Hernias in the emergency department
A tense, tender lump that won't go back is strangulated until proven otherwise. Always feel below the inguinal ligament.
A 74-year-old woman has vomited all day. She has colicky abdominal pain and a distended abdomen. Nobody has examined her groins. On doing so, you find a small, hard, tender lump below and lateral to the pubic tubercle.
A 45-year-old man has a large right groin hernia that has been going in and out for years. Today it has been out for 2 hours and is painful, but soft and not red.
Which is the emergency, and can you try to reduce the second?
- Examine every hernial orifice in every patient with obstructionInguinal, femoral, umbilical, incisional.
- AssessTender, hard, red, irreducible, signs of obstruction, fever, tachycardia, raised lactate.
- Strangulation signsNil by mouth, IV fluids, analgesia, antibiotics, surgeons now.
- Incarcerated, no strangulationAnalgesia, lie the patient down (head down), one gentle attempt at reduction by a senior.
- After reductionObserve for peritonitis.
- Reducible, uncomplicatedRoutine surgical referral.
- Femoral herniasAlways need surgery soon, even if quiet.
- Tender irreducible hernia
- Hernia with vomiting and distension
- Skin redness over a hernia
- Peritonism after reduction
- Femoral hernia of any kind
- Femoral hernia in an elderly woman with obstruction
- Richter's hernia (obstruction may be absent)
- Reducing dead bowel (reduction en masse)
- Testicular torsion mistaken for an inguinal hernia
| Strangulation clues | Severe pain, tender, red, hot, irreducible, fever, tachycardia, raised lactate |
| Femoral hernia | Below and lateral to the pubic tubercle |
| Inguinal hernia | Above and medial to the pubic tubercle |
| Femoral strangulation risk | High (narrow neck) |
| Reduction attempt | One gentle attempt, with analgesia, only if no signs of strangulation |
Check every dose against a current drug reference and your hospital protocol.
On this page
Types
| Type | Where | Notes |
|---|---|---|
| Indirect inguinal | Through the deep ring, lateral to the inferior epigastric vessels | Most common in all ages, follows the cord |
| Direct inguinal | Through Hesselbach's triangle, medial to the inferior epigastric vessels | Older men, low strangulation risk |
| Femoral | Below the inguinal ligament, through the femoral canal | Women more, high strangulation risk |
| Umbilical or paraumbilical | At or beside the umbilicus | Obesity, pregnancy, ascites |
| Incisional | At a scar | Wide or narrow neck |
Inguinal or femoral?
Inguinal
Femoral (high risk)
Definitions
- Reducible: goes back by itself or with pressure.
- Incarcerated (irreducible): won't go back, but blood supply intact.
- Obstructed: bowel in the sac with intestinal obstruction.
- Strangulated: blood supply cut off; bowel becomes ischaemic. Emergency.
- Richter's hernia: only part of the bowel wall is trapped; strangulation without obstruction.
Management
- AssessObservations, lactate, abdomen, all hernial orifices, testes in men.
- Strangulation signsNil by mouth, IV fluids, analgesia, antibiotics, surgeons for emergency surgery.
- Irreducible, no strangulation signsAnalgesia, lie flat with head down tilt, ice, one gentle attempt at reduction by a senior.
- ReducedObserve for several hours for peritonitis. Arrange surgery.
- Not reducibleSurgery.
Never force a hernia. Forced reduction can push dead bowel back into the abdomen ("reduction en masse").
Differential diagnosis of a groin lump
| Condition | Clues |
|---|---|
| Lymph node | Firm, often multiple, infection or tumour elsewhere |
| Saphena varix | Soft, disappears lying down, fluid thrill on coughing |
| Femoral artery aneurysm | Pulsatile, expansile |
| Hydrocele or varicocele | Can get above it, scrotal |
| Testicular torsion | Sudden severe testicular pain, high-riding testis |
| Psoas abscess | Fever, hip flexed, back pain |
Investigations
| Test | Why |
|---|---|
| FBC, CRP, U&E, lactate | Sepsis, strangulation |
| Abdominal X-ray | Bowel obstruction |
| CT | Uncertain diagnosis, obese patients, incisional hernias |
| Ultrasound | Uncertain groin lumps |
Treatment
See bowel obstruction.
Common mistakes
- Not examining the groins in an elderly patient with vomiting.
- Forcing a hernia back.
- Discharging a femoral hernia without surgical follow-up.
- Missing a testicular torsion in a boy with a "hernia".
- Missing a Richter's hernia because there is no obstruction.
Frequently asked questions
How do you tell an inguinal from a femoral hernia?
Inguinal hernias appear above and medial to the pubic tubercle. Femoral hernias appear below and lateral to it.
What are the signs of a strangulated hernia?
A tender, hard, irreducible lump, often red and hot, with fever, tachycardia, vomiting and raised lactate.
Why are femoral hernias dangerous?
The femoral canal is narrow, so femoral hernias have a high risk of strangulation.
Should you try to reduce an incarcerated hernia?
One gentle attempt with analgesia is reasonable only if there are no signs of strangulation. Never force it.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 68-year-old woman has a tender, irreducible lump below and lateral to the pubic tubercle with vomiting. What is the diagnosis?
Answer: Femoral hernia. Femoral hernias are common in women and often strangulate.
- Inguinal hernia: Above and medial.
- Inguinal lymph node: Vomiting and obstruction point to hernia.
- Saphena varix: Reducible, cough impulse.
- Psoas abscess: No.
2. Which hernia type has the highest risk of strangulation?
Answer: Femoral. The narrow femoral canal makes strangulation likely.
- Epigastric: Low risk.
- Umbilical in infants: Low risk.
- Incisional with a wide neck: Lower risk.
- Direct inguinal: Low risk.
3. A painful red irreducible hernia has been present for 10 hours with raised lactate. What should be done?
Answer: Emergency surgery. Strangulation needs urgent operation.
- Analgesia and elective list: Dangerous.
- Truss: No.
- Ice packs only: No.
- Forceful reduction: May reduce dead bowel.
4. During repair of a small femoral hernia, part of the antimesenteric wall of the small bowel is found strangulated in the sac without complete bowel obstruction. What is this?
Answer: Richter hernia. Richter hernia: only part of the bowel circumference (antimesenteric border) is trapped — can strangulate and perforate without obstructive symptoms; commonest in femoral hernias. Littre: Meckel’s diverticulum; Amyand: appendix in inguinal hernia; de Garengeot: appendix in femoral; Maydl: W-loop with the middle loop strangulated inside the abdomen; sliding hernia: viscus forms part of the sac wall.
- Littre hernia: Littre hernia contains a Meckel’s diverticulum.
- Amyand hernia: Amyand hernia contains the appendix in an inguinal hernia.
- Maydl hernia: Maydl hernia is a W-loop in the sac.
5. An elderly thin woman has intermittent small bowel obstruction and pain down the inner thigh to the knee, worse on thigh extension and medial rotation. Which hernia is likely?
Answer: Obturator hernia. Obturator hernia: through the obturator canal — elderly thin multiparous women; often presents as small bowel obstruction (Richter-type), Howship–Romberg sign (pain along medial thigh from obturator nerve compression); CT diagnoses. Spigelian hernia: through Spigelian fascia at the lateral edge of rectus sheath (semilunar line), below the arcuate line — interparietal, easily missed. Lumbar hernias: Petit (inferior) and Grynfeltt (superior) triangles. Richter hernia: only part of bowel wall trapped — strangulation without obstruction.
- Spigelian hernia: Spigelian hernias lie along the semilunar line and do not cause inner thigh pain.
- Femoral hernia: Femoral hernias do not cause the Howship–Romberg sign.
- Lumbar hernia: Lumbar hernias occur in the Petit or Grynfeltt triangles.
6. Which nerve runs through the inguinal canal but outside the spermatic cord?
Answer: Ilioinguinal nerve. The ilioinguinal nerve enters the inguinal canal from the side (not through the deep ring) and lies on the cord, outside its fascial coverings, before leaving through the superficial ring to supply the upper medial thigh and anterior scrotum. It can be injured in hernia repair. The genital branch of the genitofemoral nerve is inside the cord.
- Genital branch of genitofemoral nerve: Inside the cord; supplies cremaster.
- Vas deferens nerve plexus: Not the answer.
- Testicular sympathetic plexus: Inside the cord with the testicular artery.
- Pudendal nerve: Not in the inguinal canal.
7. What passes through the inguinal canal in females?
Answer: Round ligament. In females, the inguinal canal transmits the round ligament of the uterus (a gubernaculum remnant attaching to the labium majus), the ilioinguinal nerve and the genital branch of the genitofemoral nerve; lymphatics from the uterine cornu follow the round ligament. A patent processus vaginalis (canal of Nuck) can cause an indirect hernia or hydrocele in females.
- Ovarian artery: In the suspensory ligament.
- Ureter: Pelvic course.
- Uterine tube: Within the broad ligament.
- Broad ligament: Peritoneal fold in the pelvis.
References and dose sources
- WSES guidelines — complicated abdominal wall hernias
- HerniaSurge — international guidelines for groin hernia management
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Ondansetron dosing: Drugs.com: Ondansetron dosage (see also our ondansetron dose page)
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.