Hernia in detail with images and EhS classification

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Hernia: Comprehensive Overview with EHS Classification

Definition

A hernia is the protrusion of a viscus, or part of a viscus, through a normal or abnormal aperture in the walls of its containing cavity. The essential components are:

Covering (hernial sac): derived from peritoneum
Contents: bowel, omentum, or other abdominal organs
Defect: the fascial/muscular aperture through which protrusion occurs

Anatomical Classification

Groin (Inguinal Region) Hernias

Indirect inguinal hernia — the most common type (65% of all groin hernias). The sac passes through the deep inguinal ring, travels lateral to the inferior epigastric vessels, through the inguinal canal, and may descend into the scrotum. It follows the path of the processus vaginalis and is often congenital in origin.

Indirect Inguinal Hernia — sac passes through the deep inguinal ring and down the inguinal canal into the scrotum

Direct inguinal hernia — the sac pushes through the posterior wall of the inguinal canal (Hesselbach's triangle), medial to the inferior epigastric vessels. It is an acquired weakness, related to aging, obesity, and connective tissue disorders.

Direct Inguinal Hernia — protrudes medially through the posterior inguinal canal wall

Femoral hernia — protrudes through the femoral canal, inferior to the inguinal ligament, medial to the femoral vein and lateral to the lacunar ligament. More common in women. Up to 45% are incarcerated at presentation due to the narrow, rigid femoral ring.

The anatomical relationships of all three groin hernias relative to the inferior epigastric vessels and femoral sheath:

Relationships of direct, indirect inguinal, and femoral hernias — Bailey & Love's Surgery

Pantaloon hernia — a combination of direct and indirect components straddling the inferior epigastric vessels, resembling trouser legs.

Ventral (Anterior Abdominal Wall) Hernias

The major ventral hernias with their anatomical sites:

Ventral hernias — incisional (A), umbilical (B), epigastric (C), Spigelian (D) — Roberts & Hedges' Emergency Procedures

Type	Location	Key Features
Incisional	Any prior surgical scar	Occurs in ~20% post-laparotomy; 20–50% recurrence rate; incarceration risk low
Umbilical	Umbilical fibromuscular ring	Common in infants (congenital), resolves by age 5; adult form prone to strangulation
Epigastric	Linea alba, xiphoid–umbilicus	Usually small, contains preperitoneal fat; also seen in ~4% of pediatric hernias
Spigelian	Lateral rectus edge at arcuate line	Rare; interstitial position → high incarceration rate (~20%); US/CT often needed
Parastomal	Around stoma site	Incisional variant with specific repair challenges

External Surface of Abdomen — Hernia Sites Overview

Hernia sites on the anterior abdominal wall — epigastric, umbilical, Spigelian, inguinal, femoral, obturator — Bailey & Love's Surgery

Diaphragmatic Hernias

There are three main types:

Sliding (Type I) hiatal hernia — gastro-oesophageal junction migrates above the diaphragm; most common (>95% of hiatal hernias)
Rolling/Paraesophageal hernia — gastric fundus herniates alongside the oesophagus; GEJ remains below diaphragm
Congenital (Bochdalek/Morgagni) — usually left-sided; presents at birth with respiratory failure

Internal Hernias

These occur through normal or abnormal peritoneal/mesenteric apertures without external bulge:

Paraduodenal — most common congenital internal hernia
Foramen of Winslow hernia — bowel enters the lesser sac
Iatrogenic — after Roux-en-Y gastric bypass, colectomy, pancreaticoduodenectomy (mesocolon or mesentery division)
Obturator / sciatic notch hernias — uncommon but important causes of obscure SBO

Pathological States

State	Definition	Surgical urgency
Reducible	Contents return to abdomen spontaneously or manually	Elective
Irreducible / Incarcerated	Contents cannot be returned; no vascular compromise	Urgent
Obstructed	Incarcerated bowel with luminal obstruction	Urgent / emergency
Strangulated	Ischemia of hernial contents from compression at neck	Emergency
Richter hernia	Only part of bowel wall in the sac → partial obstruction possible without complete obstruction	Emergency

CT of a groin hernia (axial and coronal views showing the herniating segment and hernia orifice):

CT groin hernia — axial and coronal views — Mulholland & Greenfield's Surgery

Strangulation risk is highest with femoral hernias (~40–45%), intermediate with umbilical hernias (up to 60% show strangulation at surgery), and lowest with incisional hernias (~2%). — Sleisenger & Fordtran's Gastrointestinal and Liver Disease

EHS (European Hernia Society) Classification

The EHS has published distinct classification systems for three hernia categories. These are used to standardise operative reporting, tailor repair techniques, and enable registry-based comparison of outcomes.

1. EHS Groin Hernia Classification (2007)

Published by Miserez et al. based on the Aachen (Schumpelick) classification, this is a simple intraoperative grid system.

The two axes are:

Type: L = Lateral (indirect), M = Medial (direct), F = Femoral, X = No hernia
Size: 1 = small (≤1.5 cm / one finger), 2 = medium (1.5–3 cm / two fingers), 3 = large (>3 cm / more than two fingers)

EHS Groin Hernia Grid:

	Right	Left
L (Lateral/Indirect)	L0 · L1 · L2 · L3	L0 · L1 · L2 · L3
M (Medial/Direct)	M0 · M1 · M2 · M3	M0 · M1 · M2 · M3
F (Femoral)	F0 · F1 · F2 · F3	F0 · F1 · F2 · F3

Suffix 0 = no hernia present at that site
Suffixes 1–3 = size categories above
P is added for recurrent/previous repair (e.g., L2P)

Clinical significance of subgroups:

L1: Small indirect — posterior wall intact; suture repair may suffice in select cases
M3: Large direct — EHS guidelines strongly recommend mesh fixation in laparoscopic (TAPP/TEP) repair to reduce recurrence
F1–F3: All femoral hernias require urgent repair due to high strangulation risk

Laparoscopic (TAPP) view of an EHS L2 hernia with mesh placement and peritoneal closure:

TAPP repair of EHS L2 inguinal hernia — laparoscopic port placement, hernia orifice, mesh fixation, peritoneal closure

Clinical + laparoscopic findings including EHS L3 indirect and EHS F1 femoral hernia in the same patient:

Clinical and laparoscopic groin hernia — EHS L3 indirect right, EHS F1 occult left femoral hernia

2. EHS Primary Abdominal Wall Hernia Classification (2009)

Proposed by Muysoms et al. for epigastric, umbilical, Spigelian, and lumbar hernias (excluding incisional and parastomal).

Two variables:

Variable	Categories
Localisation	Epigastric / Umbilical / Spigelian / Lumbar
Size (diameter)	Small (<2 cm) / Medium (2–4 cm) / Large (>4 cm)

Parastomal hernias are deliberately excluded as a distinct group with separate classification.

3. EHS Incisional Hernia Classification (2009)

For postoperative (incisional) hernias, two variables are used. A full grid format was not achieved due to lack of consensus on a single size variable.

Localisation — based on grid coordinates of the abdominal wall:

	Midline	Lateral
Subxiphoidal (M1)	Above xiphoid	L1 = subcostal
Epigastric (M2)	Xiphoid–umbilicus	L2 = flank
Umbilical (M3)	At umbilicus	L3 = iliac
Infraumbilical (M4)	Umbilicus–pubis	L4 = lumbar
Suprapubic (M5)	Below M4

Size — width of defect (most critical variable for repair difficulty):

W1: < 4 cm
W2: ≥ 4 cm and < 10 cm
W3: ≥ 10 cm

Additional recorded variables: R (recurrent, yes/no) and number of previous repairs.

4. EHS Parastomal Hernia Classification (2012)

Defined at a consensus meeting in Toruń, Poland (April 2012):

Type I: Small (<5 cm), no bowel herniation
Type II: Small (<5 cm), bowel herniation present
Type III: Large (≥5 cm), no bowel herniation
Type IV: Large (≥5 cm), bowel herniation present

Aetiology & Risk Factors

Congenital: Patent processus vaginalis → indirect inguinal hernia; congenital diaphragmatic (Bochdalek) hernia; umbilical hernia of infancy

Acquired — predisposing factors:

Raised intra-abdominal pressure: chronic cough (COPD), straining (constipation, BPH), obesity, ascites, pregnancy
Connective tissue weakness: aging, Ehlers-Danlos, Marfan syndrome, collagen metabolism disorders
Prior surgery: disruption of fascial integrity → incisional hernia (~20% post-laparotomy)
Nutritional/metabolic: malnutrition, steroid use, wound infection post-surgery

Clinical Features & Diagnosis

Symptoms:

Reducible swelling aggravated by coughing, standing, straining; relieved by lying down
Pain or dragging discomfort at the hernia site
Signs of obstruction (nausea, vomiting, absolute constipation) if incarcerated

Physical examination:

Inguinal canal examined with inverted scrotal skin in males; Valsalva maneuver increases pressure
Indirect vs. direct differentiation:
- Indirect: starts lateral to inferior epigastric artery, tip of finger hit during cough, fills scrotum, controlled by pressure over deep ring
- Direct: pushes against finger pad, medial protrusion, not controlled by deep ring pressure
Femoral: bulge appears below and lateral to pubic tubercle (vs. inguinal = above pubic tubercle)

Imaging:

CT scan: gold standard for internal hernias, incarcerated/obstructed hernias, and obese patients where palpation is unreliable
Ultrasound: useful for Spigelian hernias and equivocal groin swellings
Dynamic MRI: considered if ultrasound is negative or non-diagnostic for occult groin hernias

Management

Conservative

Watchful waiting is acceptable for asymptomatic or minimally symptomatic hernias (especially inguinal hernias in elderly/unfit patients). Trusses are rarely used today and do not prevent incarceration.

Surgical Repair

Open techniques:

Lichtenstein (tension-free mesh repair) — gold standard for inguinal hernia; mesh laid on posterior inguinal canal wall
Bassini / Shouldice — tissue repairs (without mesh); reserved for contaminated fields
McVay (Cooper's ligament repair) — used for femoral hernia repair
Mayo repair — for umbilical hernia

Laparoscopic / Endoscopic techniques:

TAPP (TransAbdominal PrePeritoneal) — mesh placed preperitoneally via transabdominal approach; peritoneum closed over mesh
TEP (Totally ExtraPeritoneal) — mesh placed without entering peritoneum
Benefits: bilateral repair, early return to activity, less chronic pain; mesh fixation recommended for M3 (large direct) defects

Emergency repair (incarcerated/strangulated):

Urgent resuscitation, antibiotics, then surgery
Open tissue repair preferred over mesh in contaminated fields; laparoscopy useful for reduction and viability assessment
Richter hernias may present without complete obstruction — careful vigilance required since partial strangulation occurs silently

Key Comparisons Summary

Feature	Indirect Inguinal	Direct Inguinal	Femoral
Path	Through deep ring	Hesselbach's triangle	Femoral canal
Relation to epigastric vessels	Lateral	Medial	Below inguinal ligament
Sex	M >> F	M >> F	F > M
Congenital	Yes (processus vaginalis)	No	No
Incarceration risk	Low–Moderate	Low	Very high (40–45%)
EHS code	L1–L3	M1–M3	F1–F3

Sources: Roberts & Hedges' Clinical Procedures in Emergency Medicine; Mulholland & Greenfield's Surgery (7e); Sleisenger & Fordtran's Gastrointestinal and Liver Disease; Bailey & Love's Short Practice of Surgery (28e); Miserez et al. Hernia 2007 (EHS groin classification); Muysoms et al. Hernia 2009 (EHS primary/incisional classification); EHS/AHS guidelines 2018.

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