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A 74-year-old man presents to the emergency department with nausea, vomiting, and altered mental status. His wife states that he developed diffuse abdominal pain approximately 36 hours ago, followed by non-bloody emesis. He has been unable to keep any food or fluids down.

The patient is afebrile and tachycardic to 110, and his blood pressure is 95/63. On careful abdominal examination, he is distended and diffusely tender. A firm, tender bulge is palpable in his left groin. Labwork is notable for a BUN of 45, creatinine of 2.0, and lactate of 5.2.


Management of abdominal hernias is among the most common surgical issues. The lifetime incidence of spontaneous abdominal wall hernias internationally is 5% to 10%.1 Groin hernias are the most common, accounting for about 75% of cases.1 Of the remaining hernias, about 5% are femoral and 15% are incisional hernias. Port site, parastomal, Spigelian, and a number of miscellaneous hernias account for the final 5%. Eight hundred thousand inguinal hernia repairs are performed in the United States annually.2

The majority of inguinal hernias occur in males, with a male-to-female ratio of approximately 7:1. Although the incidence of femoral hernias is higher in women than men, with a ratio of 1.8:1, inguinal hernias are the most common groin hernias irrespective of gender. Incisional hernias are also twice as common in women.


A hernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding wall. These defects occur most commonly in the abdominal wall, at sites where the aponeurosis and fascia are uncovered by striated muscle. Hernias can arise congenitally (inguinal, femoral, umbilical, linea alba, lower portion of the semilunar line) or iatrogenically (sites of prior incisions, laparoscopic ports, or stoma sites) (Figure 18–1). Abdominal wall hernias are linked to patient-related factors that predispose to increased intra-abdominal pressure including obesity, older age, sleep apnea, emphysema, and prostatism. Postoperative patients who suffer a surgical site infection also have double the risk of developing an incisional hernia.3

Figure 18–1

Diagram of the layers of the abdominal wall, above (top right) and below (bottom right) the semilunar line. Possible sites of herniation include the umbilicus, the linea alba, below the semilunar line, and the femoral and inguinal canals, as well as prior surgical incisions. (Reproduced with permission from Moore KL, Daily AF (eds): Clinically Oriented Anatomy, 4th ed. Philadelphia: Lippincott, Williams, & Wilkins, 1999.

Internal hernias, including paraduodenal, pericecal, foramen of Winslow, transmesenteric, and retro-anastamotic, are protrusions of viscus through peritoneal or mesenteric defects within the peritoneal cavity. Such apertures can be acquired, as in a post-surgical, traumatic, or post-inflammatory defects, or congenital, including normal openings such ...

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