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Abdominal Hernias Workup

  • Author: Assar A Rather, MBBS, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 01, 2015
 

Approach Considerations

Laboratory studies are not specific for hernia but may be useful for general medical evaluation. Imaging studies are not required in the normal workup of a hernia[8, 9] ; however, radiography, computed tomography (CT), or ultrasonography may be considered in certain circumstances. Sigmoidoscopy is no longer recommended as a screening test.

Evaluation for potential reversal of provocative factors (eg, prostatism, chronic cough, severe constipation, rectal cancer, and ascites) is important.

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Laboratory Studies

Laboratory studies that may be helpful include the following:

  • Stain or culture of nodal tissue - This can help diagnose atypical tuberculous adenitis
  • Complete blood count (CBC) - Results are nonspecific, but leukocytosis with left shift may occur with strangulation
  • Electrolyte, blood urea nitrogen (BUN), and creatinine levels - It is advisable to assess the hydration status of the patient with nausea and vomiting; these tests are rarely needed for patients with hernia except as part of a preoperative workup
  • Urinalysis - This can help narrow the differential diagnosis of genitourinary causes of groin pain in the setting of associated hernias
  • Lactate levels - Elevation may reflect hypoperfusion; a normal level does not necessarily rule out strangulation
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Radiography

Plain radiographs taken tangentially may show air in the intestine outside the abdomen, as may contrast studies of the bowel. Unfortunately, visualization of the perineum and pelvis is poor with these studies. Higher yields can be obtained with dynamic changes in position, intra-abdominal pressure, or both during the imaging studies. Better assessments of the perineum and pelvis are possible via external views of the intestine and their domain with herniography.

Careful instillation of water-soluble nonionic contrast through the abdominal wall helps to define most hidden hernias, such as interparietal, pelvic, obturator, sciatic, and other poorly palpable hernias (eg, small recurrent hernias).[28] However, unintentional luminal contrast injection may lead to infection.

If an incarcerated or strangulated hernia is suspected, the following imaging studies may be helpful:

  • Upright chest radiograph to exclude free air (extremely rare)
  • Flat and upright abdominal films to diagnose a small bowel obstruction (neither sensitive or specific) or to identify areas of bowel outside the abdominal cavity
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Computed Tomography

CT of the abdomen and pelvis with oral and intravenous (IV) contrast can help detect many elusive hernias by demonstrating extracoelomic location of the bowel, bladder, or female internal reproductive organs.[29] CT may be indicated in the diagnosis of a spigelian or obturator hernia and in cases where the patient’s body habitus makes it difficult for the physician to perform a good physical examination.

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Ultrasonography

Ultrasonography is helpful in narrowing the differential on both scrotal masses and masses below the inguinal ligament. It can also aid in the decision to drain or aspirate a nodal abscess. Like CT, ultrasonography may be indicated when a spigelian or obturator hernia is suspected or when the patient’s body habitus hinders physical examination.

Infants with omphaloceles require prompt, thorough evaluations to detect associated anomalies. Initial studies should include bilateral renal ultrasonography and echocardiography, as well as karyotyping and plain radiography of the sacrum.

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Histologic Findings

Pathologic evaluation of pediatric hernia sacs offers little relevant clinical information. Tubular structures found during pathologic examination may indicate aberrant ductuli of Haller or duplications instead of segments of the vas deferens. Ductuli are 50-100 µm in size, much smaller than even the infant vas deferens; duplications can be proved only through reexploration.

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Contributor Information and Disclosures
Author

Assar A Rather, MBBS, MD, FACS Minimally Invasive General and Colorectal Surgeon, Bayhealth Kent General Hospital

Assar A Rather, MBBS, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Colon and Rectal Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Bret A Nicks, MD, MHA Assistant Dean of Global Health, Assistant Professor, Medical Director, ED Clinical Operations, Department of Emergency Medicine, Wake Forest University School of Medicine

Bret A Nicks, MD, MHA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Christian Medical and Dental Associations, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Kim Askew, MD Assistant Professor, Director of Undergraduate Medical Education, Department of Emergency Medicine, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Kimberly M Erickson, MD Assistant Professor, Division of Pediatric Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Pediatric Trauma, NC Children's Hospital

Kimberly M Erickson, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and Children's Oncology Group

Disclosure: Nothing to disclose.

Eustace Stevers Golladay, MD Emeritus Clinical Professor of Pediatric Surgery, University of Michigan Medical Center; Consulting Staff, Department of Pediatric Surgery, Mott Children's Hospital

Eustace Stevers Golladay, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Surgical Association, Central Surgical Association, Johns Hopkins Medical and Surgical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Richard Lavely, MD, JD, MS, MPH Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine

Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Manthey DE. Abdominal hernia reduction. Clinical Procedures in Emergency Medicine. 2003.

  2. Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb. 88(1):27-43, vii-viii. [Medline].

  3. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. 1993 Jun. 73(3):413-26. [Medline].

  4. Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med. 2006 Feb. 30(2):155-7. [Medline].

  5. Scherer LR 3rd, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. 1993 Dec. 40(6):1121-31. [Medline].

  6. Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann. 2001 Dec. 30(12):729-35. [Medline].

  7. Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med. 1999 May-Jun. 17(3):515-6. [Medline].

  8. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. 2008 Apr. 45(4):261-312. [Medline].

  9. Bobrow RS. The hernia. J Am Board Fam Pract. 1999 Jan-Feb. 12(1):95-6. [Medline].

  10. Chen J, Lv Y, Shen Y, et al. A prospective comparison of preperitoneal tension-free open herniorrhaphy with mesh plug herniorrhaphy for the treatment of femoral hernias. Surgery. 2010 Mar 30. [Medline].

  11. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia--a condition seldom thought of and hence seldom sought. Int J Colorectal Dis. 2012 Feb. 27(2):133-41. [Medline].

  12. Wants GE. Abdominal wall hernias. Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994.

  13. Mensching JJ, Musielewicz AJ. Abdominal wall hernias. Emerg Med Clin North Am. 1996 Nov. 14(4):739-56. [Medline].

  14. Martin M, Paquette B, Badet N, Sheppard F, Aubry S, Delabrousse E. Spigelian hernia: CT findings and clinical relevance. Abdom Imaging. 2013 Apr. 38(2):260-4. [Medline].

  15. deVries PA. The pathogenesis of gastroschisis and omphalocele. J Pediatr Surg. 1980 Jun. 15(3):245-51. [Medline].

  16. Chen CP. Syndromes and disorders associated with omphalocele (II): OEIS complex and Pentalogy of Cantrell. Taiwan J Obstet Gynecol. 2007 Jun. 46(2):103-10. [Medline].

  17. Mattix KD, Winchester PD, Scherer LR. Incidence of abdominal wall defects is related to surface water atrazine and nitrate levels. J Pediatr Surg. 2007 Jun. 42(6):947-9. [Medline].

  18. Akbulut S, Cakabay B, Sezgin A. A familial tendency for developing inguinal hernias: study of a single family. Hernia. 2010 Aug. 14(4):431-4. [Medline].

  19. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol. 2007 May 15. 165(10):1154-61. [Medline].

  20. Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. 1998 Aug. 45(4):773-89. [Medline].

  21. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am. 1998 Dec. 78(6):941-51, v-vi. [Medline].

  22. Walker SH. The natural history of umbilical hernia. A six-year follow up of 314 Negro children with this defect. Clin Pediatr (Phila). 1967 Jan. 6(1):29-32. [Medline].

  23. Coelho JC, Claus CM, Michelotto JC, et al. Complications of laparoscopic inguinal herniorrhaphy including one case of atypical mycobacterial infection. Surg Endosc. 2010 Apr 8. [Medline].

  24. Anthony T, Bergen PC, Kim LT, Henderson M, Fahey T, Rege RV, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000 Jan. 24(1):95-100;discussion 101. [Medline].

  25. Henrich K, Huemmer HP, Reingruber B, Weber PG. Gastroschisis and omphalocele: treatments and long-term outcomes. Pediatr Surg Int. 2008 Feb. 24(2):167-73. [Medline].

  26. van Eijck FC, Wijnen RM, van Goor H. The incidence and morbidity of adhesions after treatment of neonates with gastroschisis and omphalocele: a 30-year review. J Pediatr Surg. 2008 Mar. 43(3):479-83. [Medline].

  27. Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg. 2012 Mar. 147(3):277-81. [Medline].

  28. Hamlin JA, Kahn AM. Herniography: a review of 333 herniograms. Am Surg. 1998 Oct. 64(10):965-9. [Medline].

  29. Toms AP, Dixon AK, Murphy JM, Jamieson NV. Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg. 1999 Oct. 86(10):1243-9. [Medline].

  30. Eubanks S. Hernias. Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 1997.

  31. London JA, Utter GH, Sena MJ, et al. Lack of insurance is associated with increased risk for hernia complications. Ann Surg. 2009 Aug. 250(2):331-7. [Medline].

  32. Abi-Haidar Y, Sanchez V, Itani KM. Risk factors and outcomes of acute versus elective groin hernia surgery. J Am Coll Surg. 2011 Sep. 213(3):363-9. [Medline].

  33. Smith S. Inguinal hernia reduction. King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008. 840-847/87.

  34. Pavlin DJ, Horvath KD, Pavlin EG, Sima K. Preincisional treatment to prevent pain after ambulatory hernia surgery. Anesth Analg. 2003 Dec. 97(6):1627-32. [Medline].

  35. Collaboration EH. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg. 2000 Jul. 87(7):860-7. [Medline].

  36. Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg. 2006 Jun. 41(6):1081-4. [Medline].

  37. Martin DF, Williams RF, Mulrooney T, Voeller GR. Ventralex mesh in umbilical/epigastric hernia repairs: clinical outcomes and complications. Hernia. 2008 Aug. 12(4):379-83. [Medline].

  38. Henderson D. Laparoscopic Repair Better for Primary Ventral Hernias?. Available at http://www.medscape.com/viewarticle/810457. Accessed: September 6, 2013.

  39. Liang MK, Berger RL, Li LT, Davila JA, Hicks SC, Kao LS. Outcomes of laparoscopic vs open repair of primary ventral hernias. JAMA Surg. 2013 Nov. 148(11):1043-8. [Medline].

  40. Sarosi GA Jr. Laparoscopic umbilical and epigastric hernia repair: the procedure of choice?. JAMA Surg. 2013 Nov. 148(11):1049. [Medline].

  41. Manoharan S, Samarakkody U, Kulkarni M, Blakelock R, Brown S. Evidence-based change of practice in the management of unilateral inguinal hernia. J Pediatr Surg. 2005 Jul. 40(7):1163-6. [Medline].

  42. Ballantyne A, Jawaheer G, Munro FD. Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia. Br J Surg. 2001 May. 88(5):720-3. [Medline].

  43. Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia following unilateral repair in a pediatric hospital. J Pediatr Surg. 1989 Oct. 24(10):963-5. [Medline].

  44. Holcomb GW 3rd. Diagnostic laparoscopy for contralateral patent processus vaginalis and nonpalpable testes. Semin Pediatr Surg. 1998 Nov. 7(4):232-8. [Medline].

  45. Bell C, Dubose R, Seashore J, Touloukian R, Rosen C, Oh TH, et al. Infant apnea detection after herniorrhaphy. J Clin Anesth. 1995 May. 7(3):219-23. [Medline].

  46. Parelkar SV, Oak S, Gupta R, et al. Laparoscopic inguinal hernia repair in the pediatric age group--experience with 437 children. J Pediatr Surg. 2010 Apr. 45(4):789-92. [Medline].

  47. Esposito C, Montinaro L, Alicchio F, et al. Laparoscopic Treatment of Inguinal Hernia in the First Year of Life. J Laparoendosc Adv Surg Tech A. 2010 Mar 31. [Medline].

  48. Niyogi A, Tahim AS, Sherwood WJ, et al. A comparative study examining open inguinal herniotomy with and without hernioscopy to laparoscopic inguinal hernia repair in a pediatric population. Pediatr Surg Int. 2010 Apr. 26(4):387-92. [Medline].

  49. Bonnard A, Zamakhshary M, de Silva N, Gerstle JT. Non-operative management of gastroschisis: a case-matched study. Pediatr Surg Int. 2008 Jul. 24(7):767-71. [Medline].

  50. Carlson GW, Elwood E, Losken A, Galloway JR. The role of tissue expansion in abdominal wall reconstruction. Ann Plast Surg. 2000 Feb. 44(2):147-53. [Medline].

  51. Barclay L. Mesh repair linked to less hernia recurrence, more risks. Medscape Medical News. February 21, 2014. [Full Text].

  52. Miller G. Sublay hernia repair superior to onlay technique: meta-analysis. Medscape Medical News. November 14, 2013; Accessed December 10, 2013. Available at http://www.medscape.com/viewarticle/814431.

  53. Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT, Kao LS, et al. Comparison of Outcomes of Synthetic Mesh vs Suture Repair of Elective Primary Ventral Herniorrhaphy: A Systematic Review and Meta-analysis. JAMA Surg. 2014 Feb 19. [Medline].

  54. Timmermans L, de Goede B, van Dijk SM, Kleinrensink GJ, Jeekel J, Lange JF. Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery. Am J Surg. 2013 Oct 26. [Medline].

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Large right inguinal hernia in 3-month-old girl.
In this baby with gastroschisis, bowel is uncovered and presents to right inferior aspect of cord.
Hernia of umbilical cord.
Note translucent sac in baby with large omphalocele. Umbilical vessels attach to sac.
Hernia content balloons over external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied first.
Infant with Silon chimney placed in treatment of gastroschisis.
Atrophy of right testis after hernia repair. Note adult-type incision.
Iatrogenic cryptorchid testis in child. Taking care to position testis in scrotum is integral part of completion of hernia repair in boys.
Erythematous edematous left scrotum in 2-month-old boy with history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
Testis at operation in 2-month-old boy with history of irritability and vomiting for 36 hours. Capsulotomy was performed, but atrophy occurred. Patient also required bowel resection.
Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy.
Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy. Abdominal radiograph shows incarcerated shunt within communicating hydrocele. Repair of hydrocele relieved increased intracranial pressure.
Bassini-type repair approximating transversus abdominis aponeurosis and transversalis fascia to iliopubic tract and inguinal ligament.
Anatomic locations for various hernias.
 
 
 
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