Ventral Hernia

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Ventral hernia is a protrusion of abdominal contents through a weakness in the abdominal wall. This includes incisional, umbilical, and epigastric hernias.

Aetiology

• Incisional hernia: occurs at the site of a previous surgical incision due to incomplete healing.
• Umbilical hernia: occurs at the umbilicus due to failure of abdominal wall closure.
• Epigastric hernia: occurs along the midline between the umbilicus and sternum due to weakness in the linea alba.

Pathophysiology

• Increased intra-abdominal pressure weakens the fascial layers of the abdominal wall.
• The protruding contents can include peritoneal fat, omentum, or bowel.
• Incarceration (trapped hernia) may occur, leading to obstruction or strangulation.

Risk factors

• Obesity.
• Previous abdominal surgery.
• Pregnancy.
• Chronic cough or straining (e.g., constipation, chronic obstructive pulmonary disease).
• Smoking (impairs wound healing).
• Connective tissue disorders (e.g., Ehlers-Danlos syndrome).

Signs and symptoms

Symptoms:

• Visible bulge in the abdominal wall, which may reduce on lying down.
• Discomfort or dull pain at the hernia site, worsened by coughing or straining.
• Symptoms of bowel obstruction if incarceration occurs (e.g., nausea, vomiting, constipation).

Signs:

• Palpable, soft mass that increases with standing or coughing.
• Irreducibility in incarcerated hernias.
• Skin changes, tenderness, or erythema in strangulated hernias.

Investigations

• Clinical examination: diagnosis is usually clinical with history and palpation (lump noticed on examination).
• Ultrasound: diagnose the type of hernia and distinguish from a lipoma.
• CT abdomen (if uncertain): for complex hernias, assessing strangulation, and pre-operative planning.

Management

1. Conservative Management:

• Small, asymptomatic hernias may be managed with observation.
• Encourage weight loss and smoking cessation to reduce risk of progression.
• Hernia support belts may be used in non-operative candidates.
• OTC analgesia as needed.

2. Surgical Management:

• Elective surgical repair: recommended for symptomatic hernias to prevent complications.
• Emergency surgery: for incarcerated or strangulated hernias.
• Repair techniques (just to be aware):
  • Open hernia repair: uses sutures or mesh reinforcement.
  • Laparoscopic repair: preferred for larger or recurrent hernias.

Referral

• Routine surgical referral: for symptomatic hernias or patient preference.
• Urgent referral: if signs of incarceration or strangulation (pain, irreducibility, bowel obstruction symptoms).