results from failure of the neonatal umbilical scar to heal fully
incidence 10-30% of children
do not usually cause problems
many close by 12-18 months of age
repair is rarely recommended under age 3 years
adult onset herniae:
result from increased intra-abdominal pressure such as pregnancy, ascites, obesity
3x more common in women
adult hernia are more likely to present as incarcerated omentum or preperitoneal fat in men
epigastric hernia
defects are usually only ~1cm and although risk is low, they are prone to developing incarceration of preperitoneal fat and usually require surgical reduction and repair
Spigelian hernia
rare with only 1,000 cases reported in medical literature and account for 1% of ventral herniae.
may be congenital or acquired, but most present in the 4th to 7th decades
occurs along the semilunar line which is caudal-most extent of the posterior rectus sheath
present as a swelling in the mid to lower abdomen just lateral to the rectus muscle and usually 0-6cm cranially above the line connecting the two ASIS
diastasis recti
acquired condition in which the left and right rectus muscles have separated but as there is no fascial defect, there is no risk of incarceration or strangulation
posterior herniae:
sciatic hernia:
rare hernia defined as protrusion of the peritoneal sac and its contents through the greater or lesser sciatic foramen
affects women more than men, can affect children
may entrap:
small bowel, resulting in gluteal mass, small bowel obstruction, and later, a gluteal abscess secondary to incarcerated and delayed diagnosis, or following intramuscular injection which inadvertently penetrates the hernial sac
omentum
ureter resulting in ureteric obstruction
ovary or Fallopian tube
colon
bladder
Meckel's diverticulum
the herniated sac may compress the sciatic nerve resulting in sciatica and atrophy of the gluteal muscles
usually requires CT scan +/- MRI scan for diagnosis
symptomatic sciatic hernia should be surgically treated as soon as possible, as the risk of strangulation of the bowel is high
lumbar herniae:
rare hernia occurring through the either the superior lumbar (Grynfeltt-Lesshaft) triangle, or less commonly, through the more superficial, inferior lumbar (Petit) triangle
20% are congenital, rare and are often seen with other anomalies, such as undescended testes, bilateral renal agenesis, and lumbocostovertebral syndrome
55% are primary acquired “spontaneous” usually due to increased intra-abdominal pressure but risk factors include:
age, extremes of body habitus, rapid weight loss, chronic disease, muscular atrophy, chronic bronchitis, wound infection, post-op sepsis, and strenuous physical activity
25% are secondary acquired resulting from surgery, hepatic abscesses, pelvic bone infections, infected retroperitoneal haematoma, trauma, etc.
urinary obstruction if contents include ureter or kidney
Mx of abdominal herniae in ED
Reducing a strangulated hernia in ED may cause peritonitis and precipitate earlier sepsis - DO NOT attempt reduction if you suspect it may be strangulated!