Alnahrain University

College of Medicine
Department of Surgery
3rd Stage, 2nd Semester, 2019-2020

Clinical preview about

hernia: it’s types, clinical
presentation, diagnosis and
repair

By
Afnan Adel Mohammed Ali
li Ϡ ϋ Ϊ i iϨ
Clinical preview about hernia: It’s types, clinical presentation, diagnosis and repair Page 1 of 10

CONTENTS
Abstract 1
Introduction 2
Causes and pathogenesis 2
Clinical history and diagnosis in hernia cases 2
Classification 3
Inguinal Hernia in Adults 3
Inguinal Hernia in Children 3
Femoral Hernia 3
Epigastric Hernia 4
Umbilical Hernia 4
Spieghelian Hernia 5
Obturator Hernia 5
Perineal Hernia 5
Hernia Lumbalis 6
Incisional or Recurrent Hernia 6
Traumatic hernia 6
Parastomal hernia 6
Gluteal and sciatic hernias 6
Types of hernia by complexity 7
Treatment 7
Conclusion 8
References 8

FIGURES

Figure 1 Suggested inguinal hernia treatment algorithm 3

Figure 2 Full circumference gangrenous segment of the small intestine, caused by strangulation. 4
Figure 3 Epigastric hernia (left) and umbilical hernia (right). 5
Figure 4 A Spigelian hernia as seen (A) clinically and (B) on CT imaging 5
Figure 5 Incisional hernia (left) and lumbar hernia (right) 6
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Abstract

A hernia is an outpouching of the parietal peritoneum through a preformed or secondarily

established hiatus. Many structures pass into and out of the abdominal cavity creating
weakness which can lead to hernia formation. Failure of normal development may lead to
weakness of the abdominal wall. Weakness of abdominal muscles may be the result of sharp
trauma. The pathogenesis of hernias is multifactorial. Congenital hernias are preformed
hernial openings caused by incomplete closure of the abdominal wall (e.g., persistent
processus vaginalis), while, in acquired hernias, the cause is increasing dehiscence of fascial
structure with accompanying loss of abdominal wall strength. The most common types of
hernias are: Inguinal hernias, femoral hernias, incisional hernias, umbilical hernias, and
epigastric hernias.
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Introduction
A hernia is an outpouching of the parietal peritoneum through a preformed or secondarily
established hiatus. If the hernia extends beyond the abdominal cavity and is thus visible on
the surface of the body, it is defined as an external hernia. If the outpouching is limited to
peritoneal pockets, it is known as an internal hernia. An intermediate position is taken by the
interparietal hernias of the abdominal wall. Hernias may include intra- and retroperitoneal
organs, either permanently or intermittently. Depending on the size of the outpouching, we
speak of complete (total) or incomplete (partial) hernias. Based on their formation, we
distinguish between congenital (e.g., umbilical hernias and indirect inguinal hernias, if the
processus vaginalis is open) and acquired hernias (e.g., direct, femoral, and incisional hernias)
(Conze, Klinge and Schumpelick, 2001).

Causes and pathogenesis

The only natural weaknesses caused by inadequate muscular strength are the lumbar
triangles and the posterior wall of the inguinal canal. Many structures pass into and out of the
abdominal cavity creating weakness which can lead to hernia formation. Failure of normal
development may lead to weakness of the abdominal wall. Weakness of abdominal muscles
may be the result of sharp trauma. Most commonly, this results from abdominal surgery but
also occurs after stabbing. The sudden presence of a mass in the rectus muscle may be a
rectus sheath haematoma. Primary muscle pathology and neurological conditions can lead to
muscle weakness and occasionally present to the surgeon as a ‘hernia’ (Williams et al.,
2018).
The pathogenesis of hernias is multifactorial. Congenital hernias are preformed hernial
openings caused by incomplete closure of the abdominal wall (e.g., persistent processus
vaginalis), while, in acquired hernias, the cause is increasing dehiscence of fascial structure
with accompanying loss of abdominal wall strength. The develop typically in locations
where larger blood vessels or the spermatic cord lie, or where previous incisions were made.
Different etiological factors, such as increased intra-abdominal pressure (in pregnancy,
intra-abdominal tumors, chronic obstructive lung disease, ascites, chronic intestinal
obstruction, and adiposity), or pathological changes in connective tissue of the abdominal
wall, are blamed, without conclusive significance (Conze, Klinge and Schumpelick, 2001).
Clinical history and diagnosis in hernia cases CHECKS
Patients are usually aware of a lump on the abdominal Reducibility
wall under the skin. Self-diagnosis is common. The hernia is Cough impulse
usually painless but patients may complain of an aching or Tenderness
Overlying skin colour changes
heavy feeling. Sharp, intermittent pains suggest pinching of
Multiple defects/contralateral
tissue. Severe pain should alert the surgeon to a high risk of side
strangulation. One should determine whether the hernia Signs of previous repair Scrotal
reduces spontaneously or needs to be helped. The patient content for groin hernia
should be asked about symptoms which might suggest bowel Associated pathology
obstruction. It is important to know if this is a primary hernia
or whether it is a recurrence after previous surgery. EXAMINATION
Recurrent hernia is more difficult to treat and may require a • A swelling with a cough
different surgical approach. General questions regarding the impulse is not necessarily
a hernia
cardiac and respiratory systems are necessary to assess a • A swelling with no cough
patient’s anaesthetic risk. In a male with a groin hernia, impulse may still be a
history of prostatic symptoms indicates a high risk of hernia
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postoperative urinary retention. Intake of anticoagulants such as warfarin is important as this

impacts on future surgery. Many hernia operations can be performed as a day case or single
overnight stay, so that suitability for such treatment needs to be assessed, including home
support, distance from the hospital, mobility levels, etc. (Williams et al., 2018).

Classification
Hernias can be classified according to their anatomical location (Conze, Klinge and
Schumpelick, 2001).
Inguinal Hernia in Adults
Inguinal hernia in the adult is the most common type of
hernia (75%) and occurs mainly in males. Indirect herniation
occurs through a persistent processus vaginalis (Bowel enters
the inguinal canal via the deep inguinal ring) (60–70%) and
direct herniation (Bowel enters the inguinal canal “directly”
through a weakness in the posterior wall of the canal, termed
Hesselbach’s triangle) (30–40%). In up to 15% of patients,
they occur bilaterally.
Inguinal Hernia in Children
Inguinal hernia is the most common surgical disease in children. In almost every case,
inguinal hernias in children result from an abnormally persistent processus vaginalis, that
remains open in 80–90% of neonates and is still present in 50% at the end of the first year.
This persistence does not imply the presence of a hernia, but means simply a potential for
hernia formation. Because of a high risk of incarceration (Figure 2), especially testis or ovar,
particularly at premature age or under 3 months, an operation should not be delayed. The
main management procedure is high ligation of the hernial sac. In girls, the hernial sac
should be sutured under the obliquus internus muscle for fixation of the rotundum ligament.

Figure 1 Suggested inguinal hernia treatment algorithm

Femoral Hernia
Five to seven percent of all hernias are femoral hernias. They occur predominantly in
females. Here, the herniation passes under the inguinal ligament through the lacuna vasorum
medially of the v. femoralis. Management involves operative therapy by crural, inguinal, or
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preperitoneal approach for direct fixation of the inguinal ligament to the fascia pectinea of
the pubic bone. Of late, reinforcement with mesh is advised.

Figure 2 Full circumference gangrenous

segment of the small intestine, caused by
strangulation.

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.

Epigastric Hernia
This type of hernia presents herniation into preformed defects of the linea alba between
xiphoid and umbilicus. Usually, the hernia sac content is preperitoneal fatty tissue. There is a
male predominance. Defects of the fascia may vary in diameter from several centimeters to
only a few millimeters. The larger ones usually readily reducible, whereas the smaller ones
often became in-carcerated. Multiple fascial defects are present in between 20 to 25% of
individuals. Clinically, the majority of epigastric hernias (75%) are asymptomatic. Vague
upper abdominal pain and nausea associated with epigastric tenderness may be present.
Incarceration is common, especially in smaller hernias, but strangulation is unusual.
Operative management aims at reposition of the hernia sac contents and direct closure of the
hernial opening with a continuous suture. Due to high recurrence rates, tension-free hernia
repair with mesh is becoming more common.
Umbilical Hernia
The umbilicus is a natural hernial opening in the abdominal wall. It can develop a hernia
at any age. In children most umbilical hernias are asymptomatic beside the obvious cosmetic
defect. Infantile umbilical hernias rarely enlarge over time and will disappear in 90% of
children by the age of 2 years. The spontaneous resolution appears to be directly influenced
by the size of the umbilical ring. Defects with an umbilical ring larger than 1.5 cm are
unlikely to resolve spontaneously. Complications such as strangulation of omentum or
intestine and evisceration are seldom and occur approximately in 4% of cases. Indication for
surgical repair are occurrence of complaints and complications or a persistence of the hernia
beyond the age of 2 years. If the fascial defect is less then 1.5 cm in diameter or is
asymptomatic a herniorrhaphy may be delayed until the child is 5 years old. Umbilical
hernias in adults are indirect herniations through the umbilical canal, and there have a high
tendency to incarce-rate and strangulate and do not resolve spontaneously. Most of these
patients are women.
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Figure 3 Epigastric hernia (left) and umbilical hernia (right).

Spieghelian Hernia
Hernias of the linea semilunaris occur usually at the intersection with the linea
semicircularis (arcuata). The majority of hernias are located below the umbilicus. With equal
frequency on the left and right side of the body and bilateral in about 10% of the cases. The
symptoms vary considerably, including abdominal pain, a mass in the anterior abdominal
wall or signs of incarceration with or without intestinal obstruction. The therapy is always
surgical.

Figure 4 A Spigelian hernia as seen (A) clinically and (B) on CT imaging

Obturator Hernia
Obturator hernias are internal herniations through the obturator foramen, bordered by the
obturator vessels and nerve. Typical symptoms are intestinal obstruction and the
Howship-Romberg sign (pain extending down the inner surface of a thigh to the knee
relieved by flexion of the thigh) and a history of previous attacks. When they case symptoms,
they are almost always incarcerated, usually on the right side and often combined with a
femoral hernial. Management includes a transperitoneal or preperitoneal approach and hernia
orifice closure with direct suture or mesh.
Perineal Hernia
Perineal hernias are primary or secondary herniations of the pelvic floor that appear para-
or retrorectally between the levator ani and coccygeal muscles. Primary hernias occur mostly
in females, secondary hernias in both females and males and rarely with an incarceration.
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Management includes transperitoneal or combined abdominal and perineal approaches and

direct suture or mesh.

Hernia Lumbalis
Hernia lumbalis (lumbar hernia) presents abdominal wall or retroperitoneal outpouchings
between the 12th rib and the iliac crest. The hernial orifice is in the muscles of the lumbar
area.
Incisional or Recurrent Hernia
Any recurrent hernia, either inguinal, epigastric, umbilical, or at any other location, must
be understood as an incisional hernia. Primary incisional herniation after laparotomy
develops in up to 15% of cases, depending on the time of follow-up, and is the most common
postoperative complication. Any factor that impairs normal wound healing may contribute
to the development of incisional hernia. Postoperative wound infection is considered to be
one of the most important risk factor. At present, two different major principles of repair are
established: mesh-free hernia repair (conventional methods) and tension-free hernia repair
with mesh.

Figure 5 Incisional hernia (left) and lumbar hernia (right)

Traumatic hernia
These hernias arise through non-anatomic defects caused by injury.
Parastomal hernia
When surgeons create a stoma, such as a colostomy or ileostomy, they are effectively
creating a hernia by bringing bowel out through the abdominal wall.
Gluteal and sciatic hernias
Both of these hernias are very rare. A gluteal hernia passes through the greater sciatic
foramen, either above or below the piriformis. A sciatic hernia passes through the lesser
sciatic foramen.
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Types of hernia by complexity

1. Occult - not detectable clinically; may cause severe pain.
2. Reducible - a swelling that appears and disappears.
3. Irreducible - a swelling that cannot be replaced in the abdomen, high risk of
complications.
4. Strangulated - painful swelling with vascular compromise, requires urgent Surgery.
5. lnfarcted - when contents of the hernia have become gangrenous, high
6. Mortality.

Treatment
The only way to
effectively treat a hernia is through surgical
repair. However, whether or not patient
needs surgery depends on the size of the
hernia and the severity of symptoms. In some
cases simply monitor hernia for possible
complications. This is called watchful
waiting.
There are 2 main ways surgery for hernias
can be carried out:
• Keyhole (laparoscopic) surgery: this is a
less invasive, but more difficult,
technique where several smaller cuts are
made, allowing the surgeon to use
various special instruments to repair the
hernia.
• Open repair: Surgeons use this procedure
with or without surgical mesh. Most open
hernia repairs use general anesthesia.
Open anterior procedure, the Shouldice
repair with local anesthesia is the
standard mesh-free procedure for
uncomplicated primary, unilateral hernias
(Conze, Klinge and Schumpelick, 2001).
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Conclusion
Most hernias occur when part of the bowel or peritoneum pushes through a gap in the
abdominal wall. The peritoneum is the membrane that lines the abdominal cavity and
(completely or partly) encloses most of the organs in the abdomen. The protruding pouch,
called the hernia or hernial sac, may contain parts of organs such as the bowel or stomach. A
bulge can usually be seen from the outside. Whether or not a hernia causes problems will
depend on where it is and how big it is. They don't always cause symptoms. But they might
lead to pain, burning, a feeling of pressure or a pulling sensation, especially during physical
strain. Some people only have symptoms when they tense their abdominal (tummy) muscles
a lot. Two factors that increase the risk of hernias are weak abdominal muscles and weak
connective tissue. Some people are born with weak connective tissue, whereas in others it
becomes weaker in older age. Illnesses or surgery can also weaken tissue and muscles. If left
untreated, hernias can get bigger over time, become more visible and cause more problems,
sometimes the hernia sac becomes constricted and may, for instance, trap part of the bowel.
Surgery is the only treatment option for hernias (Information et al., 2020).

References

1. Conze, J., Klinge, U. and Schumpelick, V. (2001). Hernias.

2. Information, N.C. for B., Pike, U.S.N.L. of M. 8600 R., MD, B. and Usa, 20894
(2020). Hernias: Overview. Institute for Quality and Efficiency in Health Care (IQWiG).
[ncbi].
3. TeachMeSurgery. (2017). Abdominal Hernia [teachmesurgery].
4. Williams, N.S., C J K Bulstrode, P Ronan O’connell, Bailey, H. and Love
(2018). Bailey & Love’s short practice of surgery. Boca Raton: Crc Press.