Hernia is a protrusion of any viscus from its surrounding tissue
walls. More than half a million hernias are repaired annually by
surgeons in the U.S.1 With nearly 10% of
the population developing some sort of hernia during their lifetime,
this is among the most common of surgical problems.2 There
are also several other types of uncommon hernias, of which the emergency
physician should be aware. Hernias are classified by anatomic location,
hernia contents, and the status of those contents (e.g., reducible,
strangulated, or incarcerated).3
A hernia is called reducible when the hernia
sac itself is soft and easy to replace back through the hernia neck
defect. A hernia is incarcerated when it is firm,
often painful, and nonreducible by direct manual pressure. Strangulation develops
as a consequence of incarceration and implies impairment of blood
flow (arterial, venous, or both). A strangulated hernia presents
as severe, exquisite pain at the hernia site, often with signs and
symptoms of intestinal obstruction, toxic appearance, and, possibly,
skin changes overlying the hernia sac. A strangulated hernia is an
acute surgical emergency. This chapter discusses hernias in adults. Hernias
in children are discussed in Chapter 124, Acute Abdominal Pain in Children.
Seventy-five percent of all hernias occur in the inguinal region,
making it the most common form of hernia, with two thirds of these
being of the indirect type (Figure 87-1).
Although there is a clear male predilection, inguinal hernias are
also the most common hernias in women. Inguinal hernias present
as a groin mass. Typically the mass has been present for some time,
but may have recently become larger or the patient may have begun
to develop symptoms of incarceration or strangulation. The differential
diagnosis for a groin mass is somewhat broad and includes, in addition
to hernia, hidradenitis, or other abscess, sebaceous cyst, lymphoma,
hydrocele, varicocele, femoral hernia, femoral aneurysm, etc. Thankfully,
the physical examination for most hernias is fairly straightforward. Bedside
US can be very helpful in the identification of an inguinal hernia
if the diagnosis remains in question (Figure 87-2).
One study reported 100% sensitivity and 100% specificity
of bedside emergency US for the diagnosis of groin hernia.4
Incarcerated hernia. A. An incarcerated
femoral hernia is demonstrated as a small bowel segment herniated
through the femoral canal. B. In an incarcerated incisional
hernia, a small-bowel segment (arrow) is demonstrated ...
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