By definition, a hernia is a protrusion of any viscus (like an intestine) from its proper cavity. Hernias usually develop gradually over time and are generally benign. Hernias, however, can also be extremely dangerous when the protruding viscus cannot be reseated in its usual cavity. This can even lead to death. There are many different types of hernias. This newsletter will discuss the features of the most common types, along with the usual complications, and the medical- legal risks.
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Inguinal hernias can be divided into indirect, direct, and femoral. An indirect inguinal hernia follows the tract through the inguinal canal. The canal begins in the intraabdominal cavity at the internal inguinal ring; located approximately midway between the pubic symphysis and anterior iliac spine. The canal courses down along the inguinal ligament to the external ring; located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac. A direct inguinal hernia usually occurs due to a defect or weakness in the traversalis area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon. The femoral hernia follows the tract below the inguinal ligament through the femoral canal. The canal lies medial to the femoral vein and lateral to the lacunar ligament. Because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated. This can result in the death of healthy bowel. Incisional hernias are iatrogenic hernias that occur in 2-10% of all abdominal operations secondary to breakdown of the fascial closure of prior surgery. Even after repair, recurrence rates approach 20-45%.
Important definitions: Reducible hernias refer to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually. Incarcerated hernias are no longer reducible. Vascular supply of the bowel is not compromised, bowel obstruction is common. Strangulated hernias occurs when vascular supply of the bowel is compromised secondary to incarceration of hernia contents. Bowel death occurs.
Approximately 25% of males and 2% of females have inguinal hernias in their lifetimes; this is the most common hernia in males and females. Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct. Only 3% of hernias are femoral hernias. Incisional and ventral hernias account for 10% of all hernias. Approximately 700,000 herniorrhaphies are performed in the US each year.
Morbidity and Mortality:
Morbidity is secondary to missing the diagnosis of the hernia or complications associated with management of the disease. A hernia can lead to an incarcerated and often obstructed bowel. The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced strangulated bowel leads to persistent ischemia/necrosis with no clinical improvement.
Hernias usually present as a slowly developing asymptomatic swelling. This is innocently brought to the attention of a physician. Sometimes, the patient complains of an aching sensation in the area of swelling or fullness. If the hernia is stangulated or incarcerated the patient may complain of a variety of symptoms including nausea and vomiting, high fever, and severe pain.
In general, the physical examination should be performed with patients in both the supine and standing positions, with and without the Valsalva maneuver. The examiner should attempt to identify the hernia sac as well as the fascial defect through which it is protruding. This allows proper direction of pressure for reduction of hernia contents. The examiner should also identify evidence of obstruction and strangulation. Strangulated hernias are differentiated from incarcerated hernias by the following: pain out of proportion to the exam, fever or a toxic appearance, and pain that persists after reduction of the hernia.
Any condition that increases the pressure in the intraabdominal cavity may contribute to the formation of a hernia, including the following: Marked obesity, Heavy lifting, Coughing, Straining with defecation or urination, Ascites, Peritoneal dialysis, Ventriculoperitoneal shunt, Chronic obstructive pulmonary disease (COPD), Family history of hernias.
Lab and Imaging Studies:
Lab tests are nonspecific and imaging studies are not required in the normal workup of a hernia. The diagnosis is usually made clinically.
Protruding hernias should be reduced unless they are strangulated and there is evidence of non-viable bowel (ie. patient is toxic or septic). This is accomplished in the following manner: First, adequate sedation and analgesia is provided to prevent straining or pain. The patient should be relaxed enough to not increase intra-abdominal pressure or to tighten the involved musculature. Place the patient supine with a pillow under his or her knees. Place the patient in a Trendelenburg position of approximately 15-20° for inguinal hernias. Apply a padded cold pack to the area to reduce swelling and blood flow while establishing appropriate analgesia. Place the ipsilateral leg in an externally rotated and flexed position resembling a unilateral frog leg position. Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding over the ring during reduction attempts. Firm steady pressure should be applied to the side of the hernia contents close to the hernia opening, guiding it back through the defect. Applying pressure at the apex, or first point, that is felt may cause the herniated bowel to "mushroom" out over the hernia opening instead of advancing through it.
The spontaneous reduction technique requires adequate sedation/analgesia, Trendelenburg positioning, and padded cold packs applied to the hernia for a duration of 20-30 minutes. This can be attempted prior to manual reduction attempts. Consult with a surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use repeated forceful attempts. Also, consult with a surgeon if there is concern for a strangulated bowel or patient appears toxic. All patients suspected of having a strangulated bowel should be started on high-dose broad spectrum IV antibiotics.
The actual techniques are beyond the scope of this newsletter, but all surgical approaches have the risk of infection and nerve injury. The most common nerve injuries involve the genitofemoral nerve, the ilioinguinal nerve and the lateral cutaneous nerves. Injury to these structures can result in permanent loss of feeling in the groin and in many instances, sexual dysfunction. The surgeon must be careful to identify and protect these nerves during the procedure.
Besides the risks of nerve injury and infection there are three main areas that result in lawsuits. The first is failure to consider the diagnosis of hernia in patients who present with nausea and vomiting. This delay can lead to incarceration and/ or strangulation. The second is diagnosing testicular torsion as a hernia. This puts the testicle at risk. The third is reducing a strangulated bowel without recognizing it. Here, the hernia will be reduced, but the bowel will remain ischemic or necrotic. The patient will rapidly become septic and can easily die.
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