Abdominal Hernias Clinical Presentation

In an emergency setting, a patient with a hernia may present because of a complication associated with the hernia, or the hernia may be detected on routine physical examination. In most instances, the diagnosis of hernia is made because a patient, parent, or provider has observed a bulge in the inguinal region or scrotum (see the images below). This bulge is not necessarily constant but may be intermittent; depending on the intra-abdominal pressure, the herniating viscus may enter the space or remain outside it.

An asymptomatic hernia commonly has the following characteristics ^[27] :

• Swelling or fullness at the hernia site
• Aching sensation (radiating into the area of the hernia)
• No true pain or tenderness upon examination
• Enlargement with increasing intra-abdominal pressure or standing

In infants, the only symptom of a hernia may be increased irritability, especially when the hernia is large. Hernias in older children and adults may be accompanied by a dull ache or burning pain that often worsens with exercise or straining (eg, coughing). Neuralgia of the ilioinguinal nerve may present with a sudden stabbing pain in the distribution.

An incarcerated hernia may be associated with the following:

• Painful enlargement of a previous hernia or defect
• Inability to manipulate the hernia (either spontaneously or manually) through the fascial defect
• Nausea, vomiting, and symptoms of bowel obstruction (possible)

A strangulated hernia may be associated with the following:

• Symptoms of an incarcerated hernia, combined with a toxic appearance
• Possibility of systemic toxicity secondary to ischemic bowel
• Probability of strangulation if pain and tenderness of an incarcerated hernia persist after reduction

In patients who have a substantial amount of pain without evidence of incarceration or strangulation, an alternative diagnosis should be suspected.

Further anatomic considerations must be assessed in relation to the above clinical findings. The location of the underlying hernia may provide a unique constellation of symptoms, with or without specific anatomic findings, as follows:

• Femoral hernia - Because of the position of this hernia, medial thigh pain is possible in addition to groin pain
• Obturator hernia - Because this hernia is hidden within deeper structures, it may not present as a swelling; patients may complain of abdominal pain or medial thigh pain, weight loss, or recurrent episodes of bowel or partial bowel obstruction; pressure on the obturator nerve causes pain in the medial thigh that is relieved by thigh flexion but may be exacerbated by extension or external rotation of the hip (Howship-Romberg sign)
• Incisional hernia - Because this hernia is usually asymptomatic, patients typically present with a bulge at the site of a previous incision; the lesion may become larger upon standing or with increasing intra-abdominal pressure

In general, the physical examination should be performed with the patient 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.

The first step in attempting to identify a hernia is to look for a swelling or mass in the area of the fascial defect. A fingertip is placed into the scrotal sac and advanced upward into the inguinal canal. If the hernia is elsewhere on the abdomen, an attempt should be made to define the borders of the fascial defect.

If the hernia comes from superolateral to inferomedial and strikes the distal tip of the finger, it most likely is an indirect hernia. If the hernia strikes the pad of the finger from deep to superficial, it is more likely to be a direct hernia. A bulge felt below the inguinal ligament is consistent with a femoral hernia.

Strangulated hernias are differentiated from incarcerated hernias by the following:

• Pain out of proportion to examination findings
• Fever or toxic appearance
• Pain that persists after reduction of hernia

Inguinal hernia

Examination of an adult for an inguinal hernia is best performed from the seated position, with the patient standing. The inguinal canal areas for the bulge are visualized. A provocative cough may be necessary to expose the hernia; the cough is repeated as the examiner invaginates the scrotum and feels for an impulse. The diameter of the internal ring is assessed. Palpation of the cord structures is performed with the finger gently rolling perpendicular to the long axis of the cord just medial to the internal ring; this can detect thickening of the cord.

For examining a child, invagination of the scrotum is counterproductive because a hyperactive cremasteric muscle contraction reduces hernial contents into the peritoneum. In the subtle hernia of a child, palpation of the cord structures facilitates recognition of a thickened cord, particularly during straining, which can be easily prompted by tickling the child. A sensation of rubbing two layers of silk together (the so-called silk sign) may be felt.

If the hernia is not demonstrable in the supine position, the child should be examined in the upright position with intermittent manual pressure applied to the abdomen. If the examiner looks down at an angle from the infant’s chest level toward the groin, a combination of gravity and increased intra-abdominal pressure will inflate the open sac and thus confirm the hernia or hydrocele. The inguinal rings may be of normal size, even in children with very large hernias.

In a sliding inguinal hernia, a portion of a viscus or its mesentery constitutes part of the hernia sac. The bladder can be seen medially in the hernia sac, and portions of the colon (cecum on the right side, sigmoid on the left) may be part of any hernia sac. In females, the ovary or fallopian tubes may become part of the wall of the hernia sac and must be carefully preserved during repair.

If the visceral contents of a hernial sac cannot easily be reduced into the peritoneal cavity, the hernia is incarcerated. If the contents cannot be reduced at all, the hernia is irreducible. A solid mass with an almondlike feeling within the labia majora of a girl is usually an ovary, which is the most frequently incarcerated intra-abdominal organ in female infants.

As many as 15% of children, especially young infants, present with incarceration. Attempts at reducing an incarcerated hernia are often successful; 80% of children do not need an immediate operation. An emergency hernia operation has 20 times the risk of complications that an elective repair does; therefore, reduction of an incarcerated hernia should be attempted by an appropriately experienced practitioner, and conscious sedation should be used if necessary. In patients with chronic hernias, adhesions may hinder reduction.

Hydrocele

A hydrocele usually transilluminates on examination; however, gas-filled intestines also transilluminate, thus precluding diagnostic aspiration. If the scrotal size vacillates or the examiner can squeeze fluid from the sac into the peritoneum, a communicating hydrocele is present. Communicating hydroceles without an obvious hernia component should be repaired electively.

Hydroceles are considered insignificant if they are present at birth, bilateral, soft, and peritesticular; do not persist beyond 6 months; and do not fluctuate in size. Because most physiologic noncommunicating hydroceles resolve spontaneously, surgical treatment is generally confined to hydroceles that have persisted for longer than 1 year, those that develop communication, or those that appear painful to the child.

An acute hydrocele may present in childhood as a rapidly growing, painful scrotal swelling simulating an incarcerated hernia. Palpating the cord structures at the internal ring while assessing their mobility helps distinguish between these two entities. A hydrocele is more mobile, has a defined proximal margin, and is not thick. A hydrocele of the cord presents in the inguinal canal as a nontender, rubbery, round mass.

An abdominoscrotal hydrocele extends from the abdominal cavity through the inguinal canal into the scrotum. With an infant, a digital rectal examination with careful internal examination of the ring can differentiate an incarcerated hernia from a hydrocele. The child should have an operation for clarification if the situation is equivocal or if the intra-abdominal component is causing a mass effect on other organs or obstructive symptoms.

Other hernia types

Hernias are the leading cause of intestinal obstruction in the world. Hidden hernias (eg, obturator, femoral, or lumbar hernias) should therefore be considered as possible causes of bowel obstruction. Intense pain is suggestive of strangulation with ischemic bowel. Torsion of the bowel on entry into the sac may lead to precipitous symptoms, whereas a more gradual onset of pain arises from progressive lymphatic, venous, and then finally arterial compromise secondary to occlusion at the neck of the sac.

Spigelian hernias present with local pain and signs of obstruction from incarceration. This pain increases with contraction of the abdominal muscles. Interparietal hernias between the layers of the abdominal wall present similarly. A mass may be just superior and lateral to the external ring, and the scrotum may not contain a testis. Internal supravesical hernias may have obstructive intestinal symptoms or symptoms resembling those of a urinary tract infection. Vague flank discomfort combined with an enlarging mass in the flank suggests a lumbar hernia.

A testicular tumor is usually presumed when splenogonadal fusion presents as a scrotal mass. Recognition of splenic tissue on frozen-section examination eliminates the need for orchiectomy. A 2- to 4-mm mass of yellow-tan tissue found in 2.5% of hernia repairs is an ectopic adrenal rest. The proximity of the developing testis and the adrenal gland invites adherence of the two structures, with the adrenal fragment accompanying the testis into the ectopic position.

The differential diagnosis of a groin mass inferior to the inguinal ligament and medial to the femoral vessels includes the following:

• Incarcerated femoral hernia
• Lymphadenopathy secondary to a variety of inflammatory or neoplastic processes
• Soft-tissue tumor

Peritoneal signs and intestinal obstruction suggest an incarcerated femoral hernia. With common lymph node swelling, the mass is located superficial and inferior to the femoral ring. On examination, enlarged lymph nodes feel firm, somewhat lobulated, and fairly mobile. A primary lesion (eg, a cut, scratch, or open wound) should be sought through careful examination of the lymph node drainage area. Culture of the lymph node aspirate guides antibiotic therapy.

Cat-scratch disease lymphadenitis commonly develops in children. Feline contact by a scratch or bite causes Bartonella henselae infection. A papule develops in 3-5 days, followed by regional lymphadenopathy in 1-2 weeks. Some 12% of cases are complicated by attendant symptoms of fever, malaise, myalgia, and anorexia; encephalitis; oculoglandular disease; and severe systemic disease. By 2 months, symptoms usually resolve spontaneously.

Infections such as toxoplasmosis, tularemia, infectious mononucleosis, actinomycosis, and HIV infection can also cause inguinofemoral adenopathy. In addition, some athletic individuals may have painful reactive inguinal or femoral lymph nodes as a consequence of repeated trauma.

Prevascular femoral hernia is rare and manifests as a bulge that may be mistaken for a femoral aneurysm. External femoral hernias pass beneath the inguinal ligament to lie lateral to the femoral vessels and deep to the iliopubic tract. A hernia of Laugier traverses a defect in the lacunar ligament. A hernia of Cloquet results from an abnormal insertion of the pectineus, which allows perforation of the aponeurosis as the hernia sac courses over the femoral canal. The retrovascular hernia sac descends in the posterior sheath of the femoral vein.

Obturator hernias are characterized by intermittent, acute, and severe hyperesthesia or pain in the medial thigh or in the region of the greater trochanter. These manifestations are usually relieved by flexion of the thigh and worsened by medial rotation, adduction, or extension at the hip. Rarely, there is a palpable mass in the medial upper thigh.

A tender mass in the gluteal area that is increasing in size is suggestive of a sciatic hernia. Sciatic neuropathy and symptoms of intestinal or ureteral obstruction can also occur. Perineal hernias generally present as a perineal mass with discomfort on sitting; occasionally, they have obstructive symptoms with incarceration.

An umbilical hernia presents as a central, midabdominal bulge. Altered sensorium and obesity enhance the danger of incarceration. Hypertrophic, hyperpigmented, papyraceous skin testifies to high pressure being placed on the skin. The size of the fascial defect and whether it is circular provide management clues.

Diastasis recti (widened linea alba) is clinically insignificant, and operative repair is not required. However, there may be small openings in the linea alba through which preperitoneal fat can protrude. These epigastric hernias occur in children as well as in adults, suggesting congenital defects. Defects adjacent to the umbilicus are referred to as paraumbilical hernias, whereas more cephalad defects are called epiploceles or ventral hernias. These midline hernias present as lumps anywhere along the linea alba and tend to cause sudden severe pain with exercise.

Some neonates have delayed separation of the umbilical cord remnant in conjunction with secondary bacterial colonization and low-grade infection. The salmon-pink, cobblestone-appearing friable mass that later persists at the umbilicus is termed an umbilical granuloma. A polyp with a glistening, cherry-red smooth surface is usually an umbilical polyp with associated intestinal or bladder mucosa (eg, an omphalomesenteric duct or urachal remnant).

Congenital abdominal wall defects

Maternal serum α-fetoprotein screening can help identify ventral wall defects in the fetus during the second trimester. Antenatal ultrasonography can define the location of the abdominal wall defect, the status of the viscera, the defect’s involvement with associated structures, and the presence of additional malformations.

Recognition of a small omphalocele or hernia of the umbilical cord stalk may not occur until after delivery. This may result in compromise of the small bowel or damage to an omphalomesenteric duct as the cord is clamped. Therefore, in an infant with an unusual or widened umbilical cord base, the cord should be clamped well away from the abdomen to prevent iatrogenic injury to the intestine.