hernia

(hûr'nē-ə)

[Middle English, from Latin.]

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The protrusion of an organ, part of an organ, or other structure through the wall of the body cavity normally containing it. Various organs may be involved, including the bladder, brain, esophagus, intestine, ovary, and rectum. The most common location for a hernial bulge to appear is the abdominal wall, particularly the groin.

Among the most infrequent but life-threatening hernias is a cerebral hernia in which part of the brain protrudes through an opening in the skull.

A diaphragmatic hernia, which occurs when a defect is present in the muscular diaphragm separating chest from abdomen, may be present at birth or result from an injury later in life. Abdominal organs, such as the liver, spleen, stomach, and intestine, can pass through the diaphragmatic defect and lodge in the chest cavity, so that the lungs become compressed and breathing is impaired. Hiatal or esophageal hernia results when a portion of the stomach slides into the chest cavity through the normal diaphragmatic opening for the esophagus.

Groin hernias consist of two major types, inguinal and femoral. Inguinal hernias account for 75% of all hernias of the body, and are divided into two anatomic variants, indirect and direct. Indirect inguinal hernias are caused by a weakness in the abdominal wall that corresponds to an area where the testis descended into the scrotum during embryological development. With direct inguinal hernias, the defect results mainly from strain on the abdominal muscles which have been weakened by age. Inguinal hernias are 10 times as common in men as in women. Femoral hernias are more common in women, but are infrequent. The weakness in a femoral hernia originates in the area where the major veins, arteries, and nerves pass from the abdomen into the lower extremities. A femoral hernia bulge is always located in the upper inner part of the thigh, just below the groin crease.

With rare exceptions, all hernias should be corrected surgically to prevent the possibilities of incarceration, intestinal obstruction, and strangulation.

The protrusion of an organ or other body structure through a weakness in the wall of the cavity that usually confines it. One of the most common hernias associated with sport is an inguinal hernia (commonly called a rupture). This occurs in the lower abdomen when a sac made from the membrane (peritoneum) lining the abdominal wall and organs passes through the abdominal wall into the inguinal canal, an opening that leads, in males, into the testes. Inguinal hernias are often caused by lifting heavy weights, but they are also associated with obesity. Some hernias are quite easy to return to their normal site (reducible hernias) but others (irreducible hernias) may be impossible to replace. Some unresolved hernias, particularly in those who weight train and exercise vigorously, are potentially dangerous. An increase in the intra-abdominal pressure that accompanies exertion can cause strangulation, stopping blood flow and resulting in gangrene. In these cases, surgical repair is usually recommended. However, there is a tendency not to perform surgery on hernias that are causing no symptoms. Physicians usually evaluate each case individually before offering sufferers advice about participating in particular physical activities. See also fascial hernia.

A hernia is where a part of the abdominal content protrudes or bulges through an abnormal opening in the inner layers of the wall of the abdomen. The hernial ‘sac’ usually contains either fatty tissue or a loop of intestine. Some common types are groin, umbilical, and incisional hernias.

Groin hernias

There are two types of groin hernia, inguinal or femoral, the former being far more common and making up 98% of all groin hernias. Inguinal hernias are common in newborn boys, where they arise as a result of a ‘canal’ normally present in the embryo between the inside of the abdomen and the scrotum, which fails to close. They are also common in adult life and increase in frequency as one grows older. Inguinal hernias are approximately twenty times more common in men than women, while, interestingly, femoral hernias are more common in women.

Usually a groin hernia presents with a lump in the groin, felt all the time or only when straining. It often causes a dull ache that is worse with activity. The lump may get bigger with coughing or straining and shrink or disappear with lying down. Not all hernias are easily felt, however. When the contents can be pushed back into the abdomen the hernia is said to be ‘reducible’ — and ‘irreducible’ if not.

Surgeons have been treating and repairing hernias for over 3000 years, with varying degrees of success. The Mummy of Pharaoh Merneptah (nineteenth dynasty, 1224-14 bc) showed a large wound in the groin, with the scrotum separated from the body indicating that crude surgery had been performed on an inguinal hernia that had passed down into the scrotum. Nowadays many hernia repairs are performed worldwide each year, some 80 000 in the UK alone. The repair is usually performed by reinforcing the defect with stitches or a plastic mesh, often as a day case procedure, using either a local or a general anaesthetic.

While most hernias are usually just troublesome, on rare occasions they enlarge quickly with a sudden intense pain and part of the bowel gets trapped and becomes blocked. This intestinal obstruction is an emergency situation and requires surgery to free the trapped piece of bowel or to excise it if irretrievably damaged by ‘strangulation’ of its blood supply.

Umbilical hernias

Up to a fifth of babies are born with a bulge through a defect at the site of the umbilical cord. The majority will close by themselves and they only occasionally need surgical repair if the hernia becomes excessively large or inflamed, or if it is still present by the age of about four. Adults also develop hernias in the region of the umbilicus (paraumbilical). These are often associated with obesity, can be uncomfortable, and may become irreducible. Again they are usually repaired as a day case or overnight stay procedure.

Incisional hernias

These occur months or years after abdominal surgery and are common after such procedures as large bowel surgery in either sex, or hysterectomy in women. They are more common in obese patients or following a postoperative wound infection. They may become very large and unsightly. Rarely they may cause the bowel to obstruct and require emergency surgery. Nowadays they are usually repaired with a large piece of mesh, as there is a high recurrence rate after a sutured repair.

— S. G. Taylor, P. J. O'Dwyer

See also alimentary system; scrotum.

Definition

A hernia is the protrusion of an organ through the structure or muscle that usually contains it.

Description

There are many different types of hernias in children. The most common are direct inguinal hernias, indirect inguinal hernias, and umbilical hernias. A direct inguinal hernia occurs when a small section of bowel herniates, or protrudes, through the groin muscle. Indirect inguinal hernia occurs when part of the bowel protrudes through the muscles of the groin into a sac left over from fetal development. An umbilical hernia occurs when a portion of the bowel protrudes through a small defect in the abdominal wall muscle near where the umbilical cord attaches to the baby's abdomen. More serious defects involving herniation of abdominal contents outside the infant's body are omphalocele and gastroschisis. These are not a result of an organ protruding through weakened muscle tissue but rather are a result of a much larger defect of the muscles of the abdomen that causes the internal organs to develop outside the body. Omphalocele and gastroschisis are considered abdominal wall defects and are not called hernias.

While an umbilical hernia usually resolves spontaneously as the abdominal muscles grow and requires no further treatment, in children with direct and indirect inguinal hernia, surgery is almost always required to prevent the herniated bowel from becoming incarcerated or strangulated. When an inguinal hernia is incarcerated, the bowel becomes swollen and trapped outside the body. If the hernia remains incarcerated for too long, strangulation can occur. In strangulation, the blood supply to the section of bowel that has herniated is cut off, and the tissue begins to die. When this happens, the intestines cannot function properly and are said to be obstructed. If the bowel perforates, or develops a hole in it, emergency surgery is required to repair the intestine and prevent infection.

A more severe, but less common, hernia is a diaphragmatic hernia. This occurs inside the body when the diaphragm, the large muscle that separates the abdominal cavity from the chest cavity, fails to develop fully. In children with diaphragmatic hernia, the contents of the abdomen protrude into the chest cavity. These children may have difficulty breathing. During fetal development the presence of abdominal organs in the fetal chest cavity prevents the lungs from growing normally. A diaphragmatic hernia can occur as an isolated defect or as part of a more complex syndrome. Children with diaphragmatic hernias are usually very ill and require immediate treatment after birth. Some of these children have other defects such as cardiac anomalies, chromosomal abnormalities, kidney and genital anomalies, and neural tube defects, such as spina bifida.

Demographics

Estimates of the true incidence of inguinal hernias vary, but they may affect 1–5 percent of all births in the United States. International rates appear to be similar. Males are more than seven times more likely to have an inguinal hernia than females, and premature infants are more likely than full term infants to have inguinal hernias and to have incarcerated hernias. While inguinal hernias seem to affect all racial groups at the same rate, umbilical hernias occur more frequently in African Americans.

Diaphragmatic hernias occur in approximately one in every 3,000 births. These hernias do not seem to affect any race or nationality more than another.

Causes and Symptoms

A direct inguinal hernia is caused when the muscles of the floor of the groin area are weak and allow the bowel to press through. An indirect inguinal hernia is caused when remnants of early fetal genital development stay within the body after this development is complete. In early fetal development male and female genitalia are identical. At around the seventh week of gestation, the gonads (sex organs) begin to change, or differentiate, into the characteristic genitalia of males and females. Males develop testes, and females develop ovaries. During this process, in some fetuses, a small sac may form near the genitalia. Most often the opening to this sac, called the processus vaginalis, closes. However, in children with inguinal hernia, this sac remains patent, or open, becoming a container into which bowels may be herniated.

The main symptom of inguinal hernias (both direct and indirect) in infants is an obvious bulge in the groin in the inguinoscrotal region (near the scrotum) in boys and in the inguinolabial (near the labia) in girls. The bulge may or may not be painful. It will usually appear after straining or crying and then disappear after a period of time. If the hernia has incarcerated, the infant will be in obvious pain, appearing fussy, crying, and refusing to eat. The skin over the hernia may be discolored and swollen.

Umbilical hernia is caused by a small defect in the muscles of the abdominal wall. These hernias are usually small and have no symptoms other than a small protrusion near the base of the umbilical cord.

Like inguinal hernias, diaphragmatic hernias are caused early in fetal development. The structures that form the diaphragm do not properly form, allowing the contents of the lower abdomen to migrate up near the heart and lungs. The increased pressure these organs place on the lungs causes the lungs to remain small and underdeveloped. When the infant is born and must breathe air, the lungs are not able to work properly.

Children with diaphragmatic hernia have the following symptoms immediately after birth: breathing difficulty, a bluish skin color (cyanosis), rapid breathing, rapid heat rate, and asymmetrical chests—one side is not the same size as the other. These infants are often critically ill and are be placed on a ventilator—a machine to help them breath. Because the lungs have not had enough room to grow and are small, doctors must stabilize the baby's breathing before the hernia can be repaired.

When to Call the Doctor

If a small child, especially an infant, has a bulge in the abdominal or groin area, the child's pediatrician should be consulted. If the child is in severe pain, and the skin is discolored or swollen, medical help should be sought immediately.

Diagnosis

Umbilical and inguinal hernias are diagnosed by physical examination. For some children with inguinal hernia, a laparoscopic examination may be performed. A laparoscopy is an exploratory surgical procedure in which the doctor makes an incision and inserts a small tube connected to a camera to view the herniated area. This procedure is used most often in patients who have already had one hernia repair to see if the hernia has returned in a new location.

Diaphragmatic hernia may be diagnosed while the fetus is still in the womb using prenatal ultrasonography. After birth, physical symptoms of respiratory distress, cyanosis, and chest asymmetry can indicate the presence of a diaphragmatic hernia. In children with less severe diaphragmatic hernias, the diagnosis may be made later in childhood if the child develops intestinal obstructions. An x ray showing bowel loops within the chest cavity confirms the diagnosis.

Treatment

Umbilical hernia is generally a benign condition that will resolve spontaneously as the muscles of the abdomen grow. No treatment is usually required. For children in whom the umbilical hernia does not resolve, surgery is not usually performed until after the age of five. The only treatment necessary is observation of the hernia during routine physical examinations.

The standard treatment for inguinal hernias is a surgical repair called herniorrhaphy. Unlike umbilical hernias, inguinal hernias do not resolve spontaneously. Because of the risk of incarceration and strangulation, most doctors prefer to repair these hernias as soon after the initial diagnosis as possible. Herniorrhaphies are performed as an outpatient procedure in otherwise healthy full-term infants and children.

Prior to repair surgery, parents may be taught how to apply pressure to the hernia, thereby reducing it temporarily and preventing incarceration. If the hernia has already become incarcerated, the doctor will attempt to force the hernia out of the sac and back into the body manually. This process is called manual reduction. With the child on his back, the doctor will use his fingers to press the hernia back into the body. If successful, manual reduction relieves the child's pain and prevents strangulation until surgery can be scheduled. Repair surgery is usually performed within 72 hours. If an incarcerated hernia is not reducible, surgery must be performed much sooner to prevent strangulation. If strangulation occurs, emergency surgery is the only treatment.

Treatment for diaphragmatic hernia involves treatment of the other accompanying health issues. First and foremost, the infant's respiratory distress must be addressed. Most newborns with diaphragmatic hernias require intubation and ventilation. A tube is inserted through the mouth into the throat, and breathing is assisted by a ventilation machine. A feeding tube may be inserted through the nose and into the stomach to insure the infant receives sufficient nutrition. After the infant is stabilized, surgery to repair the hernia is performed. In diaphragmatic hernia repair surgery, the herniated abdominal organs are forced back into their proper position within the abdomen. If the bowels are injured or malrotated, this will be repaired, and the hole in the diaphragm is sewn closed and patched, if necessary, with surgical mesh.

Prognosis

If diagnosed early in childhood, the prognosis for children who have had a surgically repaired inguinal hernia is excellent. Occasionally there are complications associated with inguinal hernias including death, but these are rare, occurring most often in children who were diagnosed later in childhood or whose hernias were strangulated.

The prognosis for children with diaphragmatic hernia depends on the extent of the defects of the lungs and the impact of the treatments necessary to save their lives. Children with diaphragmatic hernias have an increased incidence of chromic lung disease. These children also have an increased risk for slow growth and development. The survival rate of these children is also related to the other anomalies these children may have. If the diaphragmatic hernia is part of a syndrome, the other birth defects may be life threatening. The survival rate after surgical repair of a diaphragmatic hernia is 60–80 percent.

Prevention

The exact cause of umbilical hernias, inguinal hernias, and diaphragmatic hernias is as of 2004 unknown. Until a cause is discovered, no prevention is available.

Parental Concerns

Prior to surgery, parents of a child with an inguinal hernia can be taught to apply pressure to the hernia, preventing incarceration. Parents should be aware of the circumstances under which to seek immediate medical attention for their child.

See also Abdominal wall defects.

Resources

Books

Hernia Repair: Medical Dictionary, Bibliography, and Annotated Research Guide to Internet Research. San Diego, CA: Icon Group International, 2004.

LeBlanc, Karl, et al. Laproscopic Hernia Surgery: An Operative Guide. Oxford, UK: Oxford University Press, 2003.

Official Patient's Sourcebook on Inguinal Hernia. San Diego, CA: Icon Group International, 2002.

Parker, James, et al. Hernia: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet Research. Boulder, CO: netLibrary, 2003.

Rudolph, Colin D., and Abraham M. Rudolph, eds. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill, 2003, pp. 24–34, 36.

Web Sites

Hebra, Audre. "Pediatric Hernias." eMedicine, August 2, 2004. Available online at www.emedicine.com/ped/topic2559.htm (accessed November 21, 2004).

Lewis, Nicola and Philip L. Glick. "Diaphragmatic Hernias." eMedicine, October 8, 2004. Available online at www.emedicine.com/ped/topic2937.htm (accessed November 21, 2004).

[Article by: Deborah L. Nurmi, MS]

The protrusion of an organ through a weakness in its body cavity wall; it is commonly caused by weight-lifting, obesity, or muscle-weakness. Some hernias are quite easy to return to their normal site, but others (irreducible hernias (may be impossible to replace. See also fascial hernia, inguinal hernia.

The projection of an organ or part of an organ through the wall of the structure that surrounds it. Most often, the term is applied to the protrusion of a part of the intestine that can be observed as a lump in the lower abdomen.

The abnormal protrusion of part of an organ or tissue through the structures normally containing it.
In this condition, a weak spot or other abnormal opening in a body wall permits part of the organ to bulge through. A hernia may develop in various parts of the body; most commonly in the region of the abdomen.
A layman's term for hernia is rupture. A hernia is either acquired or congenital.
Anatomically specific hernias are listed under their individual sites.

• caudal abdominal h's — see inguinal, femoral, scrotal hernias (below).
• cerebral h. — see brain herniation.
• cord h. — a type of umbilical hernia in which the midgut has failed to return to the abdominal cavity during fetal development and remains within the umbilical cord.
• crural h. — femoral hernia.
• external h. — protrusion of abdominal contents through an opening in the abdominal wall.
• false h. — a structural defect with contents but without a peritoneal sac.
• fat h. — hernial protrusion of peritoneal fat through the abdominal wall or through the vulvar wall during a difficult calving.
• incarcerated h. — hernia so occluded that it cannot be returned by manipulation; it may or may not become strangulated.
• incisional h. — hernia after operation at the site of the surgical incision, owing to improper healing or to excessive strain on the healing tissue; such strain may be caused by excessive muscular effort, activity, or by obesity, which creates additional pressure on the weakened area.
• inguinoscrotal h. — see scrotal hernia (below).
• irreducible h. — incarcerated hernia.
• mesenteric h. — hernia of a loop of small intestine through a traumatic tear in the mesentery.
• muscle h. — the belly of the muscle protrudes through a tear in the fascia and epimysium.
• paraesophageal h. — hiatal hernia in which part or almost all of the stomach protrudes through the hiatus into the thorax to the left of the esophagus, with the gastroesophageal junction remaining in place.
• pelvic h. — hernia caused by a loop of intestine becoming incarcerated in a hiatus between the wall of the pelvis and the ductus deferens, caused by tearing of the fold of the ductus at castration. May occur many months after the castration operation. Can be resolved, if diagnosed early enough, by traction on the taut mesentery per rectum.
• pericardial h. — see peritoneopericardial hernia.
• perineal h. — see perineal hernia.
• pleuroperitoneal h. — see diaphragmatic hernia.
• prepubic h. — the result of avulsion of the cranial pubic tendon.
• reducible h. — one that can be returned by manipulation.
• scrotal h. — inguinal hernia which has passed into the scrotum. When these become strangulated they cause severe abdominal pain and acute local swelling. In large animals the tightened spermatic cord can be felt disappearing into the inguinal canal. See also intestinal obstruction.

  Scrotal hernia in a horse. By permission from Knottenbelt DC, Pascoe RR, Diseases and Disorders of the Horse, Saunders, 2003

• sliding hiatal h. — hiatal hernia in which the stomach and the cardioesophageal junction protrude into the caudal mediastinum; the protrusion, which may be fixed or intermittent, is partially covered by a peritoneal sac.
• slip h., slipped h. — sliding hernia.
• strangulated h. — one that is tightly constricted. As any hernia progresses and bulges out through the weak point in its containing wall, the opening in the wall tends to close behind it, forming a narrow neck. If this neck is pinched tight enough to cut off the venous return, the hernia will quickly swell and become strangulated. This is a very dangerous condition that can appear suddenly and requires immediate surgical attention. Unless the blood supply is restored promptly, gangrene can set in and may cause death.
• traumatic h. — protrusion of abdominal viscera into a subcutaneous site because of traumatic injury to the abdominal muscles.
• uterine h. — a gravid uterus can prolapse through an inguinal hernia in dogs and cats.
• vaginal h. — hernia into the vagina; called also colpocele.
• ventral h. — trauma with tearing of the body wall results in prolapse of abdominal contents into the subcutaneous tissue. Also reported in ewes from violent straining during parturition.

The protrusion of an organ through an abnormal opening in the muscle wall of the cavity that surrounds it. A hernia may be congenital, may result from the failure of certain structures to close after birth, or may be acquired later in life because of obesity, muscular weakness, surgery, or illness.

• Injuries and Accidents - hernia: protrusion of tissue or organ outside cavity it normally occupies, esp. in lower abdomen, due to physical strain or coughing

Hernia
Classification and external resources
Frontal chest X-ray showing a hernia of Morgagni
ICD-10	K40-K46
ICD-9	550-553
MedlinePlus	000960
eMedicine	emerg/251 ped/2559
MeSH	D006547

Colonic herniation.

A hernia is the protrusion^[1] of an organ or the fascia of an organ through the wall of the cavity that normally contains it.

There are different kinds of hernia, each requiring a specific management or treatment.

Contents 1 Signs and symptoms 2 Causes 3 Diagnosis 3.1 Inguinal 3.2 Femoral 3.3 Umbilical 3.4 Incisional 3.5 Diaphragmatic 3.6 Other hernias 3.7 Characteristics 4 Treatment 5 Complications 6 References 7 External links 7.1 Pictures

Signs and symptoms

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. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.

Hernias may or may not present either pain at the site, a visible or palpable lump, or in some cases 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 or accompanied by an organ.

Symptoms may not be present in some inguinal hernias while in some other hernias, including inguinal, they are. Symptoms and signs vary depending on the type of hernia. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be see and felt. When standing, such bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.^[2]

Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.

Strangulated hernias are always painful and pain is followed by tenderness. Nausea and vomiting also may occur as well due to bowel obstruction. The patient may also experience fever.^[3]

In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.^[4]

Causes

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.

Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, tight clothing and incorrect posture.^[5]

Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination, chronic lung disease, and also, fluid in the abdominal cavity.^[6]

Also, if muscles are weakened due to poor nutrition, smoking, and overexertion, hernias are more likely to occur.

The physiological school of thought contends that in the case of inguinal hernia, the above mentioned are only an anatomical symptom of the underlying physiological cause. They contend that the risk of hernia is due to a physiological difference between patients who suffer hernia and those who do not, namely the presence of aponeurotic extensions from the transversus abdominis aponeurotic arch. ^[7]

Diagnosis

An incarcerated inguinal hernia as seen on CT

Inguinal

Main article: inguinal hernia

Diagram of an indirect, scrotal inguinal hernia (median view from the left).

By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. Inguinal hernias are further divided into the more common indirect inguinal hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are the most common type of hernia in both men and women. In some selected cases, they may require surgery.

Femoral

Main article: femoral hernia

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia.

Umbilical

Main article: umbilical hernia

They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute.

Incisional

Main article: incisional hernia

An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue.

Diaphragmatic

Main article: diaphragmatic hernia

Diagram of a hiatus hernia (coronal section, viewed from the front).

Higher in the abdomen, an (internal) "diaphragmatic hernia" results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.

A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach (esophageal hiatus) serves as a functional "defect", allowing part of the stomach to (periodically) "herniate" into the chest. Hiatus hernias may be either "sliding", in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding (also known as para-esophageal), in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised.

A congenital diaphragmatic hernia is a distinct problem, occurring in up to 1 in 2000 births, and requiring pediatric surgery. Intestinal organs may herniate through several parts of the diaphragm, posterolateral (in Bochdalek's triangle, resulting in Bochdalek's hernia), or anteromedial-retrosternal (in the cleft of Larrey/Morgagni's foramen, resulting in Morgagni-Larrey hernia, or Morgagni's hernia).

Other hernias

Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with "visceral hernias", where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:

• Cooper's hernia: a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing almost immediately beneath the skin.
• Epigastric hernia: a hernia through the linea alba above the umbilicus.
• Hiatal hernia: a hernia due to "short oesophagus" — insufficient elongation — stomach is displaced into the thorax
• Littre's hernia: a hernia involving a Meckel's diverticulum. It is named after the French anatomist Alexis Littre (1658–1726).
• Lumbar hernia (Bleichner's Hernia): a hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains the following entities:
  • Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674–1750).
  • Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840–1913).
• Maydl's hernia: two adjacent loops of small intestine are within a hernial sac with a tight neck. The intervening portion of bowel within the abdomen is deprived of its blood supply and eventually becomes necrotic.
• Morgagni hernia: a type of hernia where abdominal contents pass into the thorax through a weakness in the diaphragm
• Obturator hernia: hernia through obturator canal
• Pantaloon hernia/ Saddle Bag hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels
• Paraesophageal hernia
• Paraumbilical hernia: a type of umbilical hernia occurring in adults
• Perineal hernia: a perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.
• Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space.
• Richter's hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation leading to perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter (1742–1812).
• Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach.
• Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause of sciatic neuralgia.
• Spigelian hernia, also known as spontaneous lateral ventral hernia
• Sports hernia: a hernia characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal.
• Velpeau hernia: a hernia in the groin in front of the femoral blood vessels
• Amyand's hernia: containing the appendix vermiformis within the hernia sac
• Busse's Hernia: a testicle within the hernia sac

Characteristics

Hernias can be classified according to their anatomical location:

Examples include:

• abdominal hernias
• diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach)
• pelvic hernias, for example, obturator hernia
• anal hernias
• hernias of the nucleus pulposus of the intervertebral discs
• intracranial hernias
• Spigelian hernia ^[8]

Each of the above hernias may be characterized by several aspects:

• congenital or acquired: congenital hernias occur prenatally or in the first year(s) of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistantiae (Lat. place of least resistance) that is congenital, but only becomes symptomatic later in life, when degeneration and increased stress (for example, increased abdominal pressure from coughing in COPD) provoke the hernia.
• complete or incomplete: for example, the stomach may partially or completely herniate into the chest.
• internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).
• intraparietal hernia: hernia that does not reach all the way to the subcutis, but only to the musculoaponeurotic layer. An example is a Spigelian hernia. Intraparietal hernias may produce less obvious bulging, and may be less easily detected on clinical examination.
• bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.
• irreducible (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation.

If irreducible, hernias can develop several complications (hence, they can be complicated or uncomplicated):

• strangulation: pressure on the hernial contents may compromise blood supply (especially veins, with their low pressure, are sensitive, and venous congestion often results) and cause ischemia, and later necrosis and gangrene, which may become fatal.
• obstruction: for example, when a part of the bowel herniates, bowel contents can no longer pass the obstruction. This results in cramps, and later on vomiting, ileus, absence of flatus and absence of defecation.
• dysfunction: another complication arises when the herniated organ itself, or surrounding organs, start to malfunction (for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causing sciatic nerve pain, etc.).

Treatment

Main articles: Hernia repair and Inguinal hernia surgery

Hernia repair being performed aboard the amphibious assault ship USS Bataan

For a hernia like inguinal hernia, surgery is no longer recommended in most cases. However, it is in few cases advisable to repair some other kinds of hernias, in order to prevent complications such as organ dysfunction, gangrene and multiple organ dysfunction syndrome. Most abdominal hernias can be surgically repaired, but surgery often has complications, such as chronic groin pain. Time needed for recovery after treatment is greatly reduced if hernias are operated on laparoscopically, the minimally invasive operation most commonly used today.^[9] Uncomplicated hernias are principally repaired by pushing back, or "reducing", the herniated tissue, and then mending the weakness in muscle tissue (an operation called herniorrhaphy). If complications have occurred, the surgeon will check the viability of the herniated organ, and resect it if necessary.

Muscle reinforcement techniques often involve synthetic materials (a mesh prosthesis). The mesh is placed either over the defect (anterior repair) or under the defect (posterior repair). At times staples are used to keep the mesh in place. These mesh repair methods are often called "tension free" repairs because, unlike some suture methods (e.g. Shouldice), muscle is not pulled together under tension. However, this widely used terminology is misleading, as there also exists many tension-free suture methods that do not use mesh (e.g. Desarda, Lipton-Estrin...).

Evidence suggests that tension-free methods (with or without mesh) often have lower percentage of recurrences and the fastest recovery period compared to tension suture methods. However, among other possible complications, prosthetic mesh usage seems to have a higher incidence of chronic pain and, sometimes, infection.^[10]

One study attempted to identify the factors related to mesh infections and found that compromised immune systems (such as diabetes) was a factor.^[11] Mesh has also become the subject of recalls and class action lawsuits.^[12]

Laparoscopic surgery is also referred to as "minimally invasive" surgery, which requires one or more small incisions for the camera and instruments to be inserted, as opposed to traditional "open" or "microscopic" surgery, which requires an incision large enough for the surgeon's hands to be inserted into the patient. The term microscopic surgery refers to the magnifying devices used during open surgery.

Many patients are managed through day surgery centers, and are able to return to work within a week or two, while intensive activities are prohibited for a longer period. Patients who have their hernias repaired with mesh often recover in a number of days, though pain can last longer, and often forever. Surgical complications have been estimated to be more than 20 percent. They include chronical pain, surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence.

Due to surgical risks, mainly chronic pain risk, the use of external devices to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.) are often used. In particular, we can mention uncomplicated incisional hernias that arise shortly after the operation (should only be operated after a few months), or inoperable patients. There have been known cases where hiatal and esophageal hernias have shown signs of improvements after the patient stopped producing stress on the affected area by fasting or parenteral nutrition. It is essential that the hernia not be further irritated by carrying out strenuous labour.

Complications

Complications may arise post-operation, including rejection of the mesh that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localised swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed.

A surgically treated hernia can lead to complications, while an untreated hernia may be complicated by:

• Inflammation
• Irreducibility
• Obstruction of any lumen, such as bowel obstruction in intestinal hernias
• Strangulation
• Hydrocele of the hernial sac
• Haemorrhage
• Autoimmune problems
• Incarceration, which is where it cannot be reduced, or pushed back into place,^[13] at least not without very much external effort.^[14] In intestinal hernias, this also substantially increases the risk of bowel obstruction and strangulation.

References

1. ^ "hernia" at Dorland's Medical Dictionary
2. ^ "Symptoms". http://www.mayoclinic.com/health/inguinal-hernia/DS00364/DSECTION=symptoms. Retrieved 2010/05/24. 
3. ^ "Hernia Symptoms and Signs". http://www.emedicinehealth.com/hernia/page4_em.htm. Retrieved 2010-05-24. 
4. ^ Lee HK, Park SJ, Yi BH (2010). "Multidetector CT reveals diverse variety of abdominal hernias". Diagnostic Imaging 32 (5): 27–31. http://www.diagnosticimaging.com/ct/content/article/113619/1575055. 
5. ^ "Hiatal Hernia Symptoms, Causes And Relation To Acid Reflux And Heartburn". http://inguinalhernia.us/hiatal-hernia-causes.html. Retrieved 2010-05-24. ^{[dead link]}
6. ^ "Hernia Causes". http://www.emedicinehealth.com/hernia/page2_em.htm. Retrieved 2010-05-24. 
7. ^ Desarda MP (2003). "Surgical physiology of inguinal hernia repair—a study of 200 cases". BMC Surg 3: 2. doi:10.1186/1471-2482-3-2. PMC 155644. PMID 12697071. http://www.biomedcentral.com/1471-2482/3/2. 
8. ^ Bittner JG, Edwards MA, Shah MB, MacFadyen BV, Mellinger JD (August 2008). "Mesh-free laparoscopic spigelian hernia repair". Am Surg 74 (8): 713–20; discussion 720. PMID 18705572. http://openurl.ingenta.com/content/nlm?genre=article&issn=0003-1348&volume=74&issue=8&spage=713&aulast=Bittner%20JG. 
9. ^ "Hernia Surgery". Hernia Symptoms. http://herniasymptoms.blogsavy.com/hernia-surgery/. Retrieved 11 October 2011. 
10. ^ Sohail MR, Smilack JD (June 2004). "Hernia repair mesh-associated Mycobacterium goodii infection". J. Clin. Microbiol. 42 (6): 2858–60. doi:10.1128/JCM.42.6.2858-2860.2004. PMC 427896. PMID 15184492. http://jcm.asm.org/cgi/pmidlookup?view=long&pmid=15184492. 
11. ^ http://www.uptodate.com/patients/content/topic.do?topicKey=~AewAWy90g.DiQX
12. ^ http://www.usdrugrecall.com/category/kugel-hernia-patch-recall
13. ^ Trudie A Goers; Washington University School of Medicine Department of Surgery; Klingensmith, Mary E; Li Ern Chen; Sean C Glasgow (2008). The Washington manual of surgery. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 0-7817-7447-0. 
14. ^ onlinedictionary.datasegment.com > incarcerated Citing: Webster 1913

External links

• Hernia Resources
• The Hernia Blog
• Hernia Symptoms
• Sports Hernia: Common Misdiagnosis
• Hernia:The World Journal of Hernia and Abdominal Wall Surgery

Pictures

Wikimedia Commons has media related to: Hernia

• Hernia Types and Classifications
• Photos of Hernias

Look up hernia in Wiktionary, the free dictionary.

v d e Digestive system · Digestive disease · Gastroenterology (primarily K20–K93, 530–579) Upper GI tract Esophagus Esophagitis (Candidal, Herpetiform) · rupture (Boerhaave syndrome, Mallory-Weiss syndrome) · UES (Zenker's diverticulum) · LES (Barrett's esophagus) · Esophageal motility disorder (Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, Gastroesophageal reflux disease (GERD)) · Laryngopharyngeal reflux (LPR) · Esophageal stricture · Megaesophagus Stomach Gastritis (Atrophic, Ménétrier's disease, Gastroenteritis) · Peptic (gastric) ulcer (Cushing ulcer, Dieulafoy's lesion) · Dyspepsia · Pyloric stenosis · Achlorhydria · Gastroparesis · Gastroptosis · Portal hypertensive gastropathy · Gastric antral vascular ectasia · Gastric dumping syndrome · Gastric volvulus Lower GI tract: Intestinal/ enteropathy Small intestine/ (duodenum/jejunum/ileum) Enteritis (Duodenitis, Jejunitis, Ileitis) — Peptic (duodenal) ulcer (Curling's ulcer) — Malabsorption: Coeliac · Tropical sprue · Blind loop syndrome · small bowel bacterial overgrowth syndrome  · Whipple's · Short bowel syndrome · Steatorrhea · Milroy disease · bile acid malabsorption Large intestine (appendix/colon) Appendicitis · Colitis (Pseudomembranous, Ulcerative, Ischemic, Microscopic, Collagenous, Lymphocytic) · Functional colonic disease (IBS, Intestinal pseudoobstruction/Ogilvie syndrome) — Megacolon/Toxic megacolon · Diverticulitis/Diverticulosis Large and/or small Enterocolitis (Necrotizing) · IBD (Crohn's disease) — vascular: Abdominal angina · Mesenteric ischemia · Angiodysplasia — Bowel obstruction: Ileus · Intussusception · Volvulus · Fecal impaction — Constipation · Diarrhea (Infectious) · Intestinal adhesions Rectum Proctitis (Radiation proctitis) · Proctalgia fugax · Rectal prolapse · Anismus Anal canal Anal fissure/Anal fistula · Anal abscess  · Anal dysplasia  · Pruritus ani GI bleeding/BIS Upper (Hematemesis, Melena) · Lower (Hematochezia) Accessory Liver Hepatitis (Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis) · Cirrhosis (PBC) · Fatty liver (NASH) · vascular (Budd-Chiari syndrome, Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver) · Alcoholic liver disease · Liver failure (Hepatic encephalopathy, Acute liver failure) · Liver abscess (Pyogenic, Amoebic) · Hepatorenal syndrome · Peliosis hepatis Gallbladder Cholecystitis · Gallstones/Cholecystolithiasis · Cholesterolosis · Rokitansky-Aschoff sinuses · Postcholecystectomy syndrome · Porcelain gallbladder Bile duct/ other biliary tree Cholangitis (PSC, Secondary sclerosing cholangitis, Ascending) · Cholestasis/Mirizzi's syndrome · Biliary fistula · Haemobilia · Gallstones/Cholelithiasis common bile duct (Choledocholithiasis, Biliary dyskinesia) · Sphincter of Oddi dysfunction Pancreatic Pancreatitis (Acute, Chronic, Hereditary, Pancreatic abscess) · Pancreatic pseudocyst · Exocrine pancreatic insufficiency · Pancreatic fistula Abdominopelvic Hernia Diaphragmatic (Congenital) · Hiatus Inguinal (Indirect, Direct) · Umbilical · Femoral · Obturator · Spigelian lumbar (Petit's, Grynfeltt-Lesshaft) undefined location (Incisional · Internal hernia) Peritoneal Peritonitis (Spontaneous bacterial peritonitis) · Hemoperitoneum · Pneumoperitoneum M: DIG anat(t, g, p)/phys/devp/enzy noco/cong/tumr, sysi/epon proc, drug(A2A/2B/3/4/5/6/7/14/16), blte

v d e Congenital diaphragm and abdominal wall defects, abdominopelvic cavity (Q79.0–Q79.5, 756.6–756.7) Thoracic diaphragm Hernia: Congenital diaphragmatic hernia (Bochdalek hernia) Abdominal wall Omphalocele · Gastroschisis · Prune belly syndrome M: MUS, DF+DRCT anat (h/n, u, t/d, a/p, l)/phys/devp/hist noco(m, s, c)/cong(d)/tumr, sysi/epon, injr proc, drug (M1A/3)

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Dansk (Danish)
n. - brok

Nederlands (Dutch)
hernia, breuk

Français (French)
n. - hernie

Deutsch (German)
n. - (Med.) Bruch

Ελληνική (Greek)
n. - (παθολ.) κήλη

Italiano (Italian)
ernia

Português (Portuguese)
n. - hérnia (f) (Patol.)

Русский (Russian)
грыжа

Español (Spanish)
n. - hernia

Svenska (Swedish)
n. - bråck (med.)

中文（简体）(Chinese (Simplified))
疝气, 脱肠

中文（繁體）(Chinese (Traditional))
n. - 疝氣, 脫腸

한국어 (Korean)
n. - 헤르니아, 탈장

日本語 (Japanese)
n. - ヘルニア, 脱腸

العربيه (Arabic)
‏(الاسم) فتق أو فتاق مرض‏

עברית (Hebrew)
n. - ‮בקע, שבר, חולשת חיבור בין שרירים המאפשרת בליטה של איבר פנימי דרכו‬

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