisional abdominal wall hernias. Hernia. 2009 Aug;13(4):407-14.
• P W G Carne, G M Robertson, F A Frizelle, Parastomal hernia,  British Journal of Surgery , Volume 90, Issue 7, July 2003, Pages 784–793
• Kingsnorth A. The management of incisional hernia. Ann R Coll Surg Engl. 2006 May;88(3):252-60.
• SandersD L,  Kingsnorth  A N. The modern management of incisional hernias  BMJ 2012; 344  :e2843
• Regelsberger-Alvarez CM, Pfeifer C. Richter Hernia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2022. Available from: [ LINK ]
• Sheen AJ, Stephenson BM, Lloyd DM, et al. ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. British Journal of Sports Medicine 2014; 48: 1079-1087.
• P Hernández-Granados, N A Henriksen, F Berrevoet, D Cuccurullo, M López-Cano, S Nienhuijs, D Ross, A Montgomery, European Hernia Society guidelines on management of rectus diastasis,  British Journal of Surgery , Volume 108, Issue 10, October 2021, Pages 1189–1191.

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Inguinal hernias

Peer reviewed by Dr Colin Tidy, MRCGP Last updated by Dr Laurence Knott Last updated 13 Jan 2022

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Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the  Hernia  article more useful, or one of our other  health articles .

In this article :

What is an inguinal hernia, inguinal hernia epidemiology, inguinal hernia presentation, differential diagnosis, investigations, inguinal hernia treatment and management, complications.

Continue reading below

An inguinal hernia comprises a protrusion of abdominal contents through the fascia of the abdominal wall, through the internal inguinal ring. Hernias always contain a portion of peritoneal sac and may contain viscera, usually small bowel and omentum.

Inguinal hernia

Inguinal hernias comprise approximately 7% of all surgical outpatient visits 1 .

Male:female ratio of groin hernias is 8:1 2 .

Hernias and hydroceles occur in 1-3% of full-term infants 3 .

In men, the incidence rises from 11 per 10,000 person-years, aged 16-24 years, to 200 per 10,000 person-years, aged 75 years or above 4 .

Risk factors

In infants: prematurity, male sex.

In adults: male sex, obesity, constipation, chronic cough, heavy lifting.

Swelling in the groin that may appear with lifting and be accompanied by sudden pain.

Indirect hernias are more prone to cause pain in the scrotum and cause a 'dragging sensation'.

An impulse (increase in swelling) may be palpable on coughing.

It may not be possible to see the hernia if it is reduced.

If a lump is present, it may be reducible.

Congenital inguinal hernias are usually detected at birth and all need urgent outpatient referral for surgical repair.

Inguinal hernias in older children and adults usually develop gradually but can occur suddenly with an episode of heavy lifting causing 'rupture':

At first appearance, a hernia is usually easily reducible when the patient reclines. However, it may require manual replacement if large.

With time, the hernia enlarges and becomes harder to replace, due to fibrous adhesions forming.

When it can no longer be reduced, it is irreducible or incarcerated. This can occur at any time, as can strangulation. This occurs when visceral contents of the hernia become twisted or entrapped by the narrow opening. This compromises the blood supply, causing swelling and eventually infarction. Strangulation usually leads to bowel obstruction.

There are two types of inguinal hernia:

Indirect : a protrusion through the internal inguinal ring passes along the inguinal canal through the abdominal wall, running laterally to the inferior epigastric vessels. This is the more common form accounting for 80% of inguinal hernias, especially in children. It is associated with failure of the inguinal canal to close properly after passage of the testis in utero or during the neonatal period 5 .

Direct : the hernia protrudes directly through a weakness in the posterior wall of the inguinal canal, running medially to the inferior epigastric vessels. It is more common in the elderly and rare in children.

The clinical findings will help suggest whether the inguinal hernia is direct or indirect; in adults this is usually confirmed at operation. There may be a limit to the clinical utility of such a distinction, especially in adults.

The less common form is the sliding hernia where a portion of viscera slides behind the peritoneal sac into the inguinal canal with the wall of the organ forming part of the hernial sac.

Examine the patient both standing and lying and ask them to cough or strain.

Insert a finger through the top of the scrotum into the external inguinal ring and palpate for a lump when coughing - cough impulse.

Sliding hernias are probable with large scrotal hernias.

See also the separate Lumps in the Groin and Scrotum article.

Femoral hernia : this is seen in various forms, at simplest as a small swelling in the top of the inside of the thigh. Alternatively, it may be deflected to appear higher as an inguinal hernia. It is either irreducible or reduces only slowly with pressure.

Hydrocele (when differentiating from an inguinoscrotal hernia, note that it is possible to get above a hydrocele on examination).

Spermatic cord hydrocele.

Lymph node swelling.

Saphena varix.

Varicocele .

Undescended testis .

Ultrasound is the less invasive method, if there is doubt. MRI or CT scanning may also be used 5 6 . Herniography with injection of X-ray contrast agent into the peritoneum is rarely necessary 7 .

If the inguinal hernia is small, the patient may only need reassurance. However, there is always the chance of it becoming a surgical emergency through obstruction and incarceration. Episodes of pain and tenderness suggest the need for urgent treatment but when these become prolonged and severe then emergency surgery is indicated for possible strangulation. The fundamentals of indirect inguinal hernia treatment are the same regardless of the patient's age. Reduction or excision of the sac and closure of the defect with minimal tension are the essential steps in any hernia repair.

Conventional surgery was based on Bassini's operation; this consisted of apposition of the transversus abdominis and transversalis fascia and the lateral rectus sheath to the inguinal ligament. The Shouldice technique uses two layers of running suture in a similar fashion.

However, the Lichtenstein technique is widely used, where a piece of open-weave polypropylene mesh is used to repair and reinforce the abdominal wall. This operation is easier to learn, gives earlier mobility and has a very low recurrence rate. The standard repair now uses prostheses, usually polypropylene mesh.

Concerns that some of the traditional meshes were heavy and associated with postoperative stiffness and pain led to the development of lighter meshes. A systematic review failed to find any differences in long-term and short-term complications between the two 8 . A subsequent meta-analysis concluded that heavyweight mesh had a distinctive advantage over lightweight mesh with regard to recurrence. The two types of prosthetic meshes had equivalent outcomes for postoperative pain, seroma, foreign body sensation, infection, and numbness 9 .

Postoperative infection has been a concern when a mesh is used. However, antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended.

Bilateral hernias are best repaired laparoscopically. There is less postoperative pain, full recovery is better and return to work is faster. However, the price is increased compared with the conventional approach and there appears to be a higher number of serious complications of visceral (especially bladder) and vascular injuries 10 .

There are two approaches: either the transabdominal preperitoneal (TAPP) or the totally extraperitoneal (TEP) procedure. In TAPP, the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over possible hernia sites. TEP is different, as the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum. The mesh, where used, becomes incorporated by fibrous tissue.

Meta-analyses found that laparoscopic and open mesh repairs for recurrent inguinal hernias were equivalent in most of the analysed outcomes.

Preferences in surgical techniques vary across the world. In the USA and some parts of Europe, laparoscopic repair is becoming the first-line option for all types of hernias.

The British Hernia Society has not released guidelines since the International Guidelines were released, but comment in their advice to patients that laparoscopy may be beneficial for recurrent hernias, bilateral hernias, hernias in women, and very active patients in whom the predominant symptom is pain. Open repair under anaesthetic may be better in older patients with comorbidities or in those who do not want a full general anaesthetic 11 .

Surgery can be performed on a day-case basis; for seven days afterwards the patient should avoid driving and lifting. The patient should be able to resume normal activities over the subsequent 2-3 weeks but, with a heavy job, it can take up to six weeks to return to work.

A truss may be required where surgery is inadvisable or refused; however, it can be difficult for patients to manage and cannot be recommended as a definitive form of treatment.

Inguinal hernias in children

The incidence of incarcerated or strangulated hernias in paediatric patients is 12-16% 12 . 50% of these occur in infants aged younger than 6 months 13 .

Paediatric surgeons will repair soon after diagnosis, regardless of age or weight, in healthy full-term infant boys with asymptomatic reducible inguinal hernias. There is no significant difference in operative time for unilateral hernias but laparoscopy is faster than open surgery for bilateral hernias. There is no difference in recurrence rate but wound infection is higher with open surgery than with laparoscopy 14 .

The timing of inguinal hernia repair in premature infants remains a controversial topic. They are often repaired prior to discharge from the neonatal intensive care unit (NICU). However, since infants are now being discharged home at much lower weights there has been a trend towards postponing surgery for 1-2 months to allow further growth. One study advocated early surgery in order to avoid perioperative morbidity and to reduce the risk of incarceration, subsequent testicular ischemia and hernia recurrence 15 . A systematic review concluded that repair of inguinal hernia in premature infants before NICU discharge may increase the odds of recurrence, but not incarceration or surgical complications 16 .

Herniotomy is all that is required with ligation and excision of the patent processus vaginalis.

These include 4 :

Recurrence: 1.0% - most happening within five years of operation. Recurrence rate increases:

In children aged younger than 1 year.

In elderly patients.

After incarcerations.

In those with ongoing increased intra-abdominal pressure.

Where there is growth failure.

With prematurity.

Where there are chronic respiratory problems.

In girls with sliding hernias.

Infarcted testis or ovary with atrophy.

Wound infection.

Bladder injury.

Intestinal injury.

A hydrocele from fluid accumulation in the distal sac usually resolves spontaneously but sometimes requires aspiration.

This is generally very good, depending on comorbidity.

Further reading and references

• Jorgenson E, Makki N, Shen L, et al ; A genome-wide association study identifies four novel susceptibility loci underlying inguinal hernia. Nat Commun. 2015 Dec 21;6:10130. doi: 10.1038/ncomms10130.
• Gudigopuram SVR, Raguthu CC, Gajjela H, et al ; Inguinal Hernia Mesh Repair: The Factors to Consider When Deciding Between Open Versus Laparoscopic Repair. Cureus. 2021 Nov 16;13(11):e19628. doi: 10.7759/cureus.19628. eCollection 2021 Nov.
• Seifmanesh H et al ; Castleman’s disease in a patient with inguinal mass mimicking hernia. Am J Case Rep 2010; 11:211-213.
• Burcharth J, Pedersen M, Bisgaard T, et al ; Nationwide prevalence of groin hernia repair. PLoS One. 2013;8(1):e54367. doi: 10.1371/journal.pone.0054367. Epub 2013 Jan 14.
• Docimo S ; The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, Fifth Edition, 2006.
• Jenkins JT, O'Dwyer PJ ; Inguinal hernias. BMJ. 2008 Feb 2;336(7638):269-72.
• Burkhardt J et al ; Diagnosis of Inguinal Region Hernias with Axial CT: The Lateral Crescent Sign and Other Key Findings, 2010.
• LeBlanc KE, LeBlanc LL, LeBlanc KA ; Inguinal hernias: diagnosis and management. Am Fam Physician. 2013 Jun 15;87(12):844-8.
• HerniaSurge Group ; International guidelines for groin hernia management. Hernia. 2018;22(1):1-165. doi:10.1007/s10029-017-1668-x
• Currie A, Andrew H, Tonsi A, et al ; Lightweight versus heavyweight mesh in laparoscopic inguinal hernia repair: a meta-analysis. Surg Endosc. 2012 Aug;26(8):2126-33. doi: 10.1007/s00464-012-2179-6. Epub 2012 Feb 7.
• Wu F, Zhang X, Liu Y, et al ; Lightweight mesh versus heavyweight mesh for laparo-endoscopic inguinal hernia repair: a systematic review and meta-analysis. Hernia. 2020 Feb;24(1):31-39. doi: 10.1007/s10029-019-02016-5. Epub 2019 Jul 31.
• McCormack K, Scott NW, Go PMNYH, Ross S, Grant AM, the EU Hernia Trialists Collaboration ; Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No. CD001785. DOI: 10.1002/14651858.CD001785
• Groin Hernia and You ; British Hernia Society, 2022
• Lawal TA, Egbuchulem KI, Ajao AE ; Obstructed inguinal hernia in children: case-controlled approach to evaluate the influence of socio-demographic variables. J West Afr Coll Surg. 2014 Apr-Jun;4(2):76-85.
• Nigam V ; Essentials of Abdominal Wall Hernias, 2009.
• Esposito C, St Peter SD, Escolino M, et al ; Laparoscopic versus open inguinal hernia repair in pediatric patients: a systematic review. J Laparoendosc Adv Surg Tech A. 2014 Nov;24(11):811-8. doi: 10.1089/lap.2014.0194. Epub 2014 Oct 9.
• Vaos G, Gardikis S, Kambouri K, et al ; Optimal timing for repair of an inguinal hernia in premature infants. Pediatr Surg Int. 2010 Apr;26(4):379-85. doi: 10.1007/s00383-010-2573-x. Epub 2010 Feb 19.
• Masoudian P, Sullivan KJ, Mohamed H, et al ; Optimal timing for inguinal hernia repair in premature infants: a systematic review and meta-analysis. J Pediatr Surg. 2019 Aug;54(8):1539-1545. doi: 10.1016/j.jpedsurg.2018.11.002. Epub 2018 Nov 14.

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Hernia Types, Causes, and Treatments

What Is A Hernia?  |  Types  |  Causes  |  Complications  |  Treatment  |  Next Steps

• Hernias are weaknesses in the abdominal wall, which can allow fat or intestines to bulge through. The most common type occurs in the groin area and is called an inguinal hernia.
• Hernias can create problems when the intestine gets stuck, known as hernia incarceration or hernia strangulation. Hernia strangulation is a medical emergency that requires immediate surgical attention.
• The goal of hernia repair surgery is to close the hernia defect with minimal or no tension to ensure that it does not recur.

What is a Hernia?

A hernia is a weakness or opening in the abdominal wall which often results in soft tissue such as fat or intestine protruding through the abdominal muscles and occupying the space under the skin. The mechanism of a hernia is like what happens with a bulge in a damaged tire, where the inner tube, normally contained by the hard rubber of the tire, extends through a thin or weakened place. The opening in the abdominal wall that leads to the hernia is also known as a hernia defect.

Types of Hernias

Inguinal hernias.

Inguinal hernias are the most common of all hernias and are also referred to as groin hernias. They occur near the crease between the lower abdomen and the upper thigh. When an inguinal hernia develops, intestine or fat may protrude through the defect in the abdominal wall, creating a bulge on the right or left side.

Signs and symptoms of inguinal hernias can include:

• Constant pain
• Discomfort during sitting or with activity

Sometimes, inguinal hernias cause no symptoms at all. Between 10 and 15 percent of men and 2 percent of women will develop inguinal hernias in their lifetime.

Ventral Hernias and Umbilical Hernias

Ventral hernias occur in the part of the abdominal wall above or below the umbilicus (belly button) and/or within the umbilicus itself, where they are called umbilical hernias. These hernias are less common than inguinal hernias, with some 10 percent of both men and women expected to develop either a ventral or umbilical hernia during their lifetime.

Spigelian Hernias and Flank Hernias

The Spigelian hernia, another rarer type of ventral hernia, occurs in the mid-abdomen but are more lateral than the belly button.

Flank hernias are hernias in the flank region (the side of the body, between the rib cage and the hip bone) and can present after trauma or spine surgery and cause bulging or discomfort.

Incisional Hernias

Incisional hernias are a special kind of abdominal wall hernia that occur near prior surgical incisions where prior surgery has weakened the abdominal wall, or where infection in a healing surgical incision causes breakdown of the wound closure. About 25 to 30 percent of patients will develop an incisional hernia when a wound infection occurs after abdominal surgery.

Recurrent Hernias

Recurrent hernias are hernias which recur after an attempt at fixation. Even in the best of circumstances, hernias can recur due to the nature of the weakened abdominal wall.

Recurrent hernias are much harder to fix than other types of hernias due to previous surgical scarring, previous mesh, and inflamed tissue surrounding the hernia. Recurrent hernias should be evaluated immediately for possible repair.

Sports Hernias

Despite the name, Sports hernias are not actually true hernias, but represent a constellation of symptoms, typically groin pain or pressure without an obvious bulge, arising from muscle or tendon injury or weakness in the groin. These are caused by repetitive or quick motions from hip or pelvis twisting which can occur after playing competitive sports, hence the name. There are multiple muscles and tendons which attach onto the pubic bone, and these can get stretched, torn or pulled during sports such as football, hockey, baseball, soccer, and more. As there is no obvious hernia associated with this diagnosis, they are typically diagnosed by physical exam and history, and in more complex cases, x-ray, CT, MRI or ultrasound can be used to look for injuries.

Initial treatment involves rest and anti-inflammatory medications. Physical therapy is also useful in the management of these injuries. Surgery is typically reserved for severe or acute injuries and can involve releasing tendons of affected muscles, strengthening of the pelvic floor muscles, or re-attachment of tendons or ligaments.

What Causes A Hernia?

Inguinal and ventral hernias may develop due to several factors, including obesity, aging, chronic cough such as with COPD, and strenuous physical activity requiring heavy lifting, such as construction work.

Certain rare conditions such as collagen vascular disease or genetic defects involving connective tissue may also cause abdominal hernias.

Hernia Complications

Hernia incarceration.

Intestine or other organs can get stuck inside of the hernia defect. This process is called hernia incarceration . When hernias become incarcerated, they can cause severe pain, and if the intestine becomes stuck, other symptoms such as nausea, vomiting, and diarrhea can develop. Some hernias are chronically incarcerated when they are present for so long, however if there is any concern, immediate evaluation is necessary.

Hernia Strangulation

When the stuck contents become damaged and extreme pain or other symptoms develop, this process is referred to as hernia strangulation . This is a surgical emergency which needs evaluation and surgical fixation right away to save whichever organs are stuck inside the hernia defect.

How are Hernias Treated?

Surgical hernia repair.

Anyone who has a hernia should undergo an evaluation for repair. Smaller inguinal and umbilical hernias without symptoms may be monitored without surgery, however every hernia should get evaluation by a hernia surgeon. Incisional hernias and large hernias should be repaired right away as they often enlarge over time. All candidates for hernia repair are evaluated to identify factors that can be modified to minimize the risk of complications, such as control of diabetes and smoking cessation.

The goal of hernia repair is to close the hernia defect with minimal or no tension to ensure that it does not recur. This occurs with or without mesh placement . Mesh is a surgical device used to help support the tissue around the hernia. Mesh can be either synthetic (manufactured polymer sheets), biologic (derived from human or animal tissue), or a mix of both. The secondary goal is to reduce the trauma of surgery by using minimally invasive approaches whenever possible and by ensuring that each patient is optimized.

Approaches to Hernia Repair

There are 3 different possibilities for repair approaches depending on the type of hernia and should be determined after a discussion between the patient and their hernia surgeon.

Open Surgical Repair

The surgeon makes an incision directly over the hernia defect and fixes the hernia from that incision, including mesh placement. This may be appropriate for smaller umbilical and ventral hernias and may be done under light sedation rather than general anesthesia. Open surgery may be necessary for larger or more complex hernias which are not able to be fixed minimally invasively.

The other two options are both considered examples of minimally invasive surgery :

Laparoscopic Surgery

Laparoscopic surgery is performed through several small incisions ranging from 5mm-12mm. The surgeon then uses long instruments to perform the surgery. The purpose of this is to approach the hernia from the inside-out, rather than outside-in. This approach is always performed while under general anesthesia. The surgeon inserts small tubes called cannulas through the abdominal wall at some distance from the hernia defect. The hernia is then fixed, and mesh can even be placed through these small incisions.

Robotic Surgery

Robotic surgery is like laparoscopic surgery in that smaller incisions are used in order to fix the hernia, however instead of the surgeon operating with long instruments controlled by the surgeons hands, robotic instruments are placed inside the patient and the surgeon controls them from a console in the operating room. The robotic platform enables surgeons to have more precise movements, extended reach, and even the ability to perform more complex abdominal wall reconstruction compared to laparoscopic surgery.

Robotic surgery has been around for close to 2 decades however only in the past several years has its real utility in abdominal wall construction been realized. Patients that would normally need large open incisions which would necessitate a several day hospital stay with increased pain can undergo robotic surgery with the possibility of a one day or even same day discharge.

Specialized Hernia Repairs

Non-mesh inguinal (groin) hernia repair.

While we recommend mesh reinforcement of inguinal hernias, in certain cases, non-mesh tissue repair can be an alternative. The technique mastered by our surgeons is the Shouldice technique, which is a 4-layer, sutured closure of the muscles and fascia of the groin and abdominal wall in order to repair hernias and strengthen the inguinal floor. While the recurrence rate is slightly higher without mesh reinforcement, the recovery is very similar.

Robotic Component Separation

In order to reconstruct larger hernia defects, muscle releases or component separations may need to be performed in order to bring the patient’s midline closer together. This involves either cutting the outermost oblique muscle, the external oblique, or the innermost oblique muscle, the transversus abdominis. By doing so it is possible to close hernia defects as large as 20-30 cm while preserving the function of the abdominal wall. 

Hernias requiring component separation would normally require a large midline incision, however centers adept at robotic component separation may only require 4-6 smaller incisions on the abdominal wall. This allows for a quicker recovery and reduces the rate of complications.

Totally Extraperitoneal Hernia Repair

Typically minimally invasive ventral and umbilical hernia repairs would need to be performed trans-abdominally. This involves placing trocars or tubes inside the abdomen where it is filled with carbon dioxide and the surgeon works up on the abdominal wall. Using advanced optics, high level centers can perform these hernia repairs by operating within the layers of the abdominal wall themselves. This technique is called the enhanced-view Totally Extraperitoneal access (eTEP) hernia repair. This allows for direct visualization of muscle layers and a quicker and more robust repair than would be able to be achieved otherwise.

Rectus Diastasis

Some patients may have what is known as rectus diastasis, which is where the rectus muscles (the six-pack muscles) separate at the midline. This can occur with weight gain, with aging, and most commonly after pregnancy. These can also occur along with ventral or umbilical hernias. Even in the absence of hernias, rectus diastasis can be quite debilitating in those who suffer from it.

Repair of rectus diastasis involves bringing the ab muscles back together with the repair of any associated hernias at the same time. Traditional repair of rectus diastasis associated with a hernia involved a tummy tuck by a plastic surgeon, however advanced hernia centers can offer a minimally invasive approach for diastasis and hernia repair. This is referred to as a S ub C utaneous O nlay L aparoscopic A pproach (SCOLA) Repair. This approach involves 3 small surgical incisions in the lower abdomen and involves a re-approximation of the rectus muscles as well as repair of any associated hernias using long instruments or the robotic platform. This allows for a faster recovery without the need for skin excision.

If you are dealing with a hernia, the Columbia Hernia Center can help you. Our center is among the most advanced in the country, offering all options and techniques, including advanced robotic procedures and approaches. To set up a consultation, please call us at (212) 305-5947 or use our online appointment request form . We look forward to answering your questions and meeting your hernia care needs.

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How to Tell If You Have a Hernia

Reviewed By:

Gina Lynn Adrales, M.D., M.P.H.

Wondering if the aching in your belly or groin could be a hernia? Hernias are common in both men and women, but symptoms vary. Groin hernias are much less common in women. Hernias may cause some form of discomfort and don’t go away on their own, says Gina Adrales, M.D., M.P.H. , director of the Division of Minimally Invasive Surgery at Johns Hopkins Medicine.

The good news? Nearly all hernias can be surgically repaired. Adrales explains how to recognize hernia signs in men and women, the most common types, and what surgery and recovery are like.

Q: What is a hernia?

A: Your abdomen is covered in layers of muscle and strong tissue that help you move and protect internal organs. A hernia is a gap in this muscular wall that allows the contents inside the abdomen to protrude outward. There are different types of hernias , but the most common hernias occur in the belly or groin areas.

Q: What Does a Belly or Abdominal (Ventral) Hernia Feel Like?

A: If you have a ventral hernia in the belly area, you may see or feel a bulge along the outer surface of the abdomen. Typically, patients with ventral hernias describe mild pain, aching or a pressure sensation at the site of the hernia. The discomfort worsens with any activity that puts a strain on the abdomen, such as heavy lifting, running or bearing down during bowel movements. Some patients have a bulge but do not have discomfort.

Q: Who is at higher risk for a ventral hernia?

A: Anyone can develop a ventral hernia, but those who’ve had abdominal surgery have a higher risk. If you have an incision that disrupts the abdominal wall, the scar will never be as strong as the original tissue. This makes it more likely that you’ll develop a hernia, known as an incisional hernia , along the incision area. This occurs in up to 30% of patients who have open abdominal surgery.

Pregnancy is a risk factor that makes women more susceptible to developing another type of ventral hernia near the belly button, called an umbilical hernia . The umbilicus is the thinnest part of the abdominal wall. It’s a very common site to develop a hernia, whether you’re a man or a woman.

Q: How can you tell if you have an inguinal (groin) hernia?

A: First, it’s important to understand that both men and women can develop inguinal hernias . People often believe that only men get them, and for anatomical reasons, they do have a higher risk. But women can certainly have inguinal hernias, too.

Many experts agree that women are likely underdiagnosed for this condition because they tend to have different symptoms than men. Women may not have a noticeable bulge. If symptoms indicate a possible hernia but your doctor cannot confirm it by an exam, an MRI can provide definitive evidence.

Symptoms in Men

• A bulge you can see or feel
• Aching pain in the area
• A feeling of pressure
• A tugging sensation of the scrotum around the testicles
• Pain that worsens with activities that add pressure to the area, such as heavy lifting, pushing and straining

Symptoms in Women

• Aching or sharp pain
• Burning sensation
• A bulge at the hernia site, but this may not be present with a groin hernia
• Discomfort that increases with activity

Q: How are hernias treated?

A: Treatment varies depending on the type of hernia, symptoms and the patient's sex.

Inguinal (Groin) Hernias

Inguinal hernias in women are more likely to become emergencies. Women also have a greater chance of developing complications than in men. So, we typically recommend surgical repair after diagnosis.

Men with inguinal hernias often may put off surgery if they’re not symptomatic. Studies of men with inguinal hernias indicate the risk of having an emergency, like part of the bowel getting stuck or strangled in the muscle gap, is quite low. But because hernias tend to grow larger or cause symptoms over time, most men will require surgery within 10 years of hernia diagnosis.

There are two surgical treatments for inguinal hernias. Minimally invasive surgery is often performed laparoscopically, requiring only keyhole-size incisions through which a tiny camera and instruments can be inserted to make repairs. Minimally invasive robotic surgery (similar to laparoscopy, but surgeons use a controller to move instruments) is also an option. With minimally invasive surgery, patients are back to their regular activity within two weeks. Open surgery is the other treatment option  — recovery takes four to six weeks.

Abdominal Hernias

For both men and women, repair is recommended for most abdominal hernias. The exception is if you have risk factors for complications or hernia recurrence, such as obesity or poorly controlled diabetes. It’s better to get those conditions under control before surgery. Some patients do not have symptoms and may decide to delay repair after discussion of the risks and benefits with their surgeon.

Surgical options and recovery time for ventral hernias vary widely because these hernias come in all shapes and sizes. A small umbilical or incisional hernia can often be treated on an outpatient basis. However, repairing more complicated hernias may require a hospital stay of one to five days.

Q: What are the signs of a hernia emergency?

A: When most hernias start, the internal tissue that pushes through the muscle gap is usually fat. But it’s also possible for part of the bowel to protrude through the opening. The risk of this is very low, but when it happens, it needs emergency repair. Seek immediate medical attention if you have:

• A painful bulge that doesn’t reduce in size when you lay down and rest
• Worsening pain
• Nausea and/or vomiting
• Difficulty having a bowel movement
• Racing heart rate

For more information about hernias and their treatment, visit the Johns Hopkins Comprehensive Hernia Center .

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ABDOMINAL HERNIAS

Jul 21, 2014

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ABDOMINAL HERNIAS. Fadi J. Zaben RN MSN. Definition:. A hernia is a protrusion of an organ, tissue, or structure through the wall of the cavity in which it is normally contained. It is often called a rupture.‌ The abdomen is a common place for hernias to occur .

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Presentation Transcript

ABDOMINAL HERNIAS Fadi J. Zaben RN MSN

Definition: • A hernia is a protrusion of an organ, tissue, or structure through the wall of the cavity in which it is normally contained. • It is often called a rupture.‌ • The abdomen is a common place for hernias to occur. • Hernias may be present at birth due to incomplete closure of a structure, or they may develop later due to increased abdominal pressure pushing against a weakened area of muscle or its fibrous sheath (fascia).

Etiology: • Results from congenital or acquired weakness (traumatic injury, aging) of the abdominal wall. • May result from increased intra-abdominal pressure due to heavy lifting, obesity, pregnancy, straining, coughing, or proximity to tumor.

Classification: • Classification by Site. • Classification by Severity.

Classification by Site: • Inguinal Hernia into the inguinal canal (more common in males). • Indirect inguinal: • It occurs due to a weakness of the abdominal wall at the point through which the spermatic cord emerges in the male and the round ligament in the female. • Through this opening, the hernia extends down the inguinal canal and often into scrotum or labia. • Direct inguinal: • Itpasses through the posterior inguinal wall; more difficult to repair than indirect inguinal hernia.

Continue…….. • Femoral Hernia into the femoral canal, appearing below the inguinal ligament. • Umbilical Intestinal Protrusion at the umbilicus due to failure of umbilical orifice to close. Occurs most often in obese women, children, and in patients with increased intra-abdominal pressure from cirrhosis and ascites.

Continue….. • Ventral or Incisional Intestinal Protrusion due to weakness at the abdominal wall; may occur after impaired incisional healing due to infection or drainage. • Peristomal Hernia through the fascial defect around a stoma and into the subcutaneous tissue.

Classification by Severity: • Reducible Hernia: the protruding mass can be placed back into abdominal cavity. • Irreducible Hernia: the protruding mass cannot be moved back into the abdomen.

Continue…. • Incarcerated Hernia: an irreducible hernia in which the intestinal flow is completely obstructed. • Strangulated Hernia: an irreducible hernia in which the blood and intestinal flow are completely obstructed; develops when the loop of intestine in the sac becomes twisted or swollen and a constriction is produced at the neck of the sac.

Risk Factors for Abdominal Hernia: • Abdominal surgery. • Chronic constipation. • Chronic cough. • Enlargement of the prostate or other conditions that can lead to straining to urinate. • Family history of hernias. • Lifting or pushing heavy objects. • Male gender. • Nutritional deficiencies. • Obesity. • Overexertion. • Smoking. • Undescended testes.

Clinical Manifestations: • Bulging over herniated area appears when patient stands or strains, and disappears when supine. • Pain. • Hernia tends to increase in size and recurs with intra-abdominal pressure. • Strangulated hernia presents with pain, vomiting, swelling of hernial sac, lower abdominal signs of peritoneal irritation, fever.

Diagnostic Evaluation: Based on clinical manifestations: • Physical Examination (P/E). • Abdominal X-rays: reveal abnormally high levels of gas in the bowel. • Laboratory studies (complete blood count, electrolytes)may show hemoconcentration (increased hematocrit), dehydration (increased or decreased sodium), and elevated white blood cell (WBC) count, if incarcerated.

Management: • Mechanical (non surgical) treatment. • Surgical treatment.

Mechanical Treatment: • It is for reducible hernia only. • Truss: • It is an appliance with a pad and belt that is held snugly over a hernia to prevent abdominal contents from entering the hernial sac. • A truss provides external compression over the defect. • It should be removed at night and reapplied in the morning before patient arises. • It is used only when a patient is not a surgical candidate.

Continue….. • Peristomal hernia is often managed with a hernia support belt with Velcro, which is placed around an ostomy pouching system (similar to a truss). • Conservative measures: • No heavy lifting. • NO straining at stool. • And any measures that would increase intra-abdominal pressure should be a void.

Surgical Treatment: • It recommended to correct hernia before strangulation occurs, which then becomes an emergency situation. • Herniorrhaphy: removal of hernial sac; contents replaced into the abdomen; layers of muscle and fascia sutured. • Laparoscopic herniorrhaphyis a possibility and often performed as outpatient procedure. • Hernioplasty involves reinforcement of suturing (often with mesh) for extensive hernia repair. • Strangulated hernia requires resection of ischemic bowel in addition to repair of hernia.

Complications: • Bowel obstruction. • Recurrence of hernia.

Nursing Assessment: • Ask patient if hernia is enlarging and uncomfortable, reducible or irreducible; determine relationship to exertion and activities. • Assess bowel sounds and determine bowel pattern. • Determine if patient is exhibiting signs and symptoms of strangulation

Nursing Diagnoses: • Chronic Pain related to bulging hernia (mechanical). • Acute Pain related to surgical procedure. • Risk for Infection related to emergency procedure for strangulated or incarcerated hernia.

Nursing Interventions: Achieving Comfort: • Fit patient with truss or belt when hernia is reduced, if ordered. • Trendelenburg's position may reduce pressure on hernia, when appropriate. • Emphasize to patient to wear truss under clothing and to apply before getting out of bed when hernia is reduced. • Give stool softeners as directed. • Evaluate for signs and symptoms of hernial incarceration or strangulation. • Insert NG tube for incarcerated hernia, if ordered, to relieve intra-abdominal pressure on herniated sac.

Relieving Pain Postoperatively: • Have the patient splint the incision site with hand or pillow when coughing to lessen pain and protect site from increased intra-abdominal pressure. • Administer analgesics, as ordered. • Teach about bed rest, intermittent ice packs, and scrotal elevation as measures used to reduce scrotal edema or swelling after repair of an inguinal hernia. • Encourage ambulation as soon as permitted. • Advise patient that difficulty in urinating is common after surgery; promote elimination to avoid discomfort, and catheterize if necessary.

Preventing Infection: • Check dressing for drainage and incision for redness and swelling. • Monitor for other signs and symptoms of infection: fever, chills, malaise, diaphoresis. • Administer antibiotics, if appropriate.

Patient Education and Health Maintenance: • Advise that pain and scrotal swelling may be present for 24 to 48 hours after repair of an inguinal hernia. • Apply ice intermittently. • Elevate scrotum, and use scrotal support. • Take medication prescribed to relieve discomfort. • Teach to monitor self for signs of infection: pain, drainage from incision, temperature elevation. Also, report continued difficulty in voiding. • Inform that heavy lifting should be avoided for 4 to 6 weeks. Athletics and extremes of exertion are to be avoided for 8 to 12 weeks postoperatively, per provider instructions.

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• Digestive Disorders

Guide to Hernias

What Is a Hernia?

Even if you don’t have six-pack abs, your belly still has walls of muscle that support you, help you move, and hold things in place inside you. A hernia happens when part of your body squeezes through a weak spot or opening in a muscle wall. It’s like an inner tube bulging through a hole in a worn-out tire. You can get different kinds of hernias, but most of them happen somewhere between your hips and chest.

Typically, hernias don’t hurt -- you see a bulge or lump in your belly or groin. Sometimes, you only see the bulge when you laugh, cough, or strain, like when you lift a heavy object. Often, you can press it back into place. You may also notice:

• The bulge gets bigger over time.
• You have a feeling of fullness.
• Pain, pressure, or a dull ache around the bulge
• Pain when you lift something

Inguinal Hernias

This is the most common kind of hernia. It happens most often in men, but women sometimes get them during pregnancy. It’s when fat or a loop of intestine pushes into your groin through a weakness in your lower belly. You may be born with it, or the problem can come with:

• Age, as muscles shrink over time
• Chronic coughing, as with someone who smokes
• Strain from physical activity or going to the bathroom

Femoral Hernia

These are like inguinal hernias, but in a different part of the groin. Women are more likely to get them. They’re not common, but they can be dangerous -- you may not notice any symptoms unless a muscle squeezes the hole shut while the intestine is poking through (called strangulation). In that case, the lump will be hard and tender and you might have severe belly pain, nausea, or vomiting. If you have these symptoms, get medical help right away.

Ventral Hernias

You get these hernias between your belly button and chest when some tissue or intestine pops through your belly’s muscles. You may be more likely to get one if you:

• Are very overweight
• Have a cough that doesn’t go away
• Lift heavy objects, like with construction work
• Strain hard when you go the bathroom
• Throw up often

Incisional Hernias

Incisional hernias are fairly common for people who’ve had surgery on their bellies. They happen when tissue squeezes through the surgery wound before it totally heals. You’re more likely to get one if you run into problems as you heal, like an infection. The only way to fix them is with another surgery, but they’re often hard to treat.

Hiatal Hernias

With this kind of hernia, part of your stomach pops through your diaphragm and into your chest. (Your diaphragm is a sheet of muscle between your belly and chest.) You won’t see a bulge, but you might get heartburn, chest pain, and a sour taste in your mouth. People 50 and older and pregnant women are more likely to have them. Pregnancy can put pressure on the belly and weaken its muscles. They’re typically treated with medication and lifestyle changes, like having several smaller meals rather than three large ones or not lying down within 3 hours of eating.

Hernias in Children

When kids get hernias, they’re typically inguinal or umbilical hernias. Inguinal hernias are most common in babies born early and in boys born with a testicle that hasn’t dropped into the scrotum. Umbilical hernias happen right around the belly button. They don’t usually hurt and may just look like an outie belly button. They often go back into place on their own by age 2.

When to See a Doctor

While a hernia may start out as a harmless bulge, it can get bigger and start to hurt. In some cases, it can even be life-threatening. So even if it doesn’t seem like a big deal, it’s best to see your doctor if you have symptoms of a hernia, like a lump or bulge you can’t explain.

When to Go to the Emergency Room

If a loop of intestine gets trapped in a hernia, you have a serious problem called incarceration. It blocks the flow of waste through your body. If it’s trapped tightly, the intestine’s blood flow can get cut off. Get help right away if you have a hernia and these symptoms:

• Bulge is dark, purple, or red.
• You can’t pass gas or poop.
• You have a fever.
• Pain that quickly gets worse.
• You’re throwing up or have an upset stomach.

Most of the time, your doctor can tell you have a hernia with just a physical exam. They may ask you to stand and cough to make the hernia easier to see, but that’s usually it. If your doctor’s not totally sure, you might have some imaging tests to get a better look. These might include:

• Ultrasound: High-frequency sound waves make an image of your internal organs.
• Computerized tomography (CT): X-rays are taken at different angles and put together to make a more complete picture.
• Magnetic resonance imaging (MRI): This uses a powerful magnet and radio waves to get a detailed view.

Treatment: Watchful Waiting

You don’t always need to treat hernias. Umbilical hernias in kids may heal on their own, so your doctor may suggest you wait until around age 4 for treatment. For adults, especially if surgery could be risky for you, your doctor may suggest just keeping an eye on it as long as the hernia’s small and not causing any major problems for you.

Treatment: Surgery

The most common treatment for any hernia is surgery to put in a mesh that helps support the wall around your belly. You may have open surgery, where your doctor makes a long opening in your skin, or you may get laparoscopic surgery, which uses a few smaller openings. You may heal quicker from laparoscopic surgery, but some studies show the hernia may be a little more likely to come back.

Can a Truss Help?

Not really. This cloth device that’s worn like a binder around your middle or like underwear won’t make you better. You may get one to wear for a short while after surgery -- it may make you more comfortable -- but that’s likely the only time your doctor will suggest it. The same goes for tape, bandages, and anything else to hold a hernia in place -- they won’t heal the hernia or prevent more serious problems.

How to Prevent a Hernia

You can lower your odds of getting a hernia if you:

• Talk to your doctor if you have a cough or sneezing that won’t go away. Quitting smoking helps.
• Eat fruits, veggies, and whole grains to keep yourself regular. 
• Stay at a healthy weight with diet and exercise.
• Use good form when you do physical activity. For example, when lifting a heavy object, bend from your knees instead of your waist.

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Hernia PPT: Definition, Types, Causes and Prevention

Hernia PPT: Definition, Types, Causes and Prevention Free Download: When an internal organ or other bodily part protrudes through the wall of muscle or tissue that typically surrounds it, a hernia arises. The majority of hernias develop in the abdominal cavity, between the chest and hips. Inguinal hernia, femoral hernia, Umbilical hernia, and Hiatal hernia are the most prevalent types of hernia.

Inguinal and femoral hernias are caused by weakening muscles that may have existed from birth or are caused by age and frequent stresses on the abdomen and groin regions. Adults can develop an umbilical hernia by straining the abdomen region, being overweight, having a persistent cough, or giving delivery. However, the etiology of hiatal hernias is unknown, but age-related diaphragm weakness or abdominal pressure may play a role.

Table of Content

• Introduction
• Types of Hernia
• Symptoms of Hernia
• Causes of Hernia
• Complications of Hernia
• Prevention of Hernia
• Diagnosis of Hernia
• Treatment of Hernia

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Introduction, case report, conflict of interest statement.

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Pure laparoscopic bilateral arcuate line hernia repair (with video)

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J Rappoport, J Carrasco, B Gamez, Pure laparoscopic bilateral arcuate line hernia repair (with video), Journal of Surgical Case Reports , Volume 2024, Issue 8, August 2024, rjae347, https://doi.org/10.1093/jscr/rjae347

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An arcuate line hernia is a generally asymptomatic, ascending protrusion of intraperitoneal structures over the linea arcuata. Arcuate line herniae are scarcely reported in the literature. Only a few publications were found. No clear descriptions of the techniques for repair have been published either. We aim to provide diagnostic images and illustrate our method to repair this hernia.

Arcuate line hernia (ALH) is a rare pathology characterized by herniation of the peritoneum ascending from the arcuate line, passing between the rectus abdominis muscle and the aponeurotic fascia that covers it posteriorly. The true prevalence of ALH is unknown. However, it is thought that this is an underdiagnosed pathology in part because it presents mainly asymptomatically [ 1 ].

It has been reported in isolation and bilaterally or in association with other abdominal wall hernias. ALH complication has been reported due to strangulation of intestinal loops. Association with increased BMI, diabetes mellitus, and aortic aneurysm has been reported in patients with symptomatic AHL.

The diagnosis of this pathology is exceptional. Its knowledge and dissemination are essential, given the possible surgical complications that derive from this pathology.

The patient was a 49-year-old healthy female. She presented with a right-sided paramedian abdominal bulge at the level of the umbilicus. She noticed this swelling 4 years ago because of recurrent abdominal pain in the area. There have been no complicating episodes requiring immediate surgical resolution. On examination, we found a paramedian swelling in the right abdominal wall, which increased during the Valsalva manoeuvre.

A computed tomography (CT) was performed and revealed the presence of a small-bowel loop between the posterior surface of the right rectus muscle and the peritoneum over the ALH, configuring the presence of type III ALH [ 2 ]. Surgery was performed with laparoscopic technique. Pneumoperitoneum at 15 mm Hg with a Veress needle at the left Palmer point, one puncture without incident. T1, 10 mm left flank, optiview technique, camera is inserted checking Veress needle in good position without incidental injuries. T2, 5 mm in the left upper quadrant, T3, 10 mm in the left iliac fossa, T4, 5 mm in the left lower quadrant. All under direct vision without incident. At initial laparoscopic exploration, a five cm wide defect was observed in the posterior surface of the right abdominal rectus muscle, constituting a defect with the appearance of a peritoneum pocket in the abdominal wall. The same defect was found at the left side. We also found a large amount of fat covering the midline in the umbilical area, without the presence of umbilical hernia. The defects were closed using v-lock 3–0 plus with continue stiches. An intraperitoneal underlay mesh (Symbotex®, Medtronic) of 10 x 15 cm was placed over the defect and fixated with an absorbable fixation system (Absorba Tack ®, Medtronic).

Total operative time was 150 minutes. The estimated blood loss was less than 10 ml. After an uneventful postoperative course, patient was discharged the next day without complications.

An ALH is a rare pathology, whose clinical presentation and pathophysiology have not been clarified, and there are currently no management or follow-up recommendations. The ubication of the arcuate line (AL) is highly variable. Monkhouse [ 3 ] in a study carried out on cadavers, on anatomical variations of the abdominal wall, described that the apex of the AL was on some occasions as high as the umbilicus and on others almost at the level of the pubis, thus forming little more than a foramen for the passage of the inferior epigastric vessels. In addition, in his study he found that the medial end is usually lower than the lateral one, concluding that a symmetrical disposition of the AL is a rarity. We believe that these anatomical variations undoubtedly affect the clinical presentation of this pathology, since they contribute to the weakness of the abdominal wall in different areas.

Regarding the classification proposed by Coulier [ 2 ] into three types, it allows to standardize the diagnosis and with it also the treatment scheme. Patients with ALH type 1 do not require surgical treatment, however patients with HLA type 2, and especially type 3, can be symptomatic and even present with acute complications, so surgical treatment is essential.

A review of literature made by Bloemen [ 1 ] makes it clear that there is a significant percentage of patients who consult the emergency department and leave without a diagnosis presented ALH as a pathology that could explain their pain. This at least obliges us to consider this diagnosis within the differential diagnosis of a patient with predisposing factors for hernias and who presents abdominal pain in whom the usual studies do not show a defined etiology. The CT analysis is especially important in these cases and both the radiologist, and the clinician should suspect this entity and carefully review the images, since the abdominal wall is not usually considered as an etiology of the pathology.

The proposed therapeutic alternatives range from open, laparoscopic [ 4 ], or robotic surgery, including mixed techniques. There seems to be a certain consensus that laparoscopic techniques offer advantages over open ones, by maintaining the integrity of the wall, and allowing greater diagnostic accuracy, unilaterally or bilaterally, as well as evaluating the presence of other abdominal wall hernias.

Further study of the pathology is necessary to determine management and follow-up recommendations.

None declared.

Bloemen A , Kranendonk J , Sassen S ., et al.    Incidence of arcuate line hernia in patients with abdominal complaints: radiological and clinical features . Hernia J Hernias Abdom Wall Surg   2019 ; 23 : 1199 – 203 . https://doi.org/10.1007/s10029-019-02067-8 .

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Coulier B . Multidetector computed tomography features of linea arcuata (arcuate line of Douglas) and linea arcuata hernias . Surg Radiol Anat   2007 ; 29 : 397 – 403 . https://doi.org/10.1007/s00276-007-0218-0 .

Monkhouse WS , Khalique A . Variations in the composition of the human rectus sheath: a study of the anterior abdominal wall . J Anat   1986 ; 145 : 61 – 6 .

Sayers A , Laliotis A . Laparoscopic repair of a rare abdominal wall deformity and review of the literature . Cureus   2021 ; 13 : e18856 . https://doi.org/10.7759/cureus.18856 .

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