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Abdominal wall hernias (inguinal, femoral, umbilical and incisional)
A hernia is a protrusion of abdominal contents through a weak point in the wall; the key exam decision is between a hernia that can be observed or repaired electively and an incarcerated, strangulated hernia that needs urgent surgery — and a femoral hernia is always repaired.
Why it matters in the exam
Hernia questions first require anatomy: an indirect inguinal hernia leaves lateral to the inferior epigastric vessels through the deep ring, and a direct hernia leaves medial to them through Hesselbach's triangle. A femoral hernia emerges under the inguinal ligament on the inner side of the femoral vein; it is more common in women and carries the highest risk of strangulation. The indirect hernia is the most common type in both sexes — in women too.
Then the treatment decision is tested: in a man with an asymptomatic or minimally symptomatic inguinal hernia, watchful waiting is reasonable, though most patients will eventually have surgery. A symptomatic hernia is repaired with mesh — open (Lichtenstein) or laparoscopic — and the laparoscopic approach is preferred for bilateral hernias, recurrence after an open repair and in women. An incarcerated hernia without signs of strangulation may be reduced manually, and a strangulated hernia (constant pain, redness, fever, signs of obstruction) is operated on at once. Other concepts that are asked: Richter's hernia, an obturator hernia in a thin older woman, and an umbilical hernia in children that usually closes by itself.
Key points
- Indirect — lateral to the inferior epigastric vessels; direct — medial, in Hesselbach's triangle.
- Femoral — below the inguinal ligament, women, highest strangulation risk: always repair.
- Man with an asymptomatic inguinal hernia — watchful waiting possible; symptomatic — mesh.
- Strangulation (constant pain, redness, fever, obstruction) — urgent surgery.
- Umbilical hernia in children — observe until age 4–5; in adults a defect of 1 cm or more — mesh.
Summary table
| Type | Anatomy | Who | Treatment |
|---|---|---|---|
| Indirect inguinal | Lateral to the inferior epigastric vessels, through the deep ring | Most common type in both sexes and in children | Mesh repair in adults; in children closure of the sac without mesh |
| Direct inguinal | Medial to the vessels, through Hesselbach's triangle | Older men | Symptomatic — mesh (open or laparoscopic); asymptomatic in a man — observation is possible |
| Femoral | Under the inguinal ligament, on the inner side of the femoral vein | Older women | Always repair, even without symptoms — highest risk of strangulation |
| Umbilical | Through the umbilical ring | Infants; adults with obesity, ascites or pregnancy | In children it usually closes by age 4–5; in adults a defect of 1 cm or more — mesh |
| Incisional | Through a surgical scar | After laparotomy, with obesity, smoking or wound infection | Mesh repair; stop smoking and lose weight before elective surgery |
Free exam questions
מטופל בן 20 התקבל בשל כאב בטן תחתונה. בין הממצאים האחרים בבדיקה פיזיקלית, כיפוף יחד עם סיבוב חיצוני של ירך ימין(flexion and external rotation) .גורם להתגברות הכאב על איזה ?מהמצבים הבאים מעיד הסימן המתואר (the question as examined, in Hebrew)
- א. Free air in abdomen
- ב. Rt renal colic
- ג. Pelvic abscess
- ד. Incarcerated rt inguinal hernia
An 80-year-old, lucid and independent, male is admitted for inguinal hernia repair. Which of the following questions will provide simple and clear insight to his functional status?
- A. History of falls
- B. Permanent medications
- C. Aid of a walking cane
- D. Number of hours of social activity per week
בת 60 , ברקע- BMI 42, Creatinine Clearance – 50 mL/min, .לאחר ניתוח כריתת כיס מרה התפתח DVT בווריד Deep Femoral vein בגפה ימנית תחתונה. מהו טיפול הבחירה אצל מטופלת זו? (the question as examined, in Hebrew)
- א. Warfarin (Coumadin) בחפיפה עם.Enoxaparin(Clexane)
- ב. Apixaban (Eliquis)
- ג. Dabigatran (Pradaxa)
- ד. Inferior vena cava filter
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
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Sources
- International guidelines for groin hernia management (HerniaSurge Group), 2018 — Indications, choice of repair and emergency hernia
- European Hernia Society and Americas Hernia Society guidelines for umbilical and epigastric hernias, 2020 — Indications and mesh use
- Sabiston Textbook of Surgery, 21st edition (2022) — Hernias
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.