Overview of abdominal wall hernias in adults

Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Overview of abdominal wall hernias in adults
Author: David C Brooks, MD
Section Editor: Michael Rosen, MD
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Jan 21, 2017.
INTRODUCTION — 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 etiology and
location. Most abdominal wall hernias should be repaired when identified; however, there are exceptions (eg,
parastomal hernia). The nature of the repair depends upon the size of the hernia and the location on the
abdominal wall in which it has occurred.
An overview of the classification, clinical features, and treatment options for most abdominal wall hernias will be
reviewed here. More in-depth information for incisional hernias, inguinal and femoral hernias, parastomal
hernias, and hernias related to peritoneal dialysis are discussed separately.
● (See "Management of ventral hernias".)
● (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Overview
of treatment for inguinal and femoral hernia in adults".)
● (See "Parastomal hernia".)
● (See "Abdominal hernias in continuous peritoneal dialysis".)
CLASSIFICATION — Abdominal wall hernias are broadly classified according to the region of the abdominal wall
in which they occur (figure 1):
● Ventral hernia – Ventral hernias occur anteriorly and include epigastric, umbilical, spigelian, parastomal, and
most incisional hernias.

● Groin hernia – The groin is the region at the lower margin of the abdomen where the thigh meets the hip.
Groin hernias include inguinal and femoral hernias. Groin hernias are subclassified according to anatomic
factors. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)
● Pelvic hernia – Pelvic hernias can protrude through the pelvic foramina, as with sciatic and obturator
hernias, or through the pelvic floor as perineal hernias.
/>
Page 1 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

● Flank hernia – Flank hernias protrude through weakened areas of back musculature and include the
superior and inferior lumbar triangle hernias.
Abdominal wall hernias can also be classified by etiology.
● Congenital hernia – The defect in the abdominal wall is present from birth.
● Acquired hernia – The defect develops as the result of a weakening or disruption of the fibromuscular
tissues of the abdominal wall due to connective tissue abnormalities, abdominal wall trauma, or possibly
drug effects.
CLINICAL FEATURES
History — The patient's history may identify risk factors associated with hernia formation. These are reviewed
separately for the more common types of hernias. (See "Classification, clinical features, and diagnosis of inguinal
and femoral hernias in adults", section on 'Risk factors' and "Management of ventral hernias" and "Parastomal
hernia", section on 'Risk factors'.)
The clinical presentation of abdominal wall hernias can vary depending upon location. Small hernias can be
asymptomatic or present with varying degrees of pain and discomfort as the hernia contents protrude through the
abdominal wall defect. Most often, the patient will complain of a bulge somewhere in the abdominal wall.
Coughing or straining may aggravate any pain or discomfort (figure 2). Large ventral hernias can cause
excessive pressure leading to areas of ischemia and ulceration which can be seen on the skin (image 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
/>
Page 2 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
/>
Page 3 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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 daysurgery 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 fouryear 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 intraabdominal 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).

/>
Page 4 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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
/>

Page 5 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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)
/>
Page 6 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

(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
/>
Page 7 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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)")
/>
Page 8 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Steinke W, Zellweger R. Richter's hernia and Sir Frederick Treves: an original clinical experience, review,
/>
Page 9 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

and historical overview. Ann Surg 2000; 232:710.
2. Kadirov S, Sayfan J, Friedman S, Orda R. Richter's hernia--a surgical pitfall. J Am Coll Surg 1996; 182:60.
3. Murphy KP, O'Connor OJ, Maher MM. Adult abdominal hernias. AJR Am J Roentgenol 2014; 202:W506.
4. Ranney B. Diastasis recti and umbilical hernia causes, recognition and repair. S D J Med 1990; 43:5.
5. Lang B, Lau H, Lee F. Epigastric hernia and its etiology. Hernia 2002; 6:148.
6. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg
1985; 72:70.
7. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet 2003; 362:1561.
8. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major
laparotomies. Br Med J (Clin Res Ed) 1982; 284:931.
9. George CD, Ellis H. The results of incisional hernia repair: a twelve year review. Ann R Coll Surg Engl
1986; 68:185.
10. van Ramshorst GH, Nieuwenhuizen J, Hop WC, et al. Abdominal wound dehiscence in adults:
development and validation of a risk model. World J Surg 2010; 34:20.
11. Fassiadis N, Roidl M, Hennig M, et al. Randomized clinical trial of vertical or transverse laparotomy for
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
/>
Page 10 of 29


Overview of abdominal wall hernias in adults - UpToDate

/>
12/26/17, 9)25 AM

Page 11 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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

/>
Page 12 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 66840 Version 1.0

/>
Page 13 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 53985 Version 3.0

/>
Page 14 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 88742 Version 2.0

/>
Page 15 of 29

Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 58994 Version 2.0

/>
Page 16 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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,
Second Edition. Philadelphia: Lippincott Williams & Wilkins, 2003. Copyright © 2003
Lippincott Williams & Wilkins.

Graphic 69049 Version 2.0

/>
Page 17 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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, Second Edition. Philadelphia: Lippincott Williams & Wilkins, 2003.
Copyright © 2003 Lippincott Williams & Wilkins.
Graphic 72710 Version 1.0

/>
Page 18 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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
Graphic 81616 Version 3.0

/>
Page 19 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

Lumbar hernia through the superior triangle

Note the multiple bony anomalies.
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.
Graphic 65959 Version 2.0

/>
Page 20 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

Lumbar hernia through the inferior triangle

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.
Graphic 71107 Version 2.0

/>
Page 21 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 76449 Version 5.0

/>
Page 22 of 29

Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 53186 Version 3.0

/>
Page 23 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

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.
Graphic 55169 Version 1.0

/>
Page 24 of 29


Overview of abdominal wall hernias in adults - UpToDate

12/26/17, 9)25 AM

Spigelian hernia

Small bowel is trapped in the hernia sac (arrow), which arises along the left
semilunar line.
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.
Graphic 68967 Version 2.0

/>
Page 25 of 29