Abdominal Wall Hernias

Editor — Thu, 23 May 2013 04:27:32 +0000

HPI:

23M w/no known medical history presenting with abdominal “ball” x10d. Patient denies pain, and is tolerating regular diet w/o N/V. Reports lifting weights.

PMH/PSH/FHx/SHx:

None, non-contributory, no t/e/d.

Meds:

Acetaminophen, NKDA

PE:

VS: T N/A HR 86 RR 18 BP 116/64 O2 N/A
Gen: Well-appearing young male, no acute distress
HEENT: PERRL, MMM no lesions
CV: RRR, normal S1/S2, no murmurs
Lungs: CTAB, no crackles/wheezes
Abd: +BS, soft, NT/ND, 3cm bulge in right inguinal region with valsalva, above inguinal ligament, ~7cm lateral to symphysis, non-tender, reduces spontaneously after valsalva GU: uncircumcised penis, testes descended b/l, normal size, non-tender, no herniation through inguinal canal palpated with valsalva
Ext: Warm, well-perfused, 2+ peripheral pulses
Neuro: Alert and oriented, appropriate

Assessment/Plan:

23M ċ inguinal hernia, currently asymptomatic with no evidence of incarceration/strangulation. Recommend follow-up at city hospital for evaluation and possible surgical repair. Advised to refrain from strenuous activity, heavy lifting.

Physical Examination Techniques: ¹

Observation: Best performed with patient standing and physician seated on a stool facing the patient
Palpation: place hand over patient’s groin (see figure), with two fingers each superior and inferior to the inguinal ligament. Have the patient cough and feel for a palpable bulge or impulse.
GU: With a finger in the inguinal canal, bulges felt against the side of the examining finger are direct hernias, while those felt at the tip of the finger are indirect.

Types of Abdominal Wall Hernias: ²

Name	Location	Etiology/Epidemiology
1. Umbilical	Linea alba through weakened umbilical ring.Paraumbilical hernias through linea alba in the region of the umbilicus.	Congenital or acquired due to increased intra-abdominal pressure (obesity, pregnancy, ascites, PD)
2. Epigastric	Linea alba between umbilicus and xiphoid process	Congenital weakness of linea alba (lack of decussating fibers)
3. Spigelian	Semilunar line: along the lateral borders of rectus abdominus. Herniation typically occurs caudally (below arcuate line) due to absence of posterior rectus sheath.
4. Incisional	Site of prior incision	Poor fascial healing possibly due to: infection (increased risk in wound dehiscence), obesity, smoking, immunosuppression excess wound tension, CT disorders.
5. Inguinal	Indirect: internal (deep) inguinal ring, lateral to inferior epigastric vessels.Direct: external (superficial) inguinal ring, medial to inferior epigastric vessels.	Indirect > direct.
6. Femoral	Inferior to the inguinal ligament, through empty space medial to femoral sheath.	F > M, increased likelihood of incarceration/strangulation (40%)
7. Lumbar ³	Arise in two anatomical triangles:Superior lumbar triangle – lateral border internal oblique, medial border erector spinae, superior border 12^thrib.Inferior lumbar triangle – lateral border external oblique, medial border latissimus dorsi, inferior border iliac crest. (See figure)	Associated with surgery (incisional), typically urologic.
8. Obturator	Protrusion of peritoneal sac through obturator foramen.	Rare, occur primarily in elderly women (high predisposition for incarceration).

Locations of Abdominal Wall Hernias:

Layers of the Anterior Abdominal Wall:

Differential diagnosis for groin masses: ⁴

Category	Inguinal ⁵	Scrotal ⁶	Vulvar ⁷	Perineal ⁸
Vascular	Varicocele extension	Varicocele	Vulvar varicocity Hemangioma
Infectious, Inflammatory	Lymphadenopathy Abscess Inflammatory joint process (hip, related bursae) Thrombophlebitis	Epididymitis Epididymo-orchitis	Condyloma Molluscum Bartholin’s cyst
Neoplastic	Benign (lipoma) Lymph node metastatsis	Testicular malignancy	Malignant skin lesions	Soft-tissue malignancy Anal SCC Rectal GIST Metastasis (commonly anorectal, prostatic)
Congenital, Anatomic	Hernia Testis (undescended, retracted)	Epididymal cyst Spermatocele Hydrocele	Embryological remnants (mucocele)
Traumatic	Hematoma Aneurysm (complication of catheterization)	Hematoma	Hematoma

Locations of Groin Masses: ⁹

References:

Amerson JR. Inguinal Canal and Hernia Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 96. Available from: http://www.ncbi.nlm.nih.gov/books/NBK423/
Aguirre, D. A., Casola, G., & Sirlin, C. (2004). Abdominal Wall Hernias: MDCT Findings. American Journal of Roentgenology, 183(3), 681–690. doi:10.2214/ajr.183.3.1830681
Guillem, P., Czarnecki, E., Duval, G., Bounoua, F., & Fontaine, C. (2002). Lumbar hernia: anatomical route assessed by computed tomography. Surgical and radiologic anatomy : SRA, 24(1), 53–56.
Roberts, J. R., & Hedges, J. R. (2010). Clinical procedures in emergency medicine. (5th ed., Vol. section 7, p. Ch. 44). W B Saunders Co. Retrieved from http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-3623-4.00044-4
Shadbolt, C. L., Heinze, S. B., & Dietrich, R. B. (2001). Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics : a review publication of the Radiological Society of North America, Inc, 21 Spec No, S261–71.
Eyre, RC. Evaluation of nonacute scrotal pathology in adult men. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2013.
Foster, D. C. (2002). Vulvar disease. Obstetrics and gynecology, 100(1), 145–163.
Tappouni, R. F., Sarwani, N. I., Tice, J. G., & Chamarthi, S. (2011). Imaging of unusual perineal masses. American Journal of Roentgenology, 196(4), W412–20. doi:10.2214/AJR.10.4728
Collins, R. (2008). Differential diagnosis in primary care. Philadelphia: Lippincott Williams & Wilkins.

The post Abdominal Wall Hernias appeared first on Differential Diagnosis of.

Hernia Tags - Differential Diagnosis of