Download 1.4 Different types of hernias

Published on www.herniamed.de (http://www.herniamed.de)
1.4 Different types of hernias
A herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. can occur at different body sites. Different types are identified, depending on
where the hernia opening is situated. [Fig. 5]
The most important types of hernias:
Epigastric herniaA hernia of the
upper abdomen whose hernial
orifice is situated in the region of
the linea alba.
Hernia in the midline of the upper abdomenTummy, belly.
Umbilical herniaHernia protruding Hernia in the navel region
in infants or young children
through the, as yet, incompletely
closed umbilical ring (congenital
hernia), and occurring in adults
due to a weakness in the region of
the navel (acquired hernia).
Incisional herniaHernia occurring Hernia in the vicinity of a scar left after a previous operation
after an abdominal operation in the
region of the surgical scar.
Inguinal herniaThe most common Hernia in the inguinal region
type of hernia with hernial orifice
above the inguinal ligament in the
region of the lateral or medial
inguinal fossa (Latin term:
[no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis).
See also lateral inguinal hernia
and medial inguinal hernia.
Femoral herniaLatin term: hernia
femoralis. A hernia passing
through the lacuna vasorum.
Special form of inguinal hernias descending to the thigh
Parastomal herniaA parastomal
Hernia in the presence of an artificial intestinal outlet (stoma)
hernia is an incisional hernia in the
vicinity of an artificial intestinal
outlet (endostoma).
Hiatal herniaDiaphragmatic hernia Diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal hernia. at the s
protruding through the
the oesophagusGullet. enters the abdomen
oesophageal hiatus.
Page 1 of 7
Published on www.herniamed.de (http://www.herniamed.de)
Fig. 5: Different types of hernias and their localisation
1.4.1 Epigastric hernia
An epigastric herniaA hernia of the upper abdomen whose hernial orifice is situated in the region of the linea alba.
is a hernia in the midline of the upper abdomenTummy, belly. (between the breast bone (sternum) and navel). The
hernia opening is situated in the region of what is known as the linea alba. This is a tendinous strip formed from the
tendinous skin of the lateral abdominal muscles. The hernial sacEvagination of the peritoneum that protrudes
through a hernial orifice. It may contain hernia contents. may contain components of the greater omentumLatin
term: omentum majus. An adipose and connective tissue layer lined with the peritoneum and covering the small
intestine. The greater omentum is responsible for immune defence in the abdominal cavity., and in rare cases also
parts of the small intestines. Risk factors for onset of an epigastric hernia are connective tissue weakness,
increased internal abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through
coughing or pressing. (e.g. in the event of chronic cough and strong pressing because of constipation), overweight
and frequent carrying of heavy loads. In general, epigastric hernias can be seen and/or felt. It may, or may not be,
accompanied by pain. If affects men and women equally.
1.4.2 Umbilical hernia
Around 5 % of all herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes.s are umbilical herniaHernia protruding in infants or young
children through the, as yet, incompletely closed umbilical ring (congenital hernia), and occurring in adults due to a
weakness in the region of the navel (acquired hernia).s. Often, they are of a congenital nature and thus manifest
already in infancy or at a young age. In adults mainly acquired herniaHernia with hernial orifice and hernial sac
situated at a location on the abdominal wall where there is acquired weakness. The reduction in the strength of the
abdominal wall may be due to: impaired collagen synthesis, raised internal abdominal pressure, overweight,
Page 2 of 7
Published on www.herniamed.de (http://www.herniamed.de)
pregnancy.s are seen, attributable – for example in pregnant women or persons engaging in heavy physical work –
to increased internal abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through
coughing or pressing..
Since the tissue of the abdominal navel is, by nature, less stable than that of the surrounding tissues, the navel
represents a natural weak point in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose
tissue as well as muscle layers) enclosing the abdominal cavity.. In the umbilical hernia, the hernial sacEvagination
of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. protrudes through the
umbilical ringRing-shaped opening in the tissue around the navel.; this is a ring-shaped opening in the tissue
around the navel. The hernia manifests as a swelling in the navel region, and may be painful. The hernial sac may
contain lymphatic or fat tissue from the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum., and in some cases also parts of abdominal organs. Whereas strangulation is virtually never seen in
congenital umbilical hernias, this is by all means possible in the case of acquired umbilical hernias occurring in
adults. Therefore the latter cases should be operated on immediately. In most cases, a congenital umbilical hernia
heals spontaneously, hence surgery is generally not needed.
1.4.3 Incisional hernia
Incisional herniaHernia occurring after an abdominal operation in the region of the surgical scar.s occur after open
surgical procedures on the abdomenTummy, belly. in the region of the surgical scar. This type of hernia is seen
after some 10 % of all abdominal operations. Based on data from the German Federal Statistical Agency, around
50,000 incisional hernia surgical procedures are carried out each year in Germany (!).
Incisional hernias arise because of a lack of strength of the surgical scar. Contributory factors include wound
infection, bleeding, impaired wound healing, patient’s poor general and nutritional status, special diseases such as
diabetes or cancer, overweight, medications (in particular cortisone preparations), long-standing nicotine
consumption as well as defective collagenStructural protein of the connective tissue. metabolism. Incisional hernia
generally presents within one year of abdominal surgery. The main symptom is a visible or palpable protrusion in
the region of a still relatively fresh abdominal surgical scar.
Even if an incisional hernia does not give rise to any complaints, it should nonetheless be operated on since it
could cause dangerous complications, in particular strangulation of intestinal components. However, the original
surgical scar should be first allowed to heal, something that in general takes around six months after the
procedure.
1.4.4 Inguinal hernia
Inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the region of the
lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also
lateral inguinal hernia and medial inguinal hernia.s account for around 75–80 % of all hernias and are thus the most
common type of hernia. Around 27 % of men and 3 % of women will develop an inguinal hernia at some stage of
their life. Thanks to a narrower inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long,
running in the inguinal region through the abdominal wall. It originates at the internal inguinal ring and leads into the
external inguinal ring. The lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the
female, the round ligament of the uterus pass through the inguinal canal., women on the whole are less commonly
affected than men.
A distinction is made between medial (= direct) and lateral (= indirect) inguinal hernias.
1.4.4.1 Medial/direct inguinal hernia
This type of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
Page 3 of 7
Published on www.herniamed.de (http://www.herniamed.de)
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. is always acquired. It
accounts for around 30–40 % of all cases of inguinal hernias and affects in particular men of advanced age. The
hernial opening is situated in the area of what is known as Hesselbach’s triangle, a muscle-free region of the
inguinal fossa. The hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents. runs medially to the blood vessels of the lower abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. (medial = parallel to the
midline of the body). It protrudes vertically, that is through a direct pathway, through a region of the abdominal body
with acquired tissue weakness.
1.4.4.2 Lateral/indirect inguinal hernia
This type of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. can be either of
congenital or acquired origin. It accounts for around 60–70% of all cases of inguinal hernias and affects men in
particular. It occurs mainly on the right side of the body (49 %), less commonly on the left side (36 %) or on both
sides (15 %). Lateral inguinal herniaAlso called indirect inguinal hernia. A lateral inguinal hernia can be either of
congenital or acquired origin. It runs through the inguinal canal, with the internal inguinal ring as hernial orifice.s do
not project directly through the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as
well as muscle layers) enclosing the abdominal cavity., running instead – indirectly – through the inguinal
canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region through the
abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring. The lymph vessels
and, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament of the uterus pass
through the inguinal canal.. The internal inguinal ringOrigin of the inguinal canal on the inside of the abdominal wall
situated above the inguinal ligament., which is the entrance to the inguinal canal in the region of the lateral inguinal
fossaExternal inguinal fossa., serves as hernia opening. The hernial sacEvagination of the peritoneum that
protrudes through a hernial orifice. It may contain hernia contents. then protrudes towards the outside at the
external inguinal ringThis is also known as the superficial inguinal ring (Latin term: anulus inguinalis superficalis).
The opening in the inguinal canal on the outside of the abdominal wall above the pubic tubercle, formed by an
opening in the tendon of the external oblique abdominal muscle (Latin term: musculus obliquus externus
abdominis)., which is the outlet of the inguinal ring.
In females, the lateral inguinal hernia can reach as far as the labia majora and, in males, as far as the scrotum. The
terms labial and scrotal herniaLatin term: hernia scrotalis. Lateral inguinal hernia whose hernial sac stretches as far
as the scrotum.s are used, respectively, to denote these conditions.
1.4.5 Femoral hernia
Around 7 % of all herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes.s are femoral herniaLatin term: hernia femoralis. A hernia
passing through the lacuna vasorum.s. This special type of inguinal herniaThe most common type of hernia with
hernial orifice above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin term:
[no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal
hernia. is virtually always acquired and affects mainly women (around 80 % of cases). Risk factors are, in addition
to female gender, advanced age, history of pregnancy / pregnancies as well as overweight. The hernia opening of
femoral hernias is situated beneath the inguinal ligamentLatin term: ligamentum inguinale. Reinforcement of a
fascia in the lumbar region, which, inter alia, is fused with the aponeuroses of the oblique abdominal muscles and
the transverse fascia. in what is known as the lacuna vasorum, which is the entry site for the blood vessels and
nerves supplying the thigh.
Often, a femoral hernia is diagnosed only at a very late stage, or indeed commonly only when complications are
already present. This is due to the fact that the patients concerned feel only a diffuse pressure pain beneath the
Page 4 of 7
Published on www.herniamed.de (http://www.herniamed.de)
groin, or indeed no pain at all. In obese patients, in particular, it is often difficult to see or feel a femoral hernia in
the form of a swelling below the groin. Hence it is often diagnosed only when the hernial sacEvagination of the
peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is already strangulated within
the hernia opening. By that stage, there is a risk of the hernial sac (for example intestinal loops) not being
adequately supplied with blood, thus posing a risk of necrosisTissue death due to irreversible failure of cell
functions (cell death). (tissue death). For that reason a femoral hernia should always be operated on as early as
possible.
1.4.6 Parastomal hernia
Parastomal herniaA parastomal hernia is an incisional hernia in the vicinity of an artificial intestinal outlet
(endostoma).s are hernias occurring beside (Greek term para = beside) an artificial intestinal outlet (stoma). The
opening in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle
layers) enclosing the abdominal cavity., which is needed to construct the stoma, serves as the hernia opening
through which the hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents., possibly with parts of the intestines or greater omentumLatin term: omentum majus. An adipose
and connective tissue layer lined with the peritoneum and covering the small intestine. The greater omentum is
responsible for immune defence in the abdominal cavity., protrude outwards. Up to 50 % of all stoma patients are
affected by a parastomal hernia, thus making it the most common complication associated with an artificial
intestinal outlet.
A parastomal hernia occurs if the scar in the region of the stoma (opening) is not sufficiently strong. Contributory
factors are impaired wound healing, bleeding and wound infections, in addition to the patient’s poor general and
nutritional status, special diseases such as diabetes or cancer, overweight, medications (in particular cortisone
preparations), long-standing nicotine consumption as well as defective collagenStructural protein of the connective
tissue. metabolism. The symptoms of a parastomal hernia are palpable defects in the affected tissue or a
protrusion in the region of the artificial intestinal outlet, occurring when coughing or pressing.
1.4.7 Hiatal hernia
If the oesophageal hiatusLatin term: hiatus oesophageus. Opening in the diaphragm through which the
oesophagus passes. is expanded because of a congenital or acquired weakness of the surrounding tissue, a
diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal hernia. can occur at this site. In such a
hiatal herniaDiaphragmatic hernia protruding through the oesophageal hiatus. there is partial or complete
displacement of abdominal organs into the chest cavity. Depending on the size of the hernia, different types are
identified.
The most common type is the axial sliding herniaHiatal hernia, where the stomach is pushed upwards, with
the entrance to the stomach (cardia) being displaced into the chest cavity., where the stomach is pushed
somewhat upwards, resulting in the entrance to the stomach together with the cardiaThe part of the oesophagus
leading into the stomach; entrance to the stomach. (the site where the oesophagusGullet. enters the stomach)
being displaced into the chest cavity. Often, a sliding hernia causes none, or few, complaints. Hence it is commonly
diagnosed only by chance. However, if the muscular closure mechanism between the oesophagus and stomach
does not function properly because of displacement of the stomach, there can be refluxBackflow of gastric juice
into the oesophagus. (backflow) of stomach acid into the oesophagus. This, in turn, gives rise to irritation of the
oesophageal mucosa causing reflux diseaseIn the presence of an axial sliding hernia, backflow of acidic gastric
juice into the oesophagus with onset of heartburn as well as swallowing disorders. withthe typical symptoms of
heartburn, swallowing disorders and pain in the upper abdomenTummy, belly.. If hiatal hernia causes such
complaints, attempts are made first of all to treat this by means of conservative measures such as weight reduction,
change of diet, change of lifestyle and drug-based treatment. If these prove unsuccessful, the hernia should
definitely be treated surgically as soon as possible.
In the less common paraoesophageal herniaWith this type of diaphragmatic hernia the proximal section of
the stomach near the oesophagus protrudes through the oesophageal hiatus into the chest cavity. the first
(proximal) portion of the stomach is displaced through the oesophageal hiatus and along the oesophagus into the
chest cavity (the entrance to the stomach, the cardia, remains within the abdominal cavityLatin term: cavitas
Page 5 of 7
Published on www.herniamed.de (http://www.herniamed.de)
abdominalis. The region of the trunk situated between the diaphragm and pelvis containing the abdominal organs.
The abdominal cavity is lined with the peritoneum., unlike in the case of the axial sliding hernia). In some cases
with this type of hiatal hernia parts of other organs, such as intestinal loops or parts of the greater omentumLatin
term: omentum majus. An adipose and connective tissue layer lined with the peritoneum and covering the small
intestine. The greater omentum is responsible for immune defence in the abdominal cavity. are displaced into the
chest cavity. To begin with, patients have generally no complaints, as only later do symptoms such as a feeling of
fullness, or pressure occur in the chest, swallowing disorders or respiratory distress. Life-threatening complications
can occur because of strangulation of the displaced organs. Therefore the paraoesophageal hernia must always be
surgically treated as soon as possible.
In some cases mixed forms of sliding hernia and paraoesophageal hernia are seen. A rare, but severe form of
paraoesophageal hernia is the upside-down stomach, also known as a thoracic stomachSee Upside-down
stomach.. In such a case two-thirds or more of the stomach (or even the entire stomach) are displaced into the
chest cavity. This causes distortion of the stomach and displacement of the chest cavity organs, in particular of the
lungs and heart. Patients thus often suffer from cardiovascular complaints, respiratory distress or chest pain. Just
like other paraoesophageal hernias, an upside-down stomachAlso called thoracic stomach. A severe form of
paraoesophageal hernia where two-thirds or more of the stomach (or even the entire stomach) are displaced into
the chest cavity. must be operated on as quickly as possible to prevent dangerous complications.
1.4.8 Rare hernias
1.4.8.1 Internal herniaDisplacement of abdominal intestines into enlarged peritoneal pockets within the trunk,
possibly with incarceration. Often, this type of hernia cannot be detected with the naked eye.s
These types of hernias cannot as a rule be detected with the naked eye or be felt, because the hernial
sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is situated
within peritoneal pockets inside the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum..
1.4.8.2 Spieghel herniaA rare hernia which, in the region of the lateral abdominal wall, penetrates what is known as
Spieghel’s line (muscle-tendon border of the transverse abdominal muscle at the lateral margin of the rectus
abdominis muscle).
This is a hernia which occurs in the region of the lateral abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity.. It penetrates what is
known as Spieghel’s line (muscle-tendon border of the transverse abdominal muscle at the lateral margin of the
anterior rectus abdominis muscleLatin term: musculus rectus abdominis. The rectus muscle runs in two straight
lines from the chest to the pelvis. It is subdivided by several intermediate tendons.).
1.4.8.3 Morgagni’s hernia
A hernia protrudes through a small gap in the diaphragmDome-shaped muscle plate protruding into the chest
cavity, which is secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition between
the chest cavity and abdominal cavity. It is the most important respiratory muscle; its muscle fibres contract when
breathing in and relax when breathing out., known as Morgagni’s gap Morgagni’s hernias occur close to the
breast bone.
1.4.8.4 Richter’s hernia
In the case of this hernia, which is also known as an intestinal wall hernia, the hernia contentsThe components of
the abdominal cavity, such as intestines or greater omentum, contained within the hernial sac. within the hernial
Page 6 of 7
Published on www.herniamed.de (http://www.herniamed.de)
sac are composed of only a protruded part of the intestinal wall. Intestinal passage is unaffected since the entire
intestines are not involved.
Source URL: http://www.herniamed.de/?q=en/node/442
Page 7 of 7