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  • abdominal herniae excluding groin or inguinal herniae:
    • ventral
      • incisional hernia
        • develop in 10-15% of sites of surgical incision in the abdominal wall as a result of failure of the fascial layers to close post-operatively
        • risk factors include obesity, slow wound healing (eg. smoking, corticosteroids, malnutrition, wound infection, etc), excessive wound tension, connective tissue (CT) disorders, midline incisions, compromised sutures or poor surgical technique
      • umbilical hernia
        • childhood herniae:
          • 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.
      • may present as:

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!
  • determine type of hernia
  • if patient is not toxic, not unwell and has no signs of peritonitis, then try to reduce it
    • is it reducible or irreducible (incarcerated)?
  • is it strangulated?
  • if it is incarcerated or possibly strangulated then:
    • urgent general surgical consult
    • nil orally
    • iv fluids
    • FBE, U&E
    • NG tube if bowel is likely to be involved
    • consider erect/supine AXR and erect CXR to help exclude perforated bowel
    • consider contrast abdo CT scan if there is still concern of strangulation or incarceration
    • consider iv antibiotics if peritonitis
  • if there is no evidence of strangulation of bowel and it is reducible:
    • children with umbilical herniae, can generally be reassured and followed by their LMO
    • other patients can be referred to general surgery outpatients
    • ensure patients are informed as to which symptoms necessitate emergent review.
    • if examination findings are difficult to assess, consider referral to ultrasound
hernias.txt · Last modified: 2018/04/03 08:53 by

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