Protrusion of abdominal contents through a fascial defect — risk stratified by reducibility, incarceration, and strangulation.
Also known as: hernia, inguinal hernia, hiatal hernia, umbilical hernia, femoral hernia, ventral hernia, incisional hernia
Overview
Protrusion of an organ or tissue through an abnormal opening in the abdominal wall or diaphragm. Classified by location (inguinal, femoral, umbilical, ventral/incisional, hiatal) and by clinical status: reducible, incarcerated (irreducible), or strangulated (compromised blood supply).
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Risk factors
- Chronic increases in intra-abdominal pressure: chronic cough, constipation, BPH with straining, heavy lifting, ascites, pregnancy
- Obesity (especially hiatal and ventral)
- Prior abdominal surgery (incisional/ventral)
- Connective tissue disorders (Ehlers-Danlos, Marfan)
- Smoking and malnutrition (impair collagen and wound healing)
- Male sex, age, family history (inguinal)
Pathophysiology
A combination of congenital patency (e.g., processus vaginalis for indirect inguinal) and acquired fascial weakness allows abdominal contents to herniate through anatomic defects. Indirect inguinal hernias pass through the deep inguinal ring lateral to the inferior epigastric vessels; direct hernias bulge through Hesselbach triangle medial to those vessels. Femoral hernias descend through the femoral canal medial to the femoral vein. Hiatal hernias involve cephalad migration of the gastroesophageal junction (sliding, type I) or herniation of the fundus alongside (paraesophageal, types II-IV). Incarceration occurs when bowel cannot be reduced; strangulation follows when venous and then arterial supply are compromised, producing ischemia and necrosis.
Clinical presentation
Symptoms
- Bulge that enlarges with standing, coughing, or straining and reduces with recumbency (reducible)
- Dragging or burning discomfort, worse at end of day
- Acute severe pain, nausea/vomiting, irreducibility → incarceration or strangulation
- Hiatal: heartburn, regurgitation, dysphagia; large paraesophageal may cause postprandial chest pain or early satiety
Signs / physical exam
- Palpable cough impulse at the inguinal canal, umbilicus, or incisional scar
- Femoral hernia: mass below and lateral to pubic tubercle
- Strangulation: tender, tense, erythematous, skin changes, systemic signs (tachycardia, fever, peritonitis)
- Hiatal: retrocardiac air-fluid level on CXR with large paraesophageal hernia
Classic findings
Femoral hernias most likely to present strangulated due to narrow rigid neck. Pediatric inguinal hernias are almost always indirect and require repair due to high incarceration risk.
Differential diagnosis
- Inguinal lymphadenopathy — Firm, nontender to tender nodes without cough impulse; no reducibility
- Hydrocele / varicocele — Transilluminates (hydrocele) or bag-of-worms (varicocele); does not extend into the inguinal canal above
- Femoral artery aneurysm or pseudoaneurysm — Pulsatile, expansile mass below the inguinal ligament, often post-catheterization
- Lipoma of the cord — Soft, nonreducible mass that can be hard to distinguish without imaging or surgery
- Testicular torsion (in infants with inguinal swelling) — Acute pain, high-riding testis, absent cremasteric reflex; surgical emergency
- GERD without hiatal hernia — Symptoms without anatomic herniation on endoscopy or barium
- Rectus diastasis (vs ventral hernia) — Midline ridge with Valsalva but no true fascial defect; no risk of strangulation
Diagnostic workup
Diagnostic criteria
Clinical bulge with cough impulse that disappears with recumbency in a typical location is diagnostic. Strangulation is a clinical diagnosis supported by tenderness, systemic signs, and imaging evidence of bowel ischemia or obstruction.
Labs
- CBC, BMP, lactate if strangulation suspected
- Type and screen prior to operative repair
Imaging
- Diagnosis is usually clinical; imaging reserved for obesity, occult, recurrent, or atypical hernias
- Ultrasound — first-line for inguinal/femoral/umbilical evaluation, especially in children
- CT abdomen/pelvis — best for ventral, incisional, occult, and complicated hernias; can show incarceration, obstruction, ischemia
- Upper GI series or EGD for symptomatic hiatal hernia evaluation; manometry/pH testing if anti-reflux surgery considered
Treatment
First-line
- Elective surgical repair for most symptomatic hernias — open (Lichtenstein tension-free mesh) or laparoscopic (TAPP, TEP) for inguinal
- Watchful waiting acceptable for minimally symptomatic men with reducible inguinal hernias
- Pediatric inguinal hernias: prompt elective repair after diagnosis given incarceration risk
- Femoral hernias: repair at diagnosis regardless of symptoms (high strangulation risk)
- Umbilical hernia in children: most close spontaneously by age 4-5; repair if persistent, large (>1.5 cm), or symptomatic
- Hiatal: PPI (omeprazole, pantoprazole, esomeprazole) + lifestyle (weight loss, elevate head of bed, avoid late meals); fundoplication (Nissen, Toupet) for refractory GERD or large paraesophageal hernias
Second-line / adjunct
- Ventral/incisional hernia: open or laparoscopic repair with mesh; component separation for large defects
- Tobacco cessation and weight optimization before elective repair (improves outcomes, reduces recurrence)
Complications
- Incarceration and strangulation with bowel ischemia and necrosis
- Small bowel obstruction (especially femoral and incisional)
- Chronic groin pain after inguinal repair (ilioinguinal, iliohypogastric, genitofemoral nerve injury) — up to 10%
- Recurrence (1-5% with mesh repair)
- Mesh infection, seroma, hematoma
- Volvulus or gastric strangulation in large paraesophageal hiatal hernias
PANCE pearls
- Femoral hernia in an older woman with bowel obstruction is a classic exam scenario — examine the groin in every SBO.
- Indirect inguinal hernia: lateral to inferior epigastric vessels; direct: medial. Indirect can descend into the scrotum.
- Richter hernia involves only the antimesenteric border of the bowel — can strangulate without obstructing.
- Littré hernia contains a Meckel diverticulum; Amyand hernia contains the appendix.
- Paraesophageal hiatal hernia symptoms (postprandial chest pain, early satiety) warrant elective repair even if mild because of volvulus risk.
References
- ACS 2023 — American College of Surgeons / Americas Hernia Society Quality Collaborative recommendations on inguinal and ventral hernia management
- HerniaSurge 2018 — HerniaSurge Group: International guidelines for groin hernia management (Hernia 2018)
- SAGES 2013 — SAGES Guidelines for the Management of Hiatal Hernia (Kohn et al., Surg Endosc 2013)
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