Clinical signs

History and physical examination remain the best means of hernias diagnosis. The review of systems should carefully seek out associated conditions, such as ascites, constipation, obstructive uropathy, chronic obstructive pulmonary disease and cough.

Inguinal hernia. The diagnosis of hernia is usually made because a patient, parent, or physician sees a bulge in the inguinal region or scrotum. This bulge may be intermittent as the herniating viscus may or may not enter the space depending on intra-abdominal pressure.

In infants, the only symptom of hernia may be increased irritability, especially with a large hernia. Hernias in older children and adults may be accompanied by a dull ache or burning pain, which often worsens with exercise or straining (e.g., coughing).

Examination of an adult is best performed from the seated position with the patient standing. One visualizes the inguinal canal regions for the bulge. Frequently, a provocative cough is 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.

In a sliding inguinal hernia, a portion of viscus or its mesentery constitutes part of the hernia sac. The bladder can be seen medially in the hernia sac, while portions of the colon (cecum on the right side, sigmoid on the left side) 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 do not easily reduce into the peritoneal cavity, the hernia is incarcerated. If the contents cannot be reduced at all, the hernia is irreducible. In chronic hernias, adhesions may impair reduction.

Some hernias, such as obturator, femoral, or lumbar hernias, should be considered as causes of bowel obstruction. Intense pain is suggestive of strangulation with ischaemic bowel. Torsion of the bowel on entry into the sac may lead to precipitous symptoms, while 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 musculature.

Interparietal hernias between the layers of the abdominal wall present in a similar manner. 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 symptoms of the intestinal tract or those resembling a urinary tract infection.

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

Diastasis recti or a widened linea alba has no clinical significance and does not require operative repair. 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 that the defects are congenital.

The name paraumbilical hernia applies when this defect is adjacent to the umbilicus, while the term epiplocele or ventral hernia is used to describe more craniad defects. These midline hernias present as lumps anywhere along the linea alba and tend to cause sudden severe pain with exercise.

Clinical signs of hernia’s strangulation:

– acute pain;

– incarceration;

– meteorism;

– vomiting.

Surgical treatment