Abdominal Hernias: Types and Surgical Management

An abdominal hernia is an abnormal protrusion of the abdominal contents through a weakness or defect of the abdominal wall, and can be congenital or acquired. There are multiple types of hernias based on the anatomic location and the underlying pathophysiology. The most common hernias encountered in surgical practice include ventral, inguinal, and femoral hernias. Hernias are most commonly diagnosed on physical exam (abnormal bulge or protrusion), but imaging studies can sometimes be helpful for a definitive diagnosis. The management consists of surgical repair. The decision for surgery is based on patients’ symptoms, their desire for surgical repair, and risks of incarceration and strangulation. Surgical options include open and laparoscopic approaches, with or without the placement of a prosthetic mesh.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

A hernia is an abnormal protrusion of the abdominal contents through a weakness or defect along the wall of the abdomen. Hernias can be congenital or acquired.

Epidemiology

  • 5 million Americans have hernias.
  • A majority of hernias are groin hernias (inguinal/ femoral).
  • ⅓ of all repaired ventral hernias are incisional hernias and the remaining ⅔ are primary ventral hernias.

Etiology

  • Some hernias can be congenital:
    • Inguinal (failure of the closure of the processus vaginalis)
    • Umbilical (present at birth in all infants, but most close within the 1st 2 years of life)
  • Acquired hernias are due to loss of the mechanical integrity of the abdominal wall:
    • Primary: A genetic component causes weakness of the abdominal wall.
    • Incisional: damage to abdominal wall muscles and fascia during surgery

Pathophysiology

  • A hernia has a hernia sac: an outpouching of the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum and Retroperitoneum, which covers the hernia contents
  • Reducible hernia:
    • Contents of the hernia can freely return to the abdominal cavity.
    • During an examination, the hernia can be pushed back in.
  • Incarceration:
    • Inability of the contents of the hernia to return to their original cavity
    • Presents with severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and nonreducible bulge
    • Symptoms of intestinal obstruction develop if intestines are incarcerated.
  • Strangulation:
    • Contents of the hernia are incarcerated.
    • Blood supply to the incarcerated organs is compromised, causing ischemia and resultant tissue death.

Anatomic classification

Various types of abdominal wall hernias can be defined by anatomic location:

  • Anterior hernia:
    • Epigastric
    • Umbilical
    • Spigelian
    • Incisional
    • Parastomal
  • Groin hernia:
    • Inguinal
    • Femoral
  • Pelvic hernia:
    • Obturator
    • Sciatic
    • Perineal
  • Posterior hernia:
    • Superior triangle (Grynfeltt hernia)
    • Inferior triangle (Petit hernia)
Types of hernias of the abdominal wall

Types of hernias of the abdominal wall

Image by Lecturio.

Ventral Hernias

Definition

Ventral hernias occur through a weakness in the anterior abdominal wall Anterior abdominal wall The anterior abdominal wall is anatomically delineated as a hexagonal area defined superiorly by the xiphoid process, laterally by the midaxillary lines, and inferiorly by the pubic symphysis. Anterior Abdominal Wall and can be congenital or acquired.

Anatomy

Layers of the abdominal wall include:

  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • Camper’s fascia (subcutaneous fatty tissue)
  • Scarpa’s fascia (membranous layer of the anterior abdominal wall Anterior abdominal wall The anterior abdominal wall is anatomically delineated as a hexagonal area defined superiorly by the xiphoid process, laterally by the midaxillary lines, and inferiorly by the pubic symphysis. Anterior Abdominal Wall)
  • External abdominal oblique fascia and muscle (lateral), and rectus abdominis muscle (medial)
  • Rectus abdominis has:
    • Anterior rectus fascia
    • Rectus muscle
    • Posterior rectus fascia:
      • Ends midway between the umbilicus and pubic tubercle
      • The lower edge is referred to as the arcuate line.
    • Linea alba: fibrous band that runs midline between the 2 rectus muscles
  • Internal abdominal oblique muscle
  • Transversus abdominis muscle
  • Transversalis fascia (underlies the transversalis muscle and posterior rectus fascia)
  • Preperitoneal fat
  • Peritoneum
Layers of abdominal wall

Diagram of the layers of abdominal wall

Image: “Gray399” by Henry Gray. License: Public Domain

Types of ventral hernias

Epigastric hernias:

  • Hernias that occur along the linea alba, from the xiphoid process to the umbilicus
  • Constitute 1.6%–3.6% of abdominal wall hernias
  • 2–3 times more common in men
  • Small defects that produce pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain disproportionate to their size

Umbilical:

  • Hernias that occur through the umbilical ring of the linea alba
  • Pediatric population:
    • The umbilical ring is open at birth (to allow passage of umbilical vessels).
    • Spontaneous closure generally occurs during the 1st 2 years of life and is closed in most children by 5 years of age.
    • Surgical repair is indicated if umbilical hernias persist beyond the 5th year of life with no decrease in the size of the defect.
    • Up to 8 times more common in children of African American descent
  • Adult population:
    • Most commonly acquired
    • More common in women and in conditions that cause increased intra-abdominal pressure:
      • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
      • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
      • Ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites

Incisional hernias:

  • Hernias that occur through the scar tissue of past surgical incisions due to poor wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing and excessive tension
  • Risk factors for incisional hernia:
    • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
    • Malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries
    • Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by progressive, largely irreversible airflow obstruction. The condition usually presents in middle-aged or elderly persons with a history of cigarette smoking. Signs and symptoms include prolonged expiration, wheezing, diminished breath sounds, progressive dyspnea, and chronic cough. Chronic Obstructive Pulmonary Disease (COPD)
    • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
    • Chronic corticosteroid use
    • Surgical site infection

Spigelian hernias:

  • Hernias that occur through the transversus abdominis muscle aponeurosis (Spigelian aponeurosis):
    • Bound by the lateral edge of the rectus muscle medially and linea semilunaris laterally
    • Most common in the “Spigelian belt”: the transverse 6-cm zone around the arcuate line (lower edge of the posterior rectus sheath)
  • The majority of these hernias are small (1–2 cm) and most present during the 4th to 7th decades of life.
  • Difficult to identify on physical exam, often require imaging
Ct of right spigelian hernia

CT of right Spigelian hernia:
A: Hernia sac (arrow) containing loop of the small bowel (RA: right rectus abdominis)
B: Abdominal wall defect (circle)

Image: “Correspondence: Laparoscopic repair of abdominal wall hernia–“How I do it”–synopsis of a seemingly straightforward technique” by Berney CR. License: CC BY 4.0

Parastomal hernias:

  • Potential complication after creation of a stoma
  • Occurs with up to 50% of colostomies, less common with ileostomy
  • Asymptomatic in most cases and routine repair is not recommended
  • Obstruction or incarceration can occur in rare cases and require repair.

Surgical repair

Indications:

  • Strangulated hernias or hernias with incarcerated intestines need to be repaired emergently due to the risk of bowel necrosis.
  • Nonincarcerated hernias can be approached electively:
    • Should be repaired if the hernia causes pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or discomfort
    • Spigelian hernias should always be repaired due to the high risk of incarceration.

Primary repair:

  • Approximating the edges of the hernia defect with sutures
  • Suturing, by definition, is not tension-free as it entails pulling together the edges of the defect.
  • Thus, the rates of failure may be as high as 50%.
  • Generally, only suitable for very small defects (< 1 cm)
  • Other indications:
    • A contaminated surgical field, where the risk of mesh infection is unacceptably high
    • Hernias in children 

Mesh repair:

  • Involves placement of a prosthetic material to cover the hernia defect
  • Prosthetic materials can be synthetic (different types of polymers) or biologic (derived from human or animal tissues).
  • Synthetic meshes provide more durable repair and are preferred in the majority of cases.
  • Biologic meshes are preferred sometimes in a contaminated field to avoid synthetic mesh infection although evidence for their advantage in this situation is lacking.
  • Options for mesh placement:
    • Between the bellies of the rectus abdominis muscle (inlay)
    • Over the anterior aponeurosis of the rectal sheath (overlay)
    • Intraperitoneally (underlay)
    • Behind the rectus abdominis muscles (retro rectus)
    • Between the rectus abdominis muscle and the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum and Retroperitoneum (preperitoneal)
    • Between the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall and transversus abdominis muscles that run behind the rectus abdominis muscle (intramuscular)
  • Laparoscopic versus open approach:
    • Most small- and medium-sized hernias can be repaired with either approach.
    • The chosen method largely depends on the surgeon’s expertise.
    • Very large hernias, especially those involving the loss of abdominal domain, are repaired in an open fashion. The repair process can be quite complex and is sometimes done in stages.
    • Laparoscopy Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy has the advantages of a shorter hospital stay and faster recovery.

Complications:

  • Recurrence 
  • Mesh infection
  • Surgical site infection
  • Intestinal injury
  • Mesh-enteric fistula
  • Seroma: an accumulation of exudative secretions in potential spaces when the reabsorption capacity of the tissues is overwhelmed

Inguinal Hernias

Definition

Inguinal hernias Inguinal Hernias An abdominal hernia with an external bulge in the groin region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the abdominal wall (transversalis fascia) in Hesselbach's triangle. The former type is commonly seen in children and young adults; the latter in adults. Inguinal Canal and Hernias occur through the floor or the internal ring of the inguinal canal Inguinal canal The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. Inguinal Canal and Hernias.

Epidemiology

  • 75% of all hernias are inguinal.
  • Men are 25 times more likely to have a groin hernia.
  • The indirect variant is more common than the direct variant (2:1).
  • Most commonly occur on the right side
  • Strangulation occurs in 1%–3% of all inguinal hernias.

Classification

  • Indirect: 
    • The hernia sac passes through the internal inguinal ring toward the external inguinal ring and into the scrotum.
    • Frequently congenital and associated with patent processus vaginalis
  • Direct: 
    • The hernia sac protrudes anteriorly and is medial to the internal inguinal ring and inferior epigastric vessels.
    • Hesselbach’s triangle (site of direct herniation): formed by the inguinal ligament, inferior epigastric vessels, and rectus sheath
    • Mostly acquired secondary to muscular weakness and are more common in older men
  • Combined (pantaloon): both indirect and direct hernia components
Schematic diagram of the difference in location between direct inguinal hernias

Schematic diagram showing the difference in location between direct inguinal hernias, indirect inguinal hernias, and femoral hernias:
Indirect hernias occur through the internal inguinal ring. Direct hernias occur through the external inguinal ring, medially to the epigastric vessels. Femoral hernias occur through the femoral triangle, below the inguinal (Poupart’s) ligament.

Image by Lecturio.

Anatomy of the inguinal canal Inguinal canal The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. Inguinal Canal and Hernias

  • An oblique passage in the inferior aspect of the abdominal wall of the inguinal regions
  • Directed downward and medially
  • 3.5–4 cm in length
  • Allows passage of the spermatic cord in men and the round ligament Round ligament A fibromuscular band that attaches to the uterus and then passes along the broad ligament, out through the inguinal ring, and into the labium majus. Uterus, Cervix, and Fallopian Tubes in women
  • 2 openings:
    • Deep (internal) ring
    • Superficial (external) ring
  • Processus vaginalis:
    • Peritoneal outpouching into the inguinal canal Inguinal canal The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. Inguinal Canal and Hernias associated with the descent of testes during embryonic development
    • Normally obliterated by birth
    • Creates anatomical predisposition for herniation if not obliterated
Table: Boundaries of the inguinal canal Inguinal canal The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. Inguinal Canal and Hernias
Boundary Level of the deep ring Middle Level of the superficial ring
Anterior wall Internal oblique External oblique External oblique aponeurosis External oblique aponeurosis (crura)
Posterior wall Transversalis fascia Transversalis fascia Conjoint tendon
Roof Transversalis fascia Arching fibres of internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall and transversus abdominis Medial crus of external oblique
Floor Inguinal ligament Inguinal ligament Lacunar ligament
Anatomy of the inguinal region and hernia

Anatomy of the inguinal region and hernia

Image by Lecturio.

Surgical repair

Indications:

  • Incarceration or strangulation (emergent)
  • Symptomatic hernia (associated with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or discomfort)

Open approach

  • A transverse incision is made above the inguinal ligament, which is at the midpoint between the anterior superior iliac spine and the pubic tubercle.
  • The external oblique External oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall aponeurosis is incised, with care taken to identify the genital branch of the genitofemoral nerve and the ilioinguinal nerve.
  • The spermatic cord is mobilized and the hernia sac is dissected free.
  • The contents of the hernia sac are reduced.
  • The hernia sac can be reduced (direct), or the neck of the hernia sac can be ligated and excised (indirect).
  • Primary repair (tissue repair) is rarely used nowadays as the failure rates are quite high.
  • Options for tissue repair:
    • Bassini: approximation of the transversus abdominis and the conjoint tendon ( internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall aponeurosis) to the inguinal ligament
    • Shouldice: 
      • Layered repair
      • Running suture to approximate the transversus abdominis aponeurosis to the inguinal iliopubic tract
      • Running suture to approximate the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall to the inguinal ligament
    • McVay:
      • Interrupted, nonabsorbable suture to approximate the edge of the transversus abdominis aponeurosis to Cooper’s ligament
      • Cooper’s ligament and the transversus abdominis are secured to the iliopubic tract.
      • A relaxing incision is made in the anterior rectus sheath 1 cm above the pubic tubercle.
  • Mesh repair:
    • Lichtenstein repair
      • A synthetic mesh with a slit in the middle is inserted into the canal to accommodate the spermatic cord and wrap around it.
      • Using nonabsorbable suture, the mesh is secured to the pubic tubercle superiorly along the transversus abdominis and inferiorly along the shelving edge of the inguinal ligament.
    • Plug and patch:
      • A cone-shaped piece of polypropylene mesh is inserted into the internal ring.
      • A flat piece of mesh is used to reinforce the floor of the inguinal canal Inguinal canal The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. Inguinal Canal and Hernias similar to the process used in Lichtenstein repair.

Laparoscopic approach:

  • Always involves mesh placement
  • Requires technical expertise
  • Totally extraperitoneal (TEP) technique:
    • Abdominal cavity is not entered.
    • Dissection is performed in the preperitoneal space with a balloon and insufflation.
    • Limited working space
  • Transabdominal preperitoneal (TAPP) technique:
    • Abdomen is entered using the open Hassan technique or Veress needle.
    • Peritoneum is taken down and mesh is placed in the preperitoneal space.
    • Larger working space

Complications:

  • Chronic groin pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 
  • Testicular atrophy (damage to the testicular artery)
  • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility (mesh fibrosis)
  • Orchitis Orchitis Epididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis: acute inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the testis due to viral or bacterial infections
  • Seroma
  • Scrotal hematoma
  • Urinary retention

Femoral Hernias

Definition

Femoral hernias are hernias that occur through the femoral triangle (below the inguinal ligament).

Epidemiology

  • Up to 10 times more common in women than men
  • Occurs more commonly on the right side
  • The highest rate of strangulation among all hernias (10%–20%)
  • High likelihood of strangulation (40%); therefore, surgical intervention is always indicated

Anatomy

  • The femoral ring is roughly 1 cm in diameter and bound by:
    • Femoral vein laterally
    • Iliopubic tract anteriorly
    • Cooper’s ligament posteriorly
    • The pubic tubercle forms the apex of the femoral canal triangle.
  • The hernia will pass medial to the femoral vessels through the femoral canal.

Surgical repair

  • Open repair: 
    • McVay repair approximates the iliopubic tract to Cooper’s ligaments.
    • Preferred approach if there is strangulated bowel, as there is no need for mesh placement
    • The lacunar ligament should be divided if the incarcerated contents cannot be reduced.
  • Laparoscopic repair:
    • TEP laparoscopic approach
    • TAPP laparoscopic approach
  • Complications are similar to those seen in inguinal hernias.

References

  1. Malangoni, M.A., Rosen, M.J. (2012). In Mattox, K. L., et al. (Eds.), Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. pp. 1114‒1140.
  2. Turnage, R.H., Badgwell, B. (2012). In Mattox, K. L., et al. (Eds.), Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. pp. 1088‒1113.
  3. Brooke, D.C. (2020). Overview of abdominal wall hernias in adults. In Chen, W. (Ed.). UpToDate, Retrieved April 23, 2021, from https://www.uptodate.com/contents/overview-of-abdominal-wall-hernias-in-adults
  4. Ramsook, C. (2020). Inguinal hernia in children. UpToDate, Retrieved May 03, 2021, from https://www.uptodate.com/contents/inguinal-hernia-in-children
  5. Brooks, D.C., Hawn, M. (2019). Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults. UpToDate, Retrieved May 03, 2021, from https://www.uptodate.com/contents/classification-clinical-features-and-diagnosis-of-inguinal-and-femoral-hernias-in-adults

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