Overview of Abdominal Wall Hernias in Adults - UpToDate

21/4/2018 Overview of abdominal wall hernias in adults - UpToDate
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Descripción general de las hernias de la pared abdominal en adultos
Autor: David C Brooks, MD

Editor de sección: Michael Rosen, MD
Editor Adjunto: Wenliang Chen, MD, PhD
Todos los temas se actualizan a medida que hay nuevas pruebas disponibles y nuestro proceso de revisión
por pares está completo.
Revisión bibliográfica actual hasta: marzo 2018. | Última actualización de este tema: 21 de enero de
2017.
INTRODUCCIÓN - Una hernia es una protrusión, protuberancia o proyección de un órgano o parte de un

órgano a través de la pared del cuerpo que normalmente lo contiene, como la pared abdominal. Por lo
general, se clasifican por etiología y ubicación. La mayoría de las hernias de la pared abdominal deben
repararse cuando se identifican; sin embargo, hay excepciones (p. ej., hernia paraestomal). La naturaleza de
la reparación depende del tamaño de la hernia y de la ubicación en la pared abdominal en la que se ha
producido.
Aquí se revisará una descripción general de la clasificación, las características clínicas y las opciones de
tratamiento para la mayoría de las hernias de la pared abdominal. Se discute por separado la información
más detallada sobre las hernias incisionales, las hernias inguinales y femorales, las hernias paraestomales y
las hernias relacionadas con la diálisis peritoneal.
● (Ver "Manejo de hernias ventrales" ).
● (Consulte "Clasificación, características clínicas y diagnóstico de hernias inguinales y femorales en

adultos" y "Descripción general del tratamiento para la hernia inguinal y femoral en adultos" ).
● (Ver "hernia parastomal" ).
● (Ver "Hernias abdominales en diálisis peritoneal continua" ).
CLASIFICACIÓN - Las hernias de la pared abdominal se clasifican ampliamente de acuerdo con la región
de la pared abdominal en la que se producen ( figura 1 ):
● Hernia ventral: las hernias ventrales se producen en dirección anterior e incluyen las hernias
epigástricas, umbilicales, espléjicas, paraestomales y la mayoría de las incisiones.
● Hernia de la ingle: la ingle es la región en el margen inferior del abdomen donde el muslo se une con la
cadera. Las hernias de la ingle incluyen hernias inguinales y femorales. Las hernias inguinales se
subclasifican según factores anatómicos. (Consulte "Clasificación, características clínicas y diagnóstico
de hernias inguinales y femorales en adultos" ).
● Hernia pélvica: las hernias pélvicas pueden sobresalir a través de los forámenes pélvicos, como las
hernias ciáticas y obturatorias, o a través del suelo pélvico como hernias perineales.
● Hernia de flanco: las hernias de flanco sobresalen a través de las áreas debilitadas de la musculatura de
la espalda e incluyen las hernias del triángulo lumbar superior e inferior.
https://www.uptodate.com/contents/overview-of-abdominal-wall-hernias-in-adults/print?search=tipos%20de%20hernia&source=search_result&selectedTitle=1~15
Las hernias de la pared abdominal también se pueden clasificar por etiología.
● Hernia congénita: el defecto en la pared abdominal está presente desde el nacimiento.
● Hernia adquirida: el defecto se desarrolla como resultado de un debilitamiento o una rotura de los tejidos
fibromusculares de la pared abdominal debido a anomalías del tejido conectivo, traumatismo de la pared
abdominal o posiblemente efectos farmacológicos.
CARACTERÍSTICAS CLÍNICAS
Historial : el historial del paciente puede identificar los factores de riesgo asociados con la formación de la
hernia. Estos se revisan por separado para los tipos más comunes de hernias. (Consulte "Clasificación,
características clínicas y diagnóstico de hernias inguinales y femorales en adultos", sección "Factores de
riesgo" y "Manejo de hernias ventrales" y "Hernia parasomal", sección sobre "Factores de riesgo" ).
La presentación clínica de las hernias de la pared abdominal puede variar según la ubicación. Las hernias
pequeñas pueden ser asintomáticas o presentarse con diversos grados de dolor e incomodidad a medida
que el contenido de la hernia sobresale a través del defecto de la pared abdominal. Muy a menudo, el
paciente se queja de un bulto en algún lugar de la pared abdominal. Toser o forzar puede agravar cualquier
dolor o incomodidad ( figura 2 ). Las hernias ventrales grandes pueden causar una presión excesiva que
conduce a áreas de isquemia y ulceración que se pueden ver en la piel ( imagen 1 ).
A Richter's type hernia is a particular type of abdominal wall hernia for which only part of the circumference of
the bowel becomes incarcerated in the hernia defect (image 2) [1]. A Richter's type hernia can form
anywhere a defect is large enough for the bowel to enter, but small enough to prevent protrusion of an entire
loop of bowel [1]. The most common site is in the femoral canal, where it can be easily mistaken for an
enlarged lymph node. These hernias can also develop at laparoscopic port sites. The diagnosis of a Richter's
hernia can be difficult [2]. Focal strangulation of a portion of the bowel (figure 3) can progress to ischemia and
gangrene, with or without overt signs of intestinal obstruction. Patients may present initially with only local
inflammation at the site of the hernia. Richter's type hernia can also present in a delayed fashion as an
enterocutaneous fistula.
Although any abdominal wall hernia can present with complications due to incarceration of intestinal contents
in the defect, abdominal wall hernias such as femoral, obturator and sciatic hernias frequently go
unrecognized until they present as bowel obstruction. (See "Classification, clinical features, and diagnosis of
inguinal and femoral hernias in adults", section on 'Incarceration and strangulation' and "Epidemiology,
clinical features, and diagnosis of mechanical small bowel obstruction in adults" and "Overview of mechanical
colorectal obstruction".)
Physical findings — The abdominal wall should be examined with the patient both standing and lying down.
On examination, the hernia may be easy to identify, and if palpable, the edges of the fascial defect can often
be defined. Supine examination will often allow the size of the hernia defect to be determined. The entire
abdominal wall, particularly along the length of any incisions, should be palpated carefully to identify all
coexistent hernia sites.
DIAGNOSIS — Most ventral and groin hernias can be readily identified with a thorough abdominal and groin
examination, but there is a subset of patients with very small hernias that are hidden in the abdominal fat
planes. These are best characterized using imaging studies [3].
● Ultrasound – epigastric, spigelian, groin, incisional, lumbar, umbilical
● Computed tomography – lumbar, obturator, perineal, sciatic
In the obese patient with a suspected incisional hernia that cannot be confirmed on examination, abdominal
CT is the best imaging study to confirm a diagnosis of abdominal wall hernia and identify the contents
contained within the hernia sac.
DIFFERENTIAL DIAGNOSIS — Although any intra-abdominal pathology that can cause abdominal pain and
discomfort, most will be accompanied by elements of the history and other symptoms and signs. The
differential of acute abdominal pain and chronic abdominal wall pain is reviewed elsewhere. (See "Causes of
abdominal pain in adults" and "Anterior cutaneous nerve entrapment syndrome".)
Abdominal wall masses that could mimic strangulated abdominal wall hernia include abdominal wall
hematoma and abdominal wall tumors.
● Abdominal wall hematoma generally occurs in the presence of antithrombotic therapy with or without
instrumentation (eg, paracentesis).
● Desmoid tumors, which can arise from the abdominal muscular aponeurosis are characterized by slow
growth and minimal pain, and are associated with a different risk profile. Likewise, abdominal wall
sarcomas can similarly present as an abdominal wall mass. (See "Desmoid tumors: Epidemiology, risk
factors, molecular pathogenesis, clinical presentation, diagnosis, and local therapy" and "Clinical
presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma".)
Diastasis recti is rarely confused for abdominal wall hernia. The rectus muscles are normally fused at the
midline with no more than 1 to 2 mm separating them. Diastasis recti is an acquired condition in which the
rectus muscles are separated by an abnormal distance along their length, but with no fascial defect. A
separation >2 mm is considered to be a diastasis recti (figure 4 and figure 1). It is most commonly found in
middle-aged and older men with central obesity, or small women who have carried a large fetus or twins to
term [4]. Incisional hernias are found in the presence of an obvious surgical incision. Congenital or acquired
midline hernias of the abdominal wall are confined to the umbilicus or the epigastrium. Epigastric hernias are
generally ≤2 cm in diameter.
SPECIFIC HERNIA SITES
Epigastric hernia — Epigastric hernias are defects in the abdominal midline between the umbilicus and the
xiphoid process (figure 1). The defects are often no more than 1 cm in diameter (figure 5) [5].
Epigastric hernias are likely the result of multiple factors, including congenitally weakened linea alba from a
lack of decussating midline fibers, increases in intra-abdominal pressure, muscle weakness, or chronic
abdominal wall strain. The frequency of epigastric hernia is estimated to range from 3 to 5 percent in the
general population and is more common in males (male:female = 3:1). It is most commonly diagnosed in
middle age.
Epigastric hernia can be asymptomatic, but many times patients will note a small, slightly uncomfortable lump
between the umbilicus and the xiphoid. Up to 20 percent of epigastric hernias are multiple. Bowel
incarceration or strangulation is rare. Epigastric hernias that involve a peritoneal sac usually contain only
omentum, and only rarely small intestine. Laparoscopically, these hernias can be difficult to identify due to the
lack of peritoneal protrusion through the hernia defect.
Repair of the epigastric hernia is reserved for symptomatic patients, and most often can be performed as a
day-surgery procedure under local anesthesia. A small midline or transverse incision is made overlying the
hernia. The hernia contents are either reduced or resected, and the defect is closed with interrupted sutures.
Recurrence is uncommon.
Incisional hernia — Incisional hernias, by definition, develop at sites where an incision has been made for
some prior abdominal procedure. The epidemiology, risk factors, and management of incisional hernia are
reviewed elsewhere. (See "Management of ventral hernias".)
It is estimated that an incisional hernia will develop in approximately 10 to 15 percent of abdominal incisions
[6,7], and in up to 23 percent of patients who develop postoperative wound infection [8]. Any condition that
inhibits natural wound healing will make a patient susceptible to the development of an incisional hernia.
Such conditions include: infection, obesity, smoking, medications such as immunosuppressives, excessive
wound tension, malnutrition, fractured sutures, poor technique, and connective tissue disorders [9].
Emergency surgery increases the risk of incisional hernia formation. Abdominal wound dehiscence, in
particular, leads to incisional hernia. Risk factors for the development of wound dehiscence include age >70
years, male gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, coughing,
type of surgery, and wound infection [10]. (See "Complications of abdominal surgical incisions", section on
'Fascial dehiscence'.)
Postoperative ventral hernias have been described following paramedian, subcostal, McBurney, Pfannenstiel,
and flank incisions. Laparoscopic port sites may also develop hernia defects in the abdominal wall fascia.
The highest incidence is seen with midline incision, the most common incision for many abdominal
procedures [8]. Upper abdominal incisions have a higher incidence of herniation than do lower abdominal
incisions. A small, randomized trial comparing vertical and transverse incisions for abdominal aortic
aneurysm repair found, at four-year follow-up, that incisional hernia was significantly more likely to occur with
vertical laparotomy [11].
Incisional hernias typically develop in the early postoperative period, suggesting that local factors (infection,
tension, technique) are responsible. However, hernias can develop as late as 10 years after surgery; these
may arise from previously undetected small hernias. Incisional hernias can increase in size to enormous
proportions; giant ventral hernias can contain a significant amount of small or large bowel. At the extreme
end of the spectrum is the giant incisional hernia that leads to loss of abdominal domain, which occurs when
the intra-abdominal contents can no longer lie within the abdominal cavity.
The patient with an incisional hernia complains of a bulge in the abdominal wall, originating deep to the skin
scar. This may cause a varying degree of discomfort, or may present as a cosmetic concern. Symptoms are
usually aggravated by coughing or straining, as the hernia contents protrude through the abdominal wall
defect (figure 2). Presentation of the incisional hernia with incarceration causing bowel obstruction is not
uncommon. In large ventral hernias, the skin may present with ischemic or pressure necrosis leading to frank
ulceration (image 1).
The hernia, on examination, is usually easy to identify, and the edges of the fascial defect can often be
defined by palpation. The entire abdominal wall, along the length of the incision, should be inspected and
palpated carefully, as multiple hernias are often present in the setting of an incisional hernia. These are
frequently referred to as "swiss cheese hernias" because of their appearance. In the obese patient with a
suspected incisional hernia that cannot be confirmed on examination, computed tomography of the abdomen
is the best test to visualize intra-abdominal contents within the hernia sac. (See 'Diagnosis' above.)
Most incisional hernias should be repaired. Surgery should be considered when any of the following factors
are present:
● Symptoms attributable to the hernia
● Potential for bowel incarceration
● Sufficient size to complicate dressing or activities of daily living
Even the smallest incisional hernia has the potential for incarceration and, thus, repair should be considered.
Hernias that are less likely to incarcerate include upper abdominal hernias, hernias less than one cm in
diameter, and hernias larger than 7 to 8 cm (where loops of bowel can move in and out of the hernia sac
without restriction, and are therefore less likely to become incarcerated).
Contraindications to elective surgery are only those conditions that preclude any elective surgical procedure
in the unstable or high-risk patient due to comorbidities. (See "Evaluation of cardiac risk prior to noncardiac
surgery".)
Inguinal and femoral hernia — Groin hernias, including inguinal and femoral hernias, are the most common
abdominal wall hernias. Issues related to these types of hernias are discussed in detail elsewhere. (See
"Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Overview of
treatment for inguinal and femoral hernia in adults".)
Lumbar hernia — Although lying outside of the abdominal wall anatomically, lumbar hernias are typically
classified as a type of abdominal wall hernia.
The lumbar region is defined superiorly by the 12th rib, medially by the erector spinae muscle, inferiorly by
the crest of the iliac bone, and laterally by the internal oblique muscle [12]. Lumbar hernias arise in one of
two possible triangular defects in the lumbar region (figure 6):
● The superior lumbar triangle (Grynfeltt) (image 3) is an inverted triangle, its base is the twelfth rib, its
posterior border is the erector spinae, and its anterior border is the posterior margin of the external
oblique; its apex is at the iliac crest inferiorly.
● The inferior triangle (Petit) is located between the external oblique, the latissimus dorsi, and the iliac
crest caudally (image 4).
Lumbar hernias can be congenital or spontaneous, but most lumbar hernias are related to prior surgery, most
typically urologic surgery such as partial or complete nephrectomy (image 5). Denervation of the nerves from
urologic surgical approaches can aggravate an inherent weakness in the lumbar area. The apparent hernia
can be an area of diastasis, in which the muscular aponeurosis has been weakened. Traumatic injuries can
also exacerbate inherent weaknesses [13].
The most common presentation of a lumbar hernia is a palpable posterolateral mass that increases in size
with coughing and strenuous activity [14]. The mass is usually reducible, and disappears when the patient
assumes a decubitus position [13]. Lumbar hernias can also present as vague back pain, bowel obstruction,
urinary obstruction, pelvic mass, or, rarely, as a retroperitoneal or gluteal abscess.
Repairs can be performed laparoscopically or via an open approach. Invariably, repair requires the use of
mesh. The mesh can be placed deep to the muscular wall if the procedure is performed anteriorly through an
open approach or adjacent to the defect if the hernia is repaired laparoscopically. This repair can lead to
chronic postoperative pain related to the difficulty in fixing mesh to the costal margin.
Obturator hernia — Obturator hernias are a rare type of abdominal wall hernia in which the abdominal
contents protrude through the obturator foramen. Weakening of the obturator membrane may result in
enlargement of the canal with a defect that is usually anterior and medial to the obturator neurovascular
bundle [15]. Factors that increase intra-abdominal pressure are implicated as risk factors. They are more
commonly right sided, but can be bilateral. These are much more common in women, usually in the setting of
profound weight loss [16]. A pilot tag or properitoneal fat precedes the development of a hernia sac. The
hernia sac usually contains small bowel, but may contain large bowel, omentum, fallopian tube, or appendix.
In >90 percent of cases, the diagnosis is made intraoperatively during exploration for bowel obstruction [15].
It can also present as obturator neuralgia (groin pain radiating medially to the knee) due to compression of
the obturator nerve, palpable proximal thigh mass (between pectineus and adductor longus muscles), or
ecchymosis of the thigh if bowel necrosis has occurred. Obturator hernias may be initially confused as
femoral hernias, but can also occur in conjunction with femoral hernia. Nonstrangulated obturator hernias can
be repaired using mesh via a posterior preperitoneal approach (open or laparoscopic), which provides direct
access to the hernia. Reduction of the hernia may require incision of the obturator membrane. When
strangulation is suspected, an abdominal approach is used.
Parastomal hernia — Patients with a stoma (ileostomy, colostomy) are at risk for hernia formation due to
creation of a defect in the abdominal wall through which the bowel is brought when constructing the stoma.
(See "Parastomal hernia" and "Routine care of patients with an ileostomy or colostomy and management of
ostomy complications" and "Overview of surgical ostomy for fecal diversion".)
Perineal hernia — Perineal hernias are hernias that protrude through the pelvic floor. Primary perineal
hernias are rare and most occur following surgery. Perineal hernia occurring after rectal resection is reviewed
separately. (See "Management of perineal complications following an abdominal perineal resection", section
on 'Perineal hernia'.)
Primary perineal hernias most commonly occur in older, multiparous women. Clinically, they present as a
unilateral bulge in the area of the labia, perineal regions, or gluteal regions. They are classified as anterior or
posterior based upon the position relative to the transverse perinei muscle [15]. The hernia may be detected
on bimanual rectal-vaginal examination and can be confirmed on ultrasound or pelvic computed tomography
(CT).
Sciatic hernia — Sciatic hernias pass through either the greater sciatic foramen above (suprapiriform hernia)
or below (infrapiriform hernia) the pyriformis muscle, or through the lesser sciatic foramen (spinotuberous
hernia) (figure 7). These hernias are rare. Conditions that may predispose to sciatic hernia include coexisting
hernia, malignancy, pelvic abnormalities (eg, congenital, posttraumatic), and pelvic surgery [17]. In one
review, the contents of the hernia sac were (in order of frequency) ovary, ureter, small intestine, colon,
neoplasm, omentum, or bladder [17].
These unusual hernias may present as a buttock mass, with abdominal pain, or as sciatica. Intestinal
obstruction, urinary sepsis due to herniation of the ureter, and gluteal sepsis have also been reported. A
definitive diagnosis can be made with computed tomography or magnetic resonance imaging.
Repair consists of reduction of the hernia contents and closure of the defect with or without prosthetic
material, and can be accomplished using an abdominal approach (typically laparoscopic) for strangulated
hernias, a transgluteal approach (nonstrangulated), or a combined approach.
Spigelian hernia — A Spigelian hernia occurs along the semilunar line (figure 8), which is the caudal most
extent of the posterior rectus sheath [18]. This anatomic location is weak because of the absence of a
posterior sheath behind the rectus muscle. Spigelian hernia is well described, but relatively rare. It is likely
that these hernias will become more frequently diagnosed, as they are readily seen on computed tomography
scans as well as laparoscopic views of the anterior abdominal wall.
As the hernia develops, preperitoneal fat emerges through the defect in the Spigelian fascia, bringing an
extension of the peritoneum with it through the fascia. The hernia is nevertheless covered by the intact
external oblique aponeurosis. For this reason, almost all Spigelian hernias are interparietal in nature, and
only rarely will the hernia sac lie in the subcutaneous tissues anterior to the external oblique fascia. The
hernia cannot develop medially due to resistance from the intact rectus muscle and sheath. Therefore, a
large Spigelian hernia is most often found lateral and inferior to its defect in the space directly posterior to the
external oblique muscle.
Accurate diagnosis of Spigelian hernias by physical examination is quite challenging. The patient most often
presents with a swelling in the mid to lower abdomen, just lateral to the rectus muscle. The patient may
complain of a sharp pain or tenderness at this site. The hernia is usually reducible in the supine position. The
reducible mass may be palpable, even if it is below the external oblique musculature. Up to 20 percent of
Spigelian hernias will present incarcerated.
Ultrasound is the most reliable and easiest imaging modality to assist in the diagnostic workup [19]. Even if
the hernia is fully reduced during examination and no mass is palpable, ultrasound can show a break in the
echogenic shadow of the semilunar line associated with the fascial defect. Ultrasound can also identify the
nonreduced hernia sac passing through the defect in the Spigelian fascia. Computed tomography scanning of
the abdomen will also confirm the presence of a Spigelian hernia [20]. The anatomy of the Spigelian hernia
should make it readily apparent on laparoscopic evaluation of the anterior abdominal wall (image 6 and
image 7).
Given the frequency of bowel obstruction, repair is generally recommended once the hernia is diagnosed.
Surgery is usually performed under general anesthesia. A transverse incision is made directly over the
palpable mass or fascial defect. A hernia in the subcutaneous space will be immediately obvious, whereas an
interparietal hernia will require deeper dissection. The external oblique muscle is split to identify the sac
posterior to it. The sac is isolated, opened, and the contents reduced. The sac can be excised or inverted
depending upon its size. The defect is closed by suturing the medial and lateral edges of the internal oblique
and transversus abdominis aponeuroses, which approximates the internal oblique and transverses fascia
laterally to the rectus sheath medially [21]. Although the use of mesh plugs to close the hernia defect has
been described, prosthetic mesh is not required for this repair. Laparoscopic repair has also been performed
successfully, following previously described techniques for incisional hernia [22]. Recurrence is uncommon.
Umbilical hernia — Congenital umbilical hernias in children are discussed separately. (See "Care of the
umbilicus and management of umbilical disorders".)
In adults, umbilical hernias are more often acquired and are associated with increased intra-abdominal
pressure due to obesity, abdominal distension, ascites, and pregnancy. They occur more commonly in
females than in males with a 3 to 1 ratio. In men, umbilical hernias most often present incarcerated, whereas
females, particularly those close to their ideal body weight, are more likely to have an easily reducible mass.
Typically, omentum or preperitoneal fat is contained within the hernia sac. Omental strangulation within a
hernia can cause chronic abdominal wall pain. On the other hand, if a knuckle of bowel becomes
incarcerated (Richter's hernia), bowel obstruction or bowel ischemia can develop.
The diagnosis of umbilical hernia is usually made with palpation of a soft mass at the umbilicus, which may
be asymmetric, located slightly above, slightly below, or to one side or another (picture 1). Tenderness can be
elicited with pressure and palpation, but is often not present without provocation.
Certain umbilical hernias may be so small and asymptomatic that the patient is not even aware that a hernia
is present. These hernias do not require repair and can be observed. The treatment of symptomatic umbilical
hernias is surgical, either as an open repair through a skin incision, typically for small hernias, or
laparoscopically for large hernias. For open repair, a vertical or curvilinear incision can be made overlying or
adjacent the hernia sac, identifying the hernia sac and dissecting it to its fascial attachments. Once the fascia
has been cleared, the hernia sac can either be inverted or excised, and the fascia subsequently closed with a
nonabsorbable suture (figure 9). If the defect is large, and the fascial edges cannot be approximated without
tension, mesh should be used. The mesh should be placed deep to the fascia (sublay technique) and sutured
circumferentially to the surrounding umbilical fascia to prevent migration. A variety of flat meshes and mesh
plugs are available [23]. An effort should be made to tack the skin of the umbilicus to the fascia to recreate a
cosmetically appealing umbilicus.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics"
and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Abdominal wall hernias (The Basics)")
SUMMARY AND RECOMMENDATIONS
● A hernia is a protrusion, bulge, or projection of an organ or part of an organ through the body wall that
normally contains it, such as the abdominal wall. They are typically classified by region of the abdominal
wall and etiology. (See 'Classification' above.)
● Although abdominal wall hernias can go unnoticed, patients will usually complain of a bulge that may or
may not be associated with other symptoms, most often localized pain. However, abdominal wall hernia
can present with complications related to incarceration and strangulation of contents in the hernia sac.
Large ventral hernias may present with skin ulceration due to pressure necrosis. (See 'Clinical features'
above.)
● The diagnosis of suspected abdominal wall hernia can usually be made with physical examination. For
patients in whom abdominal wall hernia is suspected but not apparent clinically, we suggest further
imaging, the nature of which depends upon the location of the suspected hernia. The differential
diagnosis of abdominal wall hernia includes anything that may produce an abdominal wall mass such as
abdominal wall hematoma or tumor, as well as other processes that produce abdominal pain and
discomfort, or can lead to bowel obstruction. (See 'Diagnosis' above and 'Differential diagnosis' above.)
● Specific hernia sites have characteristic features, which are summarized above, or in separate topic
reviews:
• Epigastric hernia (see 'Epigastric hernia' above)
• Incisional hernia (see "Management of ventral hernias")
• Inguinal and femoral hernia (see "Classification, clinical features, and diagnosis of inguinal and
femoral hernias in adults")
• Lumbar hernia (see 'Lumbar hernia' above)
• Obturator hernia (see 'Obturator hernia' above)
• Parastomal hernia (see "Parastomal hernia")
• Perineal hernia (see 'Perineal hernia' above)
• Sciatic hernia (see 'Sciatic hernia' above)
• Spigelian hernia (see 'Spigelian hernia' above)
• Umbilical hernia (see 'Umbilical hernia' above)
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abdominal aortic aneurysm repair. Br J Surg 2005; 92:1208.
12. Moreno-Egea A, Baena EG, Calle MC, et al. Controversies in the current management of lumbar
hernias. Arch Surg 2007; 142:82.
13. Orcutt TW. Hernia of the superior lumbar triangle. Ann Surg 1971; 173:294.
14. Liang TJ, Tsai CY. Images in clinical medicine. Grynfeltt hernia. N Engl J Med 2013; 369:e14.
15. Salameh JR. Primary and unusual abdominal wall hernias. Surg Clin North Am 2008; 88:45.
16. Stamatiou D, Skandalakis LJ, Zoras O, Mirilas P. Obturator hernia revisited: surgical anatomy,
embryology, diagnosis, and technique of repair. Am Surg 2011; 77:1147.
17. Losanoff JE, Basson MD, Gruber SA, Weaver DW. Sciatic hernia: a comprehensive review of the world
literature (1900-2008). Am J Surg 2010; 199:52.
18. Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Spigelian hernia: surgical anatomy, embryology,
and technique of repair. Am Surg 2006; 72:42.
19. Mufid MM, Abu-Yousef MM, Kakish ME, et al. Spigelian hernia: diagnosis by high-resolution real-time
sonography. J Ultrasound Med 1997; 16:183.
20. Shenouda NF, Hyams BB, Rosenbloom MB. Evaluation of Spigelian hernia by CT. J Comput Assist
Tomogr 1990; 14:777.
21. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World J Surg 2002;
26:1277.
22. Moreno-Egea A, Carrasco L, Girela E, et al. Open vs laparoscopic repair of spigelian hernia: a
prospective randomized trial. Arch Surg 2002; 137:1266.
23. Halm JA, Heisterkamp J, Veen HF, Weidema WF. Long-term follow-up after umbilical hernia repair: are
there risk factors for recurrence after simple and mesh repair. Hernia 2005; 9:334.
Topic 3688 Version 22.0
GRAPHICS
Abdominal wall hernias
Abdominal wall hernias include incisional hernias which occur along incisions from a
prior surgery; umbical hernias; epigastric hernias, which occur between the umbilicus
and xiphoid; spigelian hernias located at the arcuate line; lumbar hernias in the flank
(not shown); and groin hernias (inguinal and femoral hernias).
Graphic 52358 Version 3.0
Incisional hernia
An incisional hernia occurs when bowel protrudes through a defect or weakness

resulting from a surgical incision. It appears as a bulge near a surgical scar on
the abdomen.
Reproduced with permission from: Weber, J, Kelley, J. Health Assessment in Nursing,

Second Edition. Philadelphia: Lippincott Williams & Wilkins, 2003. Copyright © 2003
Lippincott Williams & Wilkins.
Obstructed incisional hernia
At the site of a prior surgical incision, dilated loops of bowel (B) can be
seen extending through an abdominal wall defect in the region of the linea
semilunaris (arrows).
Reproduced with permission from: Eisenberg, RL. Clinical imaging: An Atlas of

Differential Diagnosis, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins,
2003. Copyright © 2003 Lippincott Williams & Wilkins.
Richters hernia on computed tomography
The CT scan shows a Richter's hernia with a knuckle of part of the small bowel protruding into
a hernia of the anterior abdominal wall.
CT: computed tomography.
Richter's hernia
Schematic diagram showing a Richter's hernia, in which the antimesenteric

border, but not the whole wall, of the bowel is incarcerated.
Reproduced with permission from: Mulholland MW, Lillemoe KD. Greenfield's Surgery:
Scientific Principles And Practice, Fourth Edition. Philadelphia: Lippincott Williams &
Wilkins, 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Diastasis recti
Diastasis recti occurs when bowel protrudes through a separation between the
two rectus abdominis muscles. It appears as a midline ridge. The bulge may
appear only when client raises head or coughs. The condition is of little
significance.
Reproduced with permission from: Weber J, Kelley J. Health Assessment in Nursing,

Epigastric hernia
An epigastric hernia occurs when bowel protrudes through a weakness in the

linea alba. The small bulge appears midline between the xiphoid process and the
umbilicus. It may be discovered only on palpation.
Reproduced with permission from: Weber, J, Kelley, J. Health Assessment in Nursing,

Lumbar triangles
The superior lumbar triangle (Grynfeltt) is an inverted triangle. The base is the twelfth
rib, the posterior border is the erector spinae, the anterior border is the posterior margin
of the external oblique, and the apex is the iliac crest inferiorly.
The inferior triangle (Petit) is located between the external oblique, the latissimus dorsi,
and the iliac crest
Lumbar hernia through the superior triangle
Note the multiple bony anomalies.
Reproduced with permission from: Eisenberg, RL. Clinical Imaging: An Atlas of

Lumbar hernia through the inferior triangle

CT lumbar hernia
Computed tomogram of a left-sided lumbar hernia following nephrectomy for

renal cell cancer.
CT: computed tomography.
Reproduced with permission from: Mulholland, MW, Lillemoe, KD. Greenfield's

Surgery: Scientific Principles And Practice, Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins, 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Gluteal and sciatic hernias
Sciatic hernias are rare. The hernia can pass through the greater sciatic foramen above (1) or
below (2) the pyriformis muscle or through the lesser sciatic foramen medial to the sciatic
nerve.
Reproduced with permission from: Mulholland MW, Lillemoe KD. Greenfield's Surgery: Scientific
Principles And Practice, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, 2006. Copyright ©
2006 Lippincott Williams & Wilkins.
Spigelian hernia
Spigelian hernia. A) Usual site of occurrence. B) Transverse section of abdominal wall showing site of
defect.
Reproduced with permission from: Mulholland, MW, Lillemoe, KD. Greenfield's Surgery: Scientific Principles And
Practice, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, 2006. Copyright © 2006 Lippincott Williams
& Wilkins.
Spigelian hernia
Small bowel is trapped in the hernia sac (arrow), which arises along the left
semilunar line.

Spigelian hernia
Herniation of fat through a defect in the aponeurosis between the left rectus
abdominis (arrow) and the aponeurosis of the left transversus abdominis and
internal oblique muscles. The lateral margin of the hernia sac is the external
oblique muscle and fascia (arrowhead).

Umbilical hernia
Reproduced with permission from: Berg, D, Worzala, K. Atlas of Adult Physical

Diagnosis. Philadelphia: Lippincott Williams & Wilkins, 2006. Copyright © 2006
Umbilical hernia repair
Repair of an umbilical hernia. A) Diagram of longitudinal section through the

hernia. B) Subumbilical "smile" incision. The hernial sac is excised. C) Waistcoat
type of closure.
Reproduced with permission from: Mulholland, MW, Lillemoe, KD. Greenfield's

Surgery: Scientific Principles And Practice, Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins, 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Contributor Disclosures
David C Brooks, MD Nothing to disclose Michael Rosen, MD Grant/Research/Clinical Trial Support:
Intuitive Surgical [Inguinal hernia (Surgical robot)]; Miromatrix [Mesh (Mesh)]. Speaker's Bureau: WL Gore;
Bard [Mesh (Mesh)]. Consultant/Advisory Boards: Artiste Medical [Mesh (Mesh)]. Employment: Medical
Director of AHSQC (Americas Hernia Society Quality Collaborative). Wenliang Chen, MD, PhD Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
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21/4/2018 Overview of abdominal wall hernias in adults - UpToDate

Reimpresión oficial de UpToDate ®

Descripción general de las hernias de la pared abdominal en adultos

Autor: David C Brooks, MD

INTRODUCCIÓN - Una hernia es una protrusión, protuberancia o proyección de un órgano o parte de un

● (Ver "Manejo de hernias ventrales" ).

● (Consulte "Clasificación, características clínicas y diagnóstico de hernias inguinales y femorales en

● (Ver "hernia parastomal" ).

● (Ver "Hernias abdominales en diálisis peritoneal continua" ).

Las hernias de la pared abdominal también se pueden clasificar por etiología.

● Hernia congénita: el defecto en la pared abdominal está presente desde el nacimiento.

● Ultrasound – epigastric, spigelian, groin, incisional, lumbar, umbilical

● Computed tomography – lumbar, obturator, perineal, sciatic

SPECIFIC HERNIA SITES

● Symptoms attributable to the hernia

● Potential for bowel incarceration

● Sufficient size to complicate dressing or activities of daily living

SUMMARY AND RECOMMENDATIONS

• Epigastric hernia (see 'Epigastric hernia' above)

• Incisional hernia (see "Management of ventral hernias")

• Lumbar hernia (see 'Lumbar hernia' above)

• Obturator hernia (see 'Obturator hernia' above)

• Parastomal hernia (see "Parastomal hernia")

• Perineal hernia (see 'Perineal hernia' above)

• Sciatic hernia (see 'Sciatic hernia' above)

• Spigelian hernia (see 'Spigelian hernia' above)

• Umbilical hernia (see 'Umbilical hernia' above)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 3688 Version 22.0

Abdominal wall hernias

Graphic 52358 Version 3.0

An incisional hernia occurs when bowel protrudes through a defect or weakness

Reproduced with permission from: Weber, J, Kelley, J. Health Assessment in Nursing,

Graphic 66840 Version 1.0

Obstructed incisional hernia

Reproduced with permission from: Eisenberg, RL. Clinical imaging: An Atlas of

Graphic 53985 Version 3.0

Richters hernia on computed tomography

CT: computed tomography.

Graphic 88742 Version 2.0

Schematic diagram showing a Richter's hernia, in which the antimesenteric

Graphic 58994 Version 2.0

Reproduced with permission from: Weber J, Kelley J. Health Assessment in Nursing,

Graphic 69049 Version 2.0

An epigastric hernia occurs when bowel protrudes through a weakness in the

Reproduced with permission from: Weber, J, Kelley, J. Health Assessment in Nursing,

Graphic 72710 Version 1.0

Graphic 81616 Version 3.0

Lumbar hernia through the superior triangle

Note the multiple bony anomalies.

Reproduced with permission from: Eisenberg, RL. Clinical Imaging: An Atlas of

Graphic 65959 Version 2.0

Lumbar hernia through the inferior triangle

Reproduced with permission from: Eisenberg, RL. Clinical Imaging: An Atlas of

Graphic 71107 Version 2.0

Computed tomogram of a left-sided lumbar hernia following nephrectomy for

CT: computed tomography.

Reproduced with permission from: Mulholland, MW, Lillemoe, KD. Greenfield's

Graphic 76449 Version 5.0

Gluteal and sciatic hernias

Graphic 53186 Version 3.0

Graphic 55169 Version 1.0

Reproduced with permission from: Eisenberg, RL. Clinical Imaging: An Atlas of

Graphic 68967 Version 2.0