Updated: 4/13/2020

Hernias

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Evidence
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Snapshot
  • A 35-year-old man presents to the general surgeon's office with pain in his right groin. He recently noticed a bulge in this region after performing heavy weight lifting at the gym. The pain and bulge comes and goes sporadically and he thinks it is associated with his workouts. He denies any change in bowel or bladder function. 
Overview

 
 
Introduction
  • Clinical definition
    • a protrusion of peritoneum through an opening or weakness into another body cavity
  • Increased risk with structural weakness or increased intra-abdominal pressure
  • Classification based on the anatomy of Hesselbach's triangle
    • borders
      • lateral - inferior epigastric artery
      • medial - lateral border of rectus abdominis
      • inferior - inguinal ligament
  • Types
    • indirect inguinal
      • travels the entire length of the inguinal canal following descent path of the testes
        • enters internal inguinal ring lateral to inferior epigastric artery and exits external inguinal ring
        • may enter scrotum
      • covered by all 3 layers of spermatic fascia
      • most commonly seen in male infants
        • due to patent processus vaginalis
          • peritoneal connection between inguinal canal and tunica vaginalis
    • direct inguinal 
      • bulges through the inguinal (Hesselbach's) triangle
        • directly through abdominal wall (transversalis fascia) through the external inguinal ring 
        • medial to inferior epigastric artery
      • covered only by external spermatic fascia
      • most commonly in older men
    • femoral
      • protrudes below inguinal ligament through femoral canal
        • lateral to pubic tubercle
      • more common in women
    • umbilical
      • most commonly in adults
        • associated with pregnancy, ascites, and obesity
    • incisional
      • occurs at previous surgical sites 
Treatment
  • Indirect and direct inguinal hernia
    • surgical placement of mesh over Hesselbach's triangle/inguinal canal and reinforce abdominal wall 
  • Femoral
    • surgical joining of Cooper's ligament to transversalis fascia
  • Incisional 
    • associated with previous incision through the fascia 
    • goal is to achieve primary fascial closure with mesh reinforcement 
    • number of different repairs are possible including mesh underlay, inlay, overlay or bridging repairs 
Prognosis, Prevention, and Complications
  • Incarceration and strangulation
    • seen in all hernia types where hernia contents get stuck within the defect
    • the larger the hernia defect the smaller risk of incarceration
      • femoral hernia has greatest risk
 

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Questions (5)
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(M1.GI.14.62) A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process? Tested Concept

QID: 106455
1

Femoral hernia

17%

(33/196)

2

Hydrocele

63%

(124/196)

3

Varicocele

10%

(20/196)

4

Diaphragmatic hernia

3%

(5/196)

5

Testicular torsion

4%

(8/196)

M 1 E

Select Answer to see Preferred Response

(M1.GI.13.40) A 68-year-old man presents to his primary care physician complaining of bulge in his scrotum that has enlarged over the past several months. He is found to have a right-sided inguinal hernia and proceeded with elective hernia repair. At his first follow-up visit, he complains of a tingling sensation on his scrotum. Which of the following nerve roots communicates with the injured tissues? Tested Concept

QID: 106254
1

L1-L2

26%

(18/68)

2

L2-L3

4%

(3/68)

3

L4-L5

9%

(6/68)

4

S1-S3

24%

(16/68)

5

S2-S4

31%

(21/68)

M 4 E

Select Answer to see Preferred Response

(M1.GI.13.39) A 72-year-old man presents to his primary care physician complaining of pain and bulging in his groin. He is otherwise healthy and has never had surgery. He is referred to a general surgeon, and is scheduled for an elective hernia repair the following week. On closer inspection in the operating room, the surgeon notes a hernia sac that protrudes through the external inguinal ring, bypassing the inguinal canal. Which of the following accurately describes this patient's condition? Tested Concept

QID: 106249
1

Direct hiatal hernia

4%

(2/54)

2

Indirect femoral hernia

11%

(6/54)

3

Direct incisional hernia

0%

(0/54)

4

Isolated rectus diastasis

0%

(0/54)

5

Direct inguinal hernia

78%

(42/54)

M 2 E

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Evidence (4)
Topic COMMENTS (15)
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