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11-SEPTEMBER-2008 12:20:15 - Hernia September 2008 Hernia Classification and external resources Frontal chest X-ray showing a hernia of Morgagni ICD-10 K40-K46 ICD-9 550-553 MedlinePlus 000960 eMedicine emerg/251 ped/2559 A hernia is a protrusion of a tissue, structure, or part of an organ through the muscular tissue or the membrane by which it is normally contained. The hernia has three parts: the orifice through which it herniates, the hernial sac, and its contents. Contents 1 Pathophysiology 2 Characteristics 3 Treatment 4 Individual hernias 4.1 Inguinal hernia 4.2 Femoral hernia 4.3 Umbilical hernia 4.4 Incisional hernia 4.5 Diaphragmatic hernia 4.6 Other types of hernia 5 Complications 6 References 7 External links 7.1 Pictures Pathophysiology By far most hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or defect, through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the intervertebral disc, and causes back pain or sciatica. Hernias may present either with pain at the site, a visible or palpable lump, or in some cases by more vague symptoms resulting from pressure on an organ which has become stuck in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed by or accompanied by an organ. Most of the time, hernias develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or weakened. Weakening of containing membranes or muscles is usually congenital which explains part of the tendency of hernias to run in families, and increases with age for example, degeneration of the annulus fibrosus of the intervertebral disc, but it may be on the basis of other illnesses, such as Ehlers-Danlos syndrome or Marfan syndrome, stretching of muscles during pregnancy, losing weight in obese people, etc., or because of scars from previous surgery. Many conditions chronically increase intra-abdominal pressure, pregnancy, ascites, COPD, dyschezia, benign prostatic hypertrophy and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to herniate through narrowed portions of the cranial cavity or through the foramen magnum. Increased pressure on the intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation. Characteristics Hernias can be classified according to their anatomical location: Examples include: abdominal hernias diaphragmatic hernias and hiatal hernias for example, paraesophageal hernia of the stomach pelvic hernias, for example, obturator hernia hernias of the nucleus pulposus of the intervertebral discs intracranial hernias Each of the above hernias may be characterised by several aspects: congenital or acquired: congenital hernias occur prenatally or in the first years of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistentiae Lat. place of least resistance that is congenital, but only becomes symptomatic later on in life, when degeneration and increased stress for example, increased abdominal pressure from coughing in COPD provoke the hernia. complete or incomplete: for example, the stomach may partially herniate into the chest, or completely. internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another for example, mesenteric hernias. intraparietal hernia: hernia that does not reach all the way to the subcutis, but only to the musculoaponeurotic layer. An example is a Spigelian hernia. Intraparietal hernias may produces less obvious bulging, and may be less easily detected on clinical examination. bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement. irreducible also known as incarcerated: the hernial contents cannot be returned to their normal site with simple manipulation If irreducible, hernias can develop several complications hence, they can be complicated or uncomplicated: strangulation: pressure on the hernial contents may compromise blood supply especially veins, with their low pressure, are sensitive, and venous congestion often results and cause ischemia, and later necrosis and gangrene, which may become fatal. obstruction: for example, when a part of the bowel herniates, bowel contents can no longer pass the obstruction. This results in cramps, and later on vomiting, ileus, absence of flatus and absence of defecation. These signs mandate urgent surgery. another complication arises when the herniated organ itself, or surrounding organs start dysfunctioning for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causing sciatic nerve pain, etc. Treatment It is generally advisable to repair hernias in a timely fashion, in order to prevent complications such as organ dysfunction, gangrene, and multiple organ dysfunction syndrome. Most abdominal hernias can be surgically repaired, and recovery rarely requires long-term changes in lifestyle. Uncomplicated hernias are principally repaired by pushing back, or reducing, the herniated tissue, and then mending the weakness in muscle tissue an operation called herniorrhaphy. If complications have occurred, the surgeon will check the viability of the herniated organ, and resect it if necessary. Modern muscle reinforcement techniques involve synthetic materials a mesh prosthesis that avoid over-stretching of already weakened tissue as in older, but still useful methods. The mesh is either placed over the defect anterior repair or more prefrably under the defect posterior repair. At times staples are used to keep the mesh in place. These mesh repair methods are often called Tension Free repairs because, unlike older traditional methods, muscle is not pulled together under tension. Evidence suggests that these Tension Free methods have the lowest percentage of recurrences and the fastest recovery period compared to older suture repair methods. Increasingly, some repairs are performed through laparoscopes. Many patients are managed through day surgery centers, and are able to return to work within a week or two, while heavy activities are prohibited for a longer period. Patients who have their hernias repaired with mesh often recover in a number of days. Surgical complications have been estimated to be up to 10%, but most of them can be easily addressed. They include surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence. Generally, the use of external devices to maintain reduction of the hernia without repairing the underlying defect such as hernia trusses, trunks, belts, etc., is not advised. Exceptions are uncomplicated incisional hernias that arise shortly after the operation should only be operated after a few months, or inoperable patients. It is essential that the hernia not be further irritated by carrying out strenuous labour. Individual hernias A sportman's hernia is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal, although a true hernia is not present. Inguinal hernia Main article: inguinal hernia Diagram of an indirect, scrotal inguinal hernia median view from the left. Diagram of an indirect, scrotal inguinal hernia median view from the left. By far the most common hernias up to 75% of all abdominal hernias are the so-called inguinal hernias. For a thorough understanding of inguinal hernias, much insight is needed in the anatomy of the inguinal canal. Inguinal hernias are further divided into the more common indirect inguinal hernia 2/3, depicted here, in which the inguinal canal is entered via a congenital weakness at its entrance the internal inguinal ring, and the direct inguinal hernia type 1/3, where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are more common in men than women while femoral hernias are more common in women. Femoral hernia Main article: femoral hernia Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type especially when ascending cephalad: however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia. Umbilical hernia Main article: umbilical hernia Umbilical hernias are especially common in infants of African descent, and occur more in boys. They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute. Incisional hernia Main article: incisional hernia An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue. Diaphragmatic hernia Main article: diaphragmatic hernia Diagram of a hiatus hernia coronal section, viewed from the front. Diagram of a hiatus hernia coronal section, viewed from the front. Higher in the abdomen, an internal diaphragmatic hernia results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm. A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach esophageal hiatus serves as a functional defect, allowing part of the stomach to periodically herniate into the chest. Hiatus hernias may be either sliding, in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding also known as para-esophageal, in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised. A congenital diaphragmatic hernia is a distinct problem, occurring in up to 1 in 2000 births, and requiring pediatric surgery. Intestinal organs may herniate through several parts of the diaphragm, posterolateral in Bochdalek's triangle, resulting in Bochdalek's hernia, or anteromedial-retrosternal in the cleft of Larrey/Morgagni's foramen, resulting in Morgagni-Larrey hernia, or Morgagni's hernia. Other types of hernia Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with visceral hernias, where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order: Brain hernia: herniation of part of the brain because of excessive intracranial pressure. This may be a life-threatening condition, especially if the brain stem responsible for some important vital signs is involved. Cooper's hernia: a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing immediately beneath the skin. Epigastric hernia: a hernia through the linea alba above the umbilicus. Littre's hernia: a hernia involving a Meckel's diverticulum. It is named after the French anatomist Alexis Littre 1658-1726. Lumbar hernia: a hernia in the lumbar region not to be confused with a lumbar disc hernia, contains the following entities: Petit's hernia - hernia through Petit's triangle inferior lumbar triangle. It is named after French surgeon Jean Louis Petit 1674-1750. Grynfeltt's hernia - hernia through Grynfeltt-Lesshaft triangle superior lumbar triangle. It is named after physician Joseph Grynfeltt 1840-1913. Obturator hernia: hernia through obturator canal Pantaloon hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels Perineal hernia: a perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually, is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration. Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space. Richter's hernia: strangulated hernia involving only one sidewall of the bowel, which can result in bowel perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter 1742-1812. Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach. Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause of sciatic neuralgia. Spigelian hernia, also known as spontaneous lateral ventral hernia Sports hernia, a hernia characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal. Velpeau hernia: a hernia in the groin in front of the femoral blood vessels Spinal disc herniation, or herniated nucleus pulposus: a condition where the central weak part of the intervertebral disc, which helps absorb shocks to our spine, herniates through the fibrous band annulus fibrosus by which it is normally bound. This usually occurs low in the back at the lumbar or lumbo-sacral level and can cause back pain which usually radiates well into the thigh or leg. When the sciatic nerve is involved, the symptom complex is called sciatica. Herniation can occur in the cervical vertebrae too. A nucleoplasty is an operation to repair the herniation. Double hernia: the presence of a hiatus hernia with concomitant severe cardiorespiratory illness. The hernia itself poses no symptoms, but preoccupies the sufferer. Complications Complications may arise post-operation, including rejection of the meshdead link that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localised swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed. An untreated hernia may complicate by: Inflammation Irreducibilty Obstruction Strangulation Hydrocele of the hernial sac References Surgical recall, 2nd ion, by Lorne. H. Blackbourne, published by Lippincott Williams Wilkins Sabiston textbook of surgery, 17th ion, Townsend et.al.e.d., Elsevier-Saunders External links Hernia Resources The Hernia Blog Hernia Symptoms Pictures Photos of Hernias Look up hernia in Wiktionary, the free dictionary. v d e Digestive system - Digestive disease - Gastroenterology primarily K20-K93, 530-579 Upper GI tract Esophagus Esophagitis Candidal - Boerhaave syndrome - UES Zenker's diverticulum - LES Barrett's esophagus, Mallory-Weiss syndrome - Esophageal motility disorder Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD - Esophageal stricture - Megaesophagus Stomach Gastritis Atrophic, Ménétrier's disease, Gastroenteritis - Peptic gastric ulcer/Dieulafoy's lesion - Dyspepsia - Pyloric stenosis - Achlorhydria - Gastroparesis - Gastroptosis - Portal hypertensive gastropathy - Gastric antral vascular ectasia - Gastric dumping syndrome - Gastric volvulus Intestinal/ enteropathy Small intestine/ duodenum/jejunum/ileum Enteritis Duodenitis, Jejunitis, Ileitis Peptic duodenal ulcer Malabsorption: Coeliac - Tropical sprue - Blind loop syndrome - Whipple's - Short bowel syndrome - Steatorrhea Large intestine appendix/colon Appendicitis - Colitis Pseudomembranous, Ulcerative, Ischemic Functional colonic disease IBS, Intestinal pseudoobstruction/Ogilvie syndrome Megacolon/Toxic megacolon - Diverticulitis/Diverticulosis Large and/or small Enterocolitis Necrotizing - IBD Crohn's disease vascular: Abdominal angina - Mesenteric ischemia - Angiodysplasia Bowel obstruction: Ileus - Intussusception - Volvulus - Fecal impaction Constipation - Diarrhea Rectum/anus Proctitis Radiation proctitis - Proctalgia fugax - Rectal prolapse - Anal fissure/Anal fistula - Anal abscess Accessory Liver Hepatitis Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis - Cirrhosis PBC - Fatty liver NASH - vascular Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver - Alcoholic liver disease - Liver failure Hepatic encephalopathy, Acute liver failure - Liver abscess - Hepatorenal syndrome - Peliosis hepatis Gallbladder Cholecystitis - Gallstones/Cholecystolithiasis - Cholesterolosis - Rokitansky-Aschoff sinuses - Postcholecystectomy syndrome Bile duct/ other biliary tree Cholangitis PSC, Ascending - Cholestasis/Mirizzi's syndrome - Biliary fistula - Haemobilia - Gallstones/Cholelithiasis common bile duct Choledocholithiasis, Biliary dyskinesia Pancreatic Pancreatitis Acute, Chronic, Herary - Pancreatic pseudocyst - Exocrine pancreatic insufficiency - Pancreatic fistula Hernia Diaphragmatic: Congenital diaphragmatic - Hiatus Abdominal hernia: Inguinal Indirect, Direct - Umbilical - Incisional - Femoral Obturator hernia - Spigelian hernia Peritoneal Peritonitis Spontaneous bacterial peritonitis - Hemoperitoneum - Pneumoperitoneum GI bleeding Upper Hematemesis, Melena - Lower Hematochezia See also congenital, neoplasia Retrieved from http://en..org/wiki/Hernia Categories: Diseases involving the fasciae | Surgery | HerniasHidden categories: Articles lacking sources from September 2008 | All articles lacking sources | All articles with dead external links | Articles with dead external links since August 2008 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Català Česky Deutsch Eesti Español Français í•œêµì–´ Italiano עברית Latina Nederlands 日本語 ‪Norsk bokmÃ¥l‬ ‪Norsk nynorsk‬ Polski Português РуÑ?Ñ?кий Sicilianu Åšlůnski СрпÑ?ки / Srpski Suomi Svenska Türkçe This page was last modified on 9 September 2008, at 10:28
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