Types of hernia

MB

Risk of
TypeDescription strangulation
IncisionalHerniation through an area weakened by a scar Low
UmbilicalCongenital defect of the abdominal wall seen in infants as a swelling at the Low
umbilicus
ParaumbilicalAcquired defect above or below the umbilicus High
EpigastricOften small painful swelling in the midline of abdomen above the umbilicus  
caused by a defect in linea alba, usually contains extrapentoneal fat
FemoralHerniation through the femoral canal which appears 'below and lateral to the Highest
pubic tubercle'. More common in women than men
InguinalTypically seen 'above and medial to the pubic tubercle' swelling is caused by Low
weakness in the abdominal wall in the area of Hasselbach's triangle. Risk of
strangulation is low.
Indirect This is the most common. There are two types. First, congenital, which is High
caused by a patent processus vaginalis. Second, acquired, herniates through
the deep ring and travels along the inguinal canal within the coverings of the
spermatic cord. It can go into the scrotum. Risk of strangulation is high.

INGIUNAL HERNIA

I. Inguinal Hernia
1. Small Indirect Hernia may slightly tap end of finger
2. Large Indirect Hernia may be palpable as mass
3. Direct Inguinal Hernia may be felt on pad of finger
B. Inguinal Canal components
1. Internal inguinal ring
a. Lateral to inferior epigastrics
b. Landmark: Middle of inguinal ligament
2. Canal
a. Follows spermatic cord course in men
b. Follows round ligament in women
3. External inguinal ring
a. Located at pubic tubercle
b. Occurs just above inguinal ligament
c. Medial and inferior to internal inguinal ring
II. Epidemiology
A. Accounts for 96% groin hernias (other 4% are femoral)
B. Bilateral in 20% of cases
C. Gender predisposition: Male by 9 to 1 ratio
D. Lifetime risk of inguinal herniation: 10%
III. Types
A. Indirect inguinal hernia (most common)
1. Course
a. Hernia sac passes outside Hasselbach's Triangle:
IV. Boundaries of Hasselbach's Triangle
A. Medial boundary: Rectus abdominis
B. Lateral boundary: Inferior epigastric vessels
C. Inferior boundary: Inguinal ligament
1. Herniates via Inguinal Canal :
2. Internal inguinal ring
a. Lateral to inferior epigastrics
b. Landmark: Middle of inguinal ligament
3. Canal
a. Follows spermatic cord course in men
b. Follows round ligament in women
4. External inguinal ring

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 a. Located at pubic tubercle
b. Occurs just above inguinal ligament
c. Medial and inferior to internal inguinal ring
i. Enters through Internal Inguinal Ring
ii. Lateral to inferior epigastrics
d. May result in scrotal hernia in males
5. Pathophysiology
a. Nonobliterated processus vaginalis (congenital)
b. Internal abdominal ring weakened fascia
D. Direct inguinal hernia
1. Hernia sac passes within Hasselbach's Triangle
2. Breaches posterior inguinal wall
3. Passes medial to inferior epigastrics
4. Pathophysiology
a. Usually occurs in males
b. Acquired deficiency in transversus abdominis muscle
V. Symptoms
A. Often asymptomatic (especially in direct hernias)
B. Pain or dull sensation in groin
VI. Signs
A. Palpable defect or swelling may be present
1. Indirect Hernia may bulge at Internal Inguinal Ring
a. Look for bulge site at mid-inguinal ligament
2. Direct Hernia may bulge at External Inguinal Ring
a. Look for bulge site at pubic tubercle
b. Occurs just above inguinal ligament
c. Seen medial and inferior to indirect hernia bulge
B. Distinguishing indirect and direct hernias difficult
1. Experienced clinicians are incorrect in 30% of cases
C. Indirect inguinal hernia palpation difficult in women
D. Inguinal hernias difficult to palpate in children
VII. Differential Diagnosis
A. See Groin Pain
VIII. Radiology: Inguinal Ultrasound
A. Technique: Ultrasound in various patient positions
1. Supine
2. Upright
3. Valsalva maneuver
B. Efficacy
1. High Test Sensitivity (>90%)
2. High Test Specificity
a. Distinguish Incarcerated Hernia from firm mass
IX. Complications
A. Bowel incarceration and strangulation
B. Small Bowel Obstruction

HASELLBACH’S TRIANGLE

I. Definition
A. Anatomical triangle used to define Inguinal Hernias
II. Boundaries of Hasselbach's Triangle
A. Medial boundary: Rectus abdominis
B. Lateral boundary: Inferior epigastric vessels

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 C. Inferior boundary: Inguinal ligament
III. Interpretation
A. Indirect Inguinal Hernia (out of Hasselbach's Triangle)
1. Enters Inguinal Canal lateral to inferior epigastrics
2. Exits Inguinal Canal inferior to inguinal ligament
B. Direct Inguinal Hernia (within Hasselbach's Triangle)
1. Breaches posterior inguinal wall
2. Passes medial to inferior epigastric vessels

Pathophysiology

By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or
"defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia
involves the spinal discs and causes sciatica.

Hernias may or may not present either with pain at the site, a visible or palpable lump, or in some cases by more vague symptoms
resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue
usually enters a hernia first, but it may be followed by or accompanied by an organ.

Most of the time, hernias develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or
weakened.

 Weakening of containing membranes or muscles is usually congenital (which explains part of the tendency of hernias to
run in families), and increases with age (for example, degeneration of the annulus fibrosus of the intervertebral disc), but it
may be on the basis of other illnesses, such as Ehlers-Danlos syndrome or Marfan syndrome, stretching of muscles during
pregnancy, losing weight in obese people, etc., or because of scars from previous surgery.
 Many conditions chronically increase intra-abdominal pressure, (pregnancy, ascites, COPD, dyschezia, benign prostatic
hypertrophy) and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to
herniate through narrowed portions of the cranial cavity or through the foramen magnum. Increased pressure on the
intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation

Indirect hernia

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

Types of Hernia - Condition

Reducible hernia

This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually.

Incarcerated hernia

An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised. Bowel obstruction is common.

Strangulated hernia

A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents.

Mortality/Morbidity

Morbidity is secondary to missing the diagnosis of the hernia or complications associated with management of the disease.

 A hernia can lead to an incarcerated and often obstructed bowel.

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  The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced strangulated bowel leads to
persistent ischemia/necrosis with no clinical improvement. Surgical intervention is required to prevent further
complications such as perforation and sepsis.
 Ensuing surgery to repair the hernia or its complications may leave the patient at risk for infection, future hernias, or intra-
abdominal adhesions.

Race

 Umbilical hernias occur 8 times more frequently in black infants than in white infants. 12

Sex

 Approximately 90% of all inguinal hernia repairs are performed on males. 11

 Reduction of hernias in females may be complicated by inclusion of the ovary in the hernia.
 Femoral hernias (although rare) occur almost exclusively in women because of the differences in the pelvic anatomy.
 The female-to-male ratio of obturator hernias is 6:1.12

Age

 Indirect hernias usually present during the first year of life, but they may not appear until middle or old age.
 Indirect hernias occur more frequently in premature infants compared to term infants. Indirect hernias develop in 13% of
infants born before 32 weeks' gestation.10
 Direct hernias occur in older patients as a result of relaxation of abdominal wall musculature and thinning of the fascia.
 Umbilical hernias usually occur 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, with only a 2-10% incidence in children older than 1 year.13

Causes

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
 Coughing
 Straining with defecation or urination
 Ascites
 Peritoneal dialysis
 Ventriculoperitoneal shunt
 Chronic obstructive pulmonary disease (COPD)
 Family history of hernias