Hernia

Hernia Landing page
Patient Information
Classification Inguinal hernia Femoral hernia Umbilical hernia Diaphragmatic hernia Incisional hernia Others
Differential Diagnosis
CNS Hernia Brain Hernia Lumbar Disc Hernia
Diaphragmatic Hernia Bochdalek Hernia Morgagni Hernia
Hiatal Hernia Sliding Hernia Paraesophageal Hernias
Lumbar Hernia Petit's Hernia Grynfeltt's Hernia
Abdominal Hernia Umbilical Hernia Epigastric Hernia Spigelian Hernia Incisional Hernia Amyand's Hernia Richter's Hernia Parastomal Hernia
Pelvic Hernia Inguinal Hernia Obturator Hernia Perineal Hernia Incisional Hernia Femoral Hernia Sciatic Hernia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2], Anmol Pitliya, M.B.B.S. M.D.[3]

Overview

A hernia is “the protrusion of an organ, organic part, or other bodily structure through the wall that usually contains it. Hernias may be congenital or acquired. Based on the protruded body structure and the location of the protrusion, the hernia may be classified into inguinal, femoral, umbilical, diaphragmatic, incisional, and other hernias. Different kinds of hernias, such as central nervous system (CNS), diaphragmatic, lumbar, abdominal, and pelvic hernias have to be differentiated on the basis of clinical manifestations.

Classification

Major classification of hernias in human body.

Hernia

CNS

Hiatal

Diaphragmatic

Lumbar

Abdominal

Pelvic

Brain hernia

Lumbar disc hernia

Morgagni hernia

Bochdalek hernia

Petit's hernia

Grynfeltt's hernia

Inguinal hernia

Obturator hernia

Perineal hernia

Femoral hernia

Sciatic hernia

Sliding hernia

Paraesophageal hernia

Umbilical hernia

Epigastric hernia

Spigelian hernia

Incisional hernia

Amyand's hernia

Littre's hernia

Richter's hernia

Parastomal hernia

Differential Diagnosis

• Different kinds of hernias, such as central nervous system (CNS), diaphragmatic, lumbar, abdominal, and pelvic hernias have to be differentiated upon various history, symptoms, and physical examination findings.

Location	Diseases	History and Symptoms						Physical Examination				Laboratory Findings			Definition
		Neurological		GI				Neurological		GI
		Confusion	Paresthesia	Dysphagia	Heartburn	Nausea	Bowel habits	Loss of Consciousness	Straight leg raise (SLR)	Mass protrusion	Tenderness/Rebound tenderness	Leukocytosis	CRP	ESR
CNS	Brain hernia	+	+	+	-	+	-	+	-	-	-	-	-	-	Brain tissue herniation through foramen magnum
	Lumbar disc hernia	-	+	-	-	-	-	-	+	-	-	-	-	-	Nucleus pulposus herniation through annulus fibrosus
Hiatal	Sliding hernia	-	-	+	+	+	-	-	-	-	-	-	+	-	Stomach herniation through diaphragm
	Paraesophageal hernia	-	-	+	+	+	-	-	-	-	-	-	-	-	Esophagus herniation through diaphragm
Diaphragmatic	Morgagni hernia	-	-	+	-	+	-	-	-	-	-	-	-	-	Congenital herniation of stomach through left side of diaphragm
	Bochdalek hernia	-	-	+	-	+	-	-	-	-	-	-	-	-	Congenital herniation of stomach through right anterior side of diaphragm
Abdominal	Umbilical hernia	-	-	-	-	+	+	-	-	+	+	+	+	-	Bowels herniation through umbilicus
	Epigastric hernia	-	-	-	+	+	+	-	-	+	+	+	+	-	Bowels herniation through epigastric abdominal wall
	Spigelian hernia	-	-	-	-	+	+	-	-	+	+	+	+	-	Bowels herniation through lateral abdominal wall
	Amyand's hernia	-	-	-	-	+	+	-	-	+	+	+	+	-	Appendix vermiformis herniation through abdominal wall
	Littre's hernia	-	-	-	-	+	+	-	-	+	+	+	+	-	Meckel's diverticulum herniation through abdominal wall
	Richter's hernia	-	-	-	-	+	+	-	-	+	+	+	+	+	Bowels herniation and strangulation through abdominal wall
	Parastomal hernia	-	-	-	-	+	+	-	-	+	+	+	+	+	Bowels herniation through stoma in the abdominal wall
Pelvic	Inguinal hernia	-	-	-	-	-	+	-	-	+	+	-	-	-	Bowels herniation through inguinal ring
	Obturator hernia	-	+	-	-	-	+	-	-	-	+	-	-	-	Viscera herniation through obturator canal
	Perineal hernia	-	-	-	-	-	+	-	-	+	+	+	-	-	Viscera herniation through pelvic floor
	Femoral hernia	-	+	-	-	-	+	-	-	+	+	-	-	-	Bowels herniation through femoral ring
	Sciatic hernia	-	+	-	-	-	+	-	+	-	+	+	-	+	Viscera herniation through sciatic canal

CNS Hernia

Different types of brain herniation - By User:Delldot, via Wikimedia Commons Lumbar disc herniation - By BruceBlaus, via Wikimedia Commons

Brain hernia

• Brain hernia is most commonly due to increase in intracranial pressure (ICP).
• The cardinal features of brain herniation is acute loss of consciousness, ipsilateral pupillary dilation, and contralateral hemiparesis.
• There are 4 types of brain hernation:
  • Type 1: Subfalcine herniation
  • Type 2: Transalar herniation (ascending and descending)
  • Type 3: Transtentorial herniation (uncal herniation)
  • Type 4: Extracranial herniation

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Lumbar disc hernia

• Lumbar disc hernia is related to old age, lack of physical activity, and all the factors that may result in dehydration of intervertebral discs.
• The cardinal features of lumbar disc herniation is radiculopathy, decreased deep tendon reflexes, and muscular atrophy.
• The mainstay of treatment in lumbar disc hernia is complete bed rest.
• Neurosurgical interventions may be indicated in patients with refractory symptoms unresponsive to medical therapy.

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Diaphragmatic Hernia

Bochdalek hernia

• Bochdalek hernia is the most common type (80-90%) of congenital diaphragmatic hernia.
• Bochdalek hernia is herniation of stomach through posterior left side of the diaphragm.
• If the Bochdalek hernia occurs in utero, the neonate present with complications including pulmonary hypoplasia and even death.

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Morgagni hernia

• Morgagni hernia is less common (10-20%) than Bochdalek congenital diaphragmatic hernia.
• Morgagni hernia is most commonly retrosternal and on the right side of the diaphragm.
• Morgagni hernia occurs in approximately 50 per 100,000 pregnancies.

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Hiatal Hernia

Sliding hernia

Different types of hiatal herniation - By Mysid, via Wikimedia Commons

Type I

• Sliding hernia accounts for more than 95% of all cases of hiatal hernia.
• Sliding hernia is herniation of distal esophagus and also gastric cardia into the thoracic space.
• Displacement of less than 2 cm is considered as physiologic displacement, mostly occurred during swallow process.

Paraesophageal hernias

Type II

• Type II of paraesophageal hernias is the classic herniation of a part of gastric fundus, but not gastroesophageal junction, into the thoracic cavity.
• Without surgical repair and fixation of the herniated portion, it leads to incarceration and may lead to complications.

Type III

• Type III of paraesophageal hernias is the combination of both type I and type II.
• In type III, gastric fundus is herniated through the diaphragm along with gastroesophageal junction.

Type IV

• The most severe form of the hiatal hernia is type IV, which consists of herniation of other abdominal organs along with stomach and distal esophagus into thoracic cavity.
• Severe respiratory distress and dyspepsia may occur secondary to type IV paraesophageal hernia.

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Lumbar Hernia

Lumbar triangles - Zyryab at English Wikipedia, via Wikimedia Commons

Petit's hernia

• Inferior lumbar region has a triangle formed by the iliac crest, the margins of the latissimus dorsi muscle, and external abdominal oblique muscles.
• Petit's hernia is defined as herniation of retroperitoneal fat through internal oblique muscle aponeurosis within the inferior lumbar triangle.
• Petit's hernia commonly occurs on the left side and in males.
• Strangulation rarely occurs in Petit's hernia, because of wide herniation neck.

Grynfeltt's hernia

• Superior lumbar region has a triangle formed formed medially by the quadratus lumborum muscle, laterally by the internal abdominal oblique muscle, and superiorly by the 12th rib.
• Grynfeltt's hernia is defined as herniation of retroperitoneal fat through transversalis muscle aponeurosis within the superior lumbar triangle.
• The mainstay of treatment for lumbar hernias is surgery fixation.

Abdominal Hernia

Umbilical hernia - By Rocco_Cusari, via Wikimedia Commons Epigastric hernia - By PacoPeramo (Own work), via Wikimedia Commons Spigelian hernia - By AfroBrazilian (Own work), via Wikimedia Commons Amyand's hernia: presence of appendix vermiformis (red arrows) in inguinal hernia - By Hellerhoff (Own work), via Wikimedia Commons

Umbilical hernia

• Umbilical hernia consists of 6% of all abdominal hernias in adults.
• The mainstay of treatment for umbilical hernia is surgery, including Mesh repair, Mayo repair, and laparoscopic repair.
• Strangulation and incarceration are very rare in umbilical hernia.

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Epigastric hernia

• Epigastric hernia is accounted for 0.5-5% of hernias.
• Epigastric hernia is a kind of abdominal wall herniation which is caused by weakness or defect in upper abdominal muscles or tendons.
• The herniated contents are mostly vascular structures and properitoneal fat, rarely abdominal viscera.

Spigelian hernia

• Spigelian hernia is caused by a defect in anterior abdominal wall. It is also named “spontaneous lateral ventral hernia” or “hernia of semilunar line”.
• The mainstay of treatment for Spigelian hernia is surgery, can be done laparoscopically or total exteraperitoneal repair method.
• Incarceration and secondary bowel obstruction are the probable complications of Spigelian hernia.

Incisional hernia

• Incisional hernia occurs in 20% of patients postoperatively.
• The common risk factors for patients with postoperative incisional hernia include obesity, diabetes, emergency surgery, postoperative wound dehiscence, smoking, and post-operative wound infection.
• The mainstay of treatment for incisional hernia is open abdominal fixation surgery.

Amyand's hernia

• Amyand's hernia is a kind of inguinal hernia which contains appendix vermiformis.
• The incidence of Amyand's hernia is approximately 0.19% to 1.7% of all reported hernias.
• The strangulation and infarction are common complications of Amyand's hernia.

Littre's hernia

• Littre's hernia is incarcerated Meckel's diverticulum in femoral, inguinal, or umbilical hernia.
• Littre's hernia is a very rare condition, reported only in 50 cases till date.
• Bowel obstruction and local inflammation are the possible complications.

Richter's hernia

• Richter's hernia is first described in 1598.
• Richter's hernia is the incarceration of a part of bowel in femoral, inguinal, or umbilical hernia.
• Since the high rates of strangulations and bowels infarctions, the mortality rate is very high and emergency surgical intervention is mandatory.

Parastomal hernia

• Parastomal hernia is a common complication of colostomy or ileostomy, actually a type of incisional hernia related to them.
• Parastomal hernia is classified into 4 subtpes:
  • Interstitial: The hernial sac lies within the layers of the abdominal wall.
  • Subcutaneous: The hernial sac lies in the subcutaneous plane.
  • Intrastomal: The hernial sac penetrates into a spout ileostomy.
  • Peristomal (prolapse): The hernial sac lies within a prolapsing stoma.

Pelvic Hernia

Inguinal hernia

• Inguinal hernia accounts for 75% of all hernias. Inguinal hernia repair is one of the most common surgeries in US (28 per 100,000 individuals).
• Inguinal hernia is a bulging lump in groin region, presents commonly without pain or local inflammation.
• Inguinal hernias classification is as follows:
  • Direct hernia: The hernia sac herniates directly through the posterior wall of the inguinal canal.
  • Indirect hernia: The hernia sac herniates through the internal inguinal ring alongside the spermatic cord.

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Obturator hernia

• Less than 1% of all hernias are obturator hernia, and majority of times occurs in elderly women with chronic disease.
• Obturator hernia is herniation of small intestine through obturator canal, therefore mechanical small intestine obstruction is the most common complication.
• The most common symptoms of obturator hernia are groin and proximal thigh pain.

Perineal hernia

• Perineal hernia is herniation of intraperitoneal or extraperitoneal contents through a congenital or acquired defect of the pelvic diaphragm.
• Perineal hernia may be anterior or posterior to the superficial perineal muscles.
• Majority of the times perineal hernias are congenital condition, while acquired perineal hernias are incisional hernia secondary to major pelvic surgeries (e.g., abdominoperineal resection of the anorectum and pelvic exenteration).

Femoral hernia

• Femoral hernia is the condition in which bowels herniate through femoral triangle medial to femoral vessels.
• The classification of femoral hernias into prevascular and retrovascular hernias is based on their position related to femoral vessels.
• Strangulation and incarceration of femoral hernias are common.

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Sciatic hernia

• Sciatic hernia is a rare herniation of bowels through the greater or lesser sciatic foramen.
• The symptoms and physical examinations are very similar to obturator hernia.
• Swelling of gluteal region, severe pelvic pain and local paresthesia are the common symptoms of sciatic hernia.
• The mainstay of treatment is surgery and includes transabdominal and transgluteal approaches.