Hernia: A protrusion of peritoneal contents through defect in abdominal wall

- Usually containing mesenteric fat and bowel

Classification:
- Inguinal - most common, 75%

- Incisional/ventral - 20%

- Other types include umbilical, femoral, obturator, spigelian, and more

Diagnosis: 

- Usually clear by physical exam

- May need ultrasound or CT if high index of suspicion but non-diagnostic exam

- Differential Diagnosis: Lymphadenopathy, Hydrocele, Aneurysm, Cyst, Lipoma, Hematoma, Seroma, Abscess

Management:

- Easily reducible

       - refer for outpatient surgery follow up and elective repair

- Incarcerated - [Unable to reduce but normal vascular supply]

       - Attempt to reduce in ED, see below for tips

       - If unsuccessful, surgical consult

- Strangulated - [Unable to reduce and with compromised vascular supply]

       - Suggested by significant tenderness or erythema over hernia and/or systemic signs and symptoms such as toxic appearance, sepsis, or symptoms of bowel obstruction

       - Do NOT attempt reduction, as the hernia may contain ischemic bowel, patients can clinically worsen if replace contents into peritoneal cavity

       - Tx: Fluids, analgesia, broad spectrum antibiotics, surgical consult

Hernia Reduction:

1.     Adequate analgesia, often requiring IV narcotics

2.     Position patient in Trendelenberg

3.     Ice packs to reduce edema

4.     Grasp and elongate hernia neck (the base) with one hand, with other hand apply firm steady pressure at neck rather than at distal portion. The goal is to guide the hernia contents gradually through the fascial defect - abrupt distal pressure can cause ballooning of the sac and make reduction more difficult. Note that this can take 5-15 minutes to gradually reduce.

5.     Attempt to reduce 1-2 times. Surgical consult warranted if unsuccessful

References: 

Byars, D, Kayagil, T. "Hernia." Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, Ch 84.

Stevens, Aaron DO. "Hernias". Critical Decisions in Emergency Medicine. Sept 2013. Vol 27 No 9.