Chapter 46. Hernia in Adults and Children

Hernia is a protrusion of any viscus from its normal cavity. Hernias are classified by anatomic location, hernia contents, and the status of those contents (eg, reducible, incarcerated, or strangulated). Hernia is typically used to describe a protrusion of bowel through the abdominal wall. The most common abdominal hernias are inguinal, ventral, and femoral hernias (Fig. 46-1).

Predisposing factors include family history, lack of developmental maturity, undescended testes, genitourinary abnormalities, conditions that increase intraabdominal pressure (eg, ascites or pregnancy), chronic obstructive pulmonary disease, and surgical incision sites.

Most hernias are detected on routine physical examination or inadvertently by the patient. When the contents of a hernia can be easily returned to their original cavity by manipulation, the hernia is defined as reducible. A hernia becomes incarcerated when its contents are not reducible. Incarcerated hernias may lead to bowel obstruction and strangulation. Strangulation refers to vascular compromise of the incarcerated contents and is an acute surgical emergency. When not relieved, strangulation may lead to gangrene, perforation, peritonitis, and septic shock.

Symptoms other than an obvious protruding mass from the abdominal wall include localized pain, nausea, and vomiting. Signs of strangulation include severe pain and tenderness, induration and erythema over the site. Children may exhibit irritability and poor feeding. Careful evaluation for obstruction is essential.

Physical examination is the predominant means of diagnosis. Laboratory testing is of minimal value. Ultrasonographic detection of hernias is operator and body habitus dependent, but can be helpful in pediatric and pregnant patients where radiation exposure is a concern (Fig. 46-2). Computed tomography remains the best radiographic test for the evaluation of hernias.

The differential diagnosis of a groin mass includes direct or indirect hernia, testicular torsion, tumor, groin abscess, hydrocele, varicocele, and hidradenitis. In children, retracted or undescended testes may be mistaken for inguinal hernias.

Do not attempt reduction if signs of strangulation exist so as not to introduce dead bowel into the abdomen.

1. To reduce a hernia, (a) place the patient in Trendelenburg, (b) externally rotate and flex the ipsilateral leg into the frog-leg position, (c) administer adequate analgesia or procedural sedation; children will require procedural sedation, (d) place a padded ice pack to reduce swelling and blood flow to the area, and (e) grasp and elongate the hernia neck with one hand, and with the other hand apply firm, steady pressure to guide the hernia through the fascial defect.

2. Adults with easily reducible hernias can be referred for outpatient surgical evaluation and repair. Patients should avoid heavy lifting and return to the ED if herniation recurs and cannot be reduced promptly. Discuss signs of obstruction.

3. Incarcerated hernias that can't be reduced with 1 or 2 attempts and strangulated hernias require emergent surgical consultation and intervention. Give nothing by mouth. Initiate intravenous fluid resuscitation and administer intravenous opioid analgesia. Broad-spectrum antibiotics, such as cefoxitin 2 grams IV or piperacillin/tazobactam 3.375 grams IV, are advised if there is evidence of perforation or strangulation.

4. Infants with successfully reduced inguinal hernias should have surgical repair within 24 to 72 hours because one-third will redevelop incarceration.

5. Children with uncomplicated umbilical hernias may be discharged and followed longitudinally by their primary care providers. Refer children older than 4 years or those with hernias greater than 2 cm in diameter for surgical evaluation.