AKT · Gastroenterology/Acute abdomen & surgical

Hernias

Protrusion of viscus through a wall defect (inguinal/femoral/umbilical/incisional)

Overview

Protrusion of a viscus (usually bowel/omentum) through a defect in its containing wall. Inguinal (commonest — indirect via the deep ring, direct through Hesselbach's triangle), femoral (below/lateral to the pubic tubercle — higher strangulation risk, commoner in women), umbilical, incisional, hiatus. Most are reducible; the danger is incarceration → obstruction → strangulation (ischaemia). Repair electively, or urgently if irreducible/obstructed/strangulated.

Recognise

A lump that appears on standing/straining/coughing and reduces on lying down; ± dragging discomfort
Inguinal: above and medial to the pubic tubercle; Femoral: below and lateral to the pubic tubercle (higher strangulation risk)
Incarcerated (irreducible) → obstruction (colic, vomiting); STRANGULATED → tender, irreducible, erythematous, systemically unwell (ischaemia)

Red flags

Strangulation (tender, irreducible, red, painful lump + obstruction/peritonism) → emergency surgery
Femoral hernias strangulate more readily → repair promptly

Differentials & how to tell them apart

Inguinal vs femoral herniarelation to the pubic tubercle (inguinal above/medial; femoral below/lateral) — femoral strangulates more

Lymph node / saphena varix / lipoma / femoral aneurysmgroin-lump differentials — no cough impulse/reducibility

Hydrocele / testicular pathologycan't get above it (scrotal); transilluminates (hydrocele)

Investigations

Clinical (cough impulse, reducibility, relation to the pubic tubercle); ultrasound/CT if uncertain or for obstruction.

Management

Elective mesh repair (emergency surgery if strangulated/obstructed)

1Confirm the hernia type and reducibility. Offer elective repair for symptomatic/enlarging hernias; safety-net for strangulation.Gate: A tender, IRREDUCIBLE, erythematous hernia with obstruction/peritonism = STRANGULATION → emergency surgery (bowel ischaemia); FEMORAL hernias strangulate readily, so repair them promptly even if asymptomatic
2Mesh repair (open/laparoscopic); emergency exploration + bowel resection for strangulated/non-viable bowel.

Elective surgical repair (mesh) — definitive for symptomatic/enlarging hernias

Emergency surgery — for strangulation/obstruction/irreducibility

Key points

Reducible lump with cough impulse = hernia. Inguinal (above/medial to pubic tubercle) vs femoral (below/lateral, strangulates more). Tender + irreducible + red = strangulation = emergency.

Monitor & prognosis

Recurrence; strangulation safety-net.

Excellent with elective repair.

Source: RCS; ACPGBI