Hernia

• Protrusion of abdominal contents through the fascia of the abdominal wall.

• If unable to reduce a hernia, the contents can trapped (incarcerated) in the abdominal wall. An irreducible hernia should be admitted for surgical assessment. Incarcerated hernia can become strangulated i.e. contents of hernia become twisted or entrapped by narrow opening compromising blood supply leading to swelling/infarction.

• Any painful hernia should always raise the possibility of strangulation, and this should prompt admission to hospital for further assessment. May have features of small bowel obstruction (abdominal pain and vomiting)

• It is likely that this hernia contains bowel and urgent surgical reduction is required to prevent bowel ischaemia or perforation

• Outpatient referral may be appropriate for reducible hernias without features of obstruction.

Inguinal

• M>F, indirect: 80%, direct commoner in elderly, refer adults if larger or symptomatic and all children for surgical assessment. Consider conservative management (e.g. trusses) if small hernia in adult or unfit for surgery: Inguinal hernia (Mayo clinic)

Femoral

• F>M, can be difficult to distinguish from inguinal: confirm with ultrasound. Refer for urgent surgical repair (risk of strangulation)

Epigastric

• M>F. May require Ultrasound or CT to confirm diagnosis. Refer for surgical repair

Umbilical

• Infants: Usually refers spontaneously. Refer for surgery if persists until aged >2 years. Adults: para-umbilical: refer for surgical assessment (risk of strangulation)

Incisional

• Post-surgery. Refer if symptomatic

Spigelian

• Hernial sac protrudes lateral to the rectus sheath midway between umbilicus and pubic bone. Refer for surgical repair

Obturator hernia

• Hernia protrudes out from pelvis through obturator canal. Usually presents with strangulation +/- pain referred to knee: admit for surgery

Richter hernia

• Knuckle of the side wall of the gut gets caught up and becomes strangulated but the bowel is not obstructed. Admit as for acute abdomen

Sport's hernia

• Not a hernia (groin sprain). Chronic groin pain / inguinal tenderness +/- swelling. Conservative approach 6-12 weeks (rest, physio, graded return to sport). Surgery highly effective (90% vs. 27%). Sports hernia: a clinical update (BJGP, 2013)

Hiatus hernia​

• Part of the stomach squeezes up into the chest through an opening in the diaphragm: Hiatus hernia (NHS Choices)

Resources

• Hernia (NHS Choices), Hernia (Patient.info), Abdominal wall hernias (patient.info)