Table of contents · 10 sections
In a nutshell. A hernia is the protrusion of organs or their parts from the abdominal cavity through "weak spots" of the abdominal wall within a sac formed by the parietal peritoneum. 4 components: defect (ring), sac, contents, coverings. The most frequent location is inguinal (75%). The main complication is strangulation, which requires emergency surgery. The modern standard is mesh repair (Lichtenstein, laparoscopic TAPP/TEP).
1. Definition and anatomy
Anterior abdominal wall hernia (hernia abdominalis) is the protrusion of internal organs covered by the parietal peritoneum through natural or acquired openings (weak spots) of the abdominal wall beyond its boundaries while the skin remains intact.
Do not confuse with evisceration (protrusion of organs through a defect with disruption of all layers, including the skin) and prolapse (prolapsus, without a peritoneal sac — e.g., mucous membrane in hemorrhoids).
Hernia components
- Hernial ring (defect) — a defect in the abdominal wall (inguinal canal, umbilical ring, linea alba).
- Hernial sac — a protrusion of the parietal peritoneum. Consists of the orifice, neck, body, and fundus.
- Sac contents — any mobile organ: intestinal loops, greater omentum, ovary, urinary bladder.
- Hernial coverings — superficial tissues overlying the sac (skin, subcutaneous adipose tissue, fasciae).
2. Risk factors for hernia development
Predisposing: congenital connective tissue weakness (dysplasia, Marfan syndrome), sex (inguinal hernias are more common in men, femoral in women), age, habitus, heredity.
Precipitating (increasing intra-abdominal pressure): heavy physical labor, chronic cough, constipation, prostate adenoma, ascites, obesity, multiple pregnancy.
3. Classification
By location
- Inguinal (75%): indirect (through the deep inguinal ring, lateral to the inferior epigastric artery) and direct (through the medial fossa, medial to the artery).
- Femoral (5–8%): through the femoral canal below the inguinal ligament; more common in women, frequently strangulated.
- Umbilical (3–5%): through the umbilical ring.
- Linea alba hernias (epigastricae): along the linea alba between the xiphoid process and the umbilicus.
- Incisional (ventral): at the site of a scar following laparotomy (5–20% of all surgical wounds).
- Rare: Spigelian, lumbar, obturator, perineal.
By clinical course
- Reducible (reponibilis) — the contents easily return to the abdominal cavity.
- Irreducible (irreponibilis) — adhesions between the sac and the contents; the hernia persists, but there is no ischemia.
- Strangulated (incarcerata) — acute compression of the contents at the hernia ring; threat of necrosis. Requires emergency surgery.
- Coprostasis, inflammation — specific complications.
Inguinal: indirect vs direct
| Sign | Indirect | Direct |
|---|---|---|
| Pathway | Through the inguinal canal (internal → external ring) | Through the posterior wall of the canal |
| Relation to the inferior epigastric artery | Lateral | Medial |
| Nature | Congenital or acquired | Acquired only |
| Age | Any | Elderly |
| Scrotum | May descend | Usually does not descend |
| Risk of strangulation | Higher | Lower |
4. Clinical presentation
Main complaints: protrusion that increases with straining and disappears in the supine position; dragging pain; discomfort during physical exertion. Large hernias limit work capacity.
Inspection and palpation must be performed in two positions: standing (hernia is most pronounced) and supine. The hernia ring, cough impulse test, and reducibility are evaluated.
5. Hernia strangulation — an emergency situation
Mechanisms
- Elastic strangulation — sudden increase in intra-abdominal pressure → protrusion of a larger volume of contents → narrowing of the ring → compression.
- Fecal strangulation — overfilling of the intestinal loop within the hernia → impaired blood flow → necrosis.
- Richter's (partial) hernia — strangulation of only a part of the intestinal wall. Dangerous: without clear clinical signs of acute intestinal obstruction upon necrosis.
- Littre's hernia — incarceration of Meckel's diverticulum.
Clinical Practice
- Sudden sharp pain in the hernia area.
- The hernia is irreducible, painful, and tense.
- Cough impulse sign is absent.
- In case of bowel loop incarceration — presentation of acute intestinal obstruction: vomiting, delayed stool and gas passage.
- Deterioration of general condition, tachycardia, followed by intoxication.
Prohibited: forceful reduction of an incarcerated hernia — risk of "false reduction" with displacement of the necrotic loop into the abdominal cavity. Exception — in children during the first 1–2 hours when attempting conservative reduction under surgical supervision.
6. Diagnostics
- Clinical examination — usually sufficient.
- Soft tissue ultrasound — confirmation of small, irreducible, and recurrent hernias.
- CT with Valsalva maneuver — for complex postoperative and rare hernias.
- CBC, biochemistry, coagulogram, ECG — preoperative.
7. Treatment: principles and methods
There is no conservative treatment. All hernias are an indication for elective surgery, incarcerated ones — for emergency surgery.
Elective surgery
Steps: herniotomy (isolation and opening of the sac), revision and reduction of contents, excision of the sac, hernioplasty (closure of the hernia ring).
| Method | Essence | Recurrences |
|---|---|---|
| Tissue-based repair (Bassini, Shouldice) | Suturing of native tissues | 10–15 % |
| Lichtenstein (tension-free) | Reinforcement of the posterior wall with a polypropylene mesh | 1–3 % |
| TAPP / TEP (laparoscopic) | Placement of the mesh into the preperitoneal space | 1–3 % |
The modern standard for primary and recurrent hernias is tension-free mesh repair (Lichtenstein or laparoscopic).
Emergency surgery for incarceration
- Herniotomy — opening of the sac before transecting the ring (otherwise the contents will "drop" into the abdominal cavity without revision).
- Assessment of bowel viability: color, peristalsis, pulsation of mesenteric vessels, luster of the serosal membrane. When in doubt — warming with warm saline for 15–20 minutes and re-evaluation.
- In case of necrosis — bowel resection with anastomosis.
- Plasty — with a polypropylene mesh only in the absence of infection; otherwise — tissue-based repair.
8. Surgical complications
- Early: hematoma, seroma, wound infection, injury to the spermatic cord / nerve (ilioinguinal n.) with chronic pain syndrome.
- Late: recurrence (the main criterion for quality assessment), chronic pain syndrome, mesh infection.
9. Prevention
- Treatment of chronic factors increasing intra-abdominal pressure: constipation, cough, prostate adenoma.
- Strengthening of the anterior abdominal wall muscles.
- Weight control.
- Wearing a truss — a temporary measure in patients with contraindications to surgery.
- Optimal laparotomy technique and rational closure — prevention of postoperative hernias.
10. FAQ
Can a hernia "go away on its own"?
No. Spontaneous resolution of hernias does not occur. Without surgery, the protrusion increases over time, and the risk of incarceration grows.
How soon after incarceration can the bowel be lost?
Irreversible changes in the intestine develop after 2–4 hours of incarceration. If viability is in doubt — resection.
Can a hernia be operated laparoscopically?
Yes — TAPP and TEP methods result in less pain, faster rehabilitation, with a comparable recurrence rate to open Lichtenstein.
What is the danger of Richter's hernia?
Only a part of the intestinal wall is incarcerated, intestinal obstruction does not develop, symptoms are masked — the diagnosis is often made late, already upon the onset of peritonitis.
When can heavy lifting be resumed after repair?
Restriction of load up to 5 kg for 4–6 weeks; full recovery of physical activity — in 2–3 months.
See also: Acute abdominal conditions · Peritonitis · Cholecystitis · Wounds and healing · Surgery catalog · Clinical scales