We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Hernia
From WikEM
(Redirected from Inguinal hernia)
Contents
Background
Classification
- Reducible
- Hernia sac soft, easy to replace back through the hernia defect
- Incarcerated
- Hernia sac firm, often painful, nonreducible
- Strangulation
- Impairment of blood flow
- Severe pain at hernia site
- Signs of intestinal obstruction
- Skin changes overlying hernia sac may be seen
Types
- Inguinal (75%)
- Most common type of hernia in both men and women
- Presents as groin mass
- Indirect (50%)
- Hernia passes from inguinal ring into scrotum (due to patent processus vaginalis)
- Direct (25%)
- Hernia passes directly through transversalis fascia in Hesselbach triangle
- Ventral
- Due to defect in anterior abdominal wall (spontaneous or acquired)
- Incisional
- Due to excess wall tension or inadequate wound healing / surgical wound infection
- Umbilical
- Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity)
- Spigelian
- Also known as lateral ventral hernia
- Nearly always acquired conditions
- Difficult to diagnose
- Classic presentation is abdominal pain associated with anterior lateral abdominal wall mass
- Physical exam is unreliable; imaging (US or CT) is often required
- Femoral
- 10:1 female:male ratio
- Hernia sac protrudes through femoral canal
- Mass is typically below the inguinal ring
- Particularly prone to complications
- Obsturator
- Bowel herniation through obturator canal
- Nearly always presents as partial or complete bowel obstruction
- High complication rate
- Richter
- Involves only antimesenteric border of intestine and only portion of the wall
- Often presents with out vomiting or intestinal obstruction
- As a result, more likely to diagnose once wall has begun to become ischemic)
Clinical Features
Differential Diagnosis
Testicular Diagnoses
- Testicular torsion
- Epididymitis
- Orchitis
- Torsion of testicular appendage
- Scrotal abscess
- Fournier gangrene
- Hydrocele
- Indirect inguinal hernia
- Hematocele
- Spermatocele
- Testicular trauma
- Testicular rupture
- Varicocele
- Inguinal lymph node (Lymphadenitis)
- Testicular tumor
- Cellulitis
- Tinea cruris
Evaluation
Work-Up
- Labs
- Not routinely necessary
- Consider CBC, chemistry, lactate if concern for strangulation
- Imaging
- CT, if concern for obstruction/strangulation
- Ultrasound (only indicated to exclude other diagnoses)
Management
- Reduction for incarcerated hernia
- If there is any concern for strangulation, do not attempt hernia reduction
- Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
- NPO (in case reduction unsuccessful)
- IV opioid analgesia
- Supine and mild Trendelenberg positioning
- Apply cold packs to hernia site to reduce swelling
- Apply firm, steady pressure to distal part of hernia
- If successful observe patient in ED period of time for serial abdominal exams
- If unsuccessful after 1 or 2 attempts consult surgery
- If there is any concern for strangulation, do not attempt hernia reduction
- Antibiotics (e.g. Cefoxitin) for
- Obstruction
- Peritonitis
Disposition
- Discharge with surgery referral:
- Easily reducible hernia
- Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration)
