Abdominal Wall Hernias: Types, Symptoms, and When to See a Surgeon

A hernia occurs when tissue — most often a portion of the intestine or intra-abdominal fat — pushes through a weakness or defect in the muscular wall of the abdomen. It is one of the most common surgical conditions in general surgery, affecting millions of Americans each year across every age group and demographic.

Hernias don’t resolve on their own. Without repair, they typically enlarge over time — and in some cases, they can become life-threatening emergencies. Yet many patients live with hernias for months or years before seeking evaluation, unsure whether their symptoms warrant attention or whether surgery is truly necessary.

At Sulphur Surgical Clinic, our board-certified surgeons have repaired hernias of every type and complexity across Southwest Louisiana for decades. This post — the first in our two-part Hernia Series — covers what hernias are, the different types you may encounter, what symptoms they cause, and when surgical repair is indicated.

What Is a Hernia?

The abdominal wall is a layered structure of muscle, fascia, and connective tissue designed to contain and protect the organs of the abdomen and pelvis. When a defect develops in this wall — whether congenital (present at birth), acquired through strain or injury, or created by a prior surgical incision — intra-abdominal contents can protrude through the gap, forming a hernia.

The three anatomic components of any hernia are:

The defect — the hole or weakness in the abdominal wall through which the hernia passes
The sac — a layer of peritoneum (the tissue lining the abdominal cavity) that envelops the protruding contents
The contents — most commonly omentum (abdominal fat) or small bowel; occasionally the colon, bladder, or other structures

Most hernias are reducible — meaning the contents can be gently pushed back into the abdominal cavity. An irreducible (or incarcerated) hernia cannot be reduced, and a strangulated hernia has lost its blood supply — a surgical emergency.

Types of Abdominal Wall Hernias

Inguinal Hernia

Inguinal hernias are by far the most common type, accounting for approximately 75% of all abdominal wall hernias. They occur in the groin region, where the abdominal wall has a natural area of relative weakness — the inguinal canal — through which structures pass between the abdomen and the lower extremity (the spermatic cord in men, the round ligament in women).

Inguinal hernias are far more common in men than women, largely because of anatomical differences in the inguinal canal. The lifetime risk of inguinal hernia in men is approximately 27%, compared to 3% in women.

There are two subtypes:

Indirect inguinal hernia — the hernia passes through the internal inguinal ring and follows the path of the inguinal canal. This is the most common type, and the most common hernia overall. Indirect hernias are often congenital in origin, resulting from a failure of the processus vaginalis (a small embryonic outpouching of peritoneum) to close after birth.

Direct inguinal hernia — the hernia protrudes directly through a weakness in the posterior wall of the inguinal canal (Hesselbach’s triangle), medial to the inferior epigastric vessels. Direct hernias are typically acquired, developing over time from chronic intra-abdominal pressure (heavy lifting, straining, obesity, chronic cough) and are more common in older men.

Symptoms of inguinal hernia:

A visible or palpable bulge in the groin — more prominent when standing, coughing, or straining
Aching or pressure in the groin, particularly with activity
A heavy or dragging sensation, especially by end of day
Pain that worsens with prolonged standing or exertion
Scrotal swelling or discomfort in men when hernia contents descend into the scrotum

Femoral Hernia

Femoral hernias pass through the femoral canal — a small potential space just below the inguinal ligament, medial to the femoral vessels. They are less common than inguinal hernias overall but proportionally more common in women, particularly those who have had multiple pregnancies. Femoral hernias have a higher risk of incarceration and strangulation than inguinal hernias because the femoral ring is a relatively narrow and rigid orifice that does not accommodate bowel well.

Femoral hernias may present as a small, firm lump at the top of the inner thigh. They are sometimes confused with inguinal hernias clinically, and the distinction may only be clear at the time of surgical exploration.

Umbilical Hernia

Umbilical hernias occur at the umbilicus (belly button) — another natural area of abdominal wall weakness where the umbilical cord once passed. They are the second most common hernia type in adults.

Umbilical hernias may be congenital or acquired. In adults, risk factors include obesity, pregnancy (which stretches and thins the abdominal wall), ascites (abdominal fluid accumulation from liver disease), and chronic straining. Umbilical hernias often become apparent as a soft, reducible bulge at the navel that appears with Valsalva maneuver and disappears when lying flat.

Many umbilical hernias are minimally symptomatic for years. However, they tend to slowly enlarge — and small umbilical hernias with a tight fascial ring carry a disproportionately high risk of incarceration relative to their size, because a small defect is less accommodating than a larger one.

Epigastric Hernia

Epigastric hernias occur in the midline of the abdomen between the xiphoid process and the umbilicus — the linea alba, where the fascial layers of the right and left rectus muscles meet. This region can develop small defects through which peritoneal fat protrudes.

Epigastric hernias are often small and may not produce a visible bulge, but they can cause surprisingly significant midline pain — particularly with exertion or palpation. They are more common in men and frequently multiple. Most contain only preperitoneal fat (no bowel sac), which makes them less prone to strangulation but no less symptomatic.

Incisional / Ventral Hernia

Incisional hernias develop through a previous surgical incision in the abdominal wall. They are among the most complex hernias to manage — not because the underlying anatomy is inherently dangerous, but because the defect is often large, the tissues are scarred and attenuated, and recurrence rates are higher than for primary hernias.

Any prior abdominal surgery carries an incisional hernia risk — estimated at 10 to 15% of laparotomy incisions overall, and higher in the setting of wound infection, obesity, malnutrition, steroid use, or other factors that impair wound healing. Midline laparotomy incisions carry the highest risk.

Incisional hernias typically present as a bulge along or adjacent to a prior scar, often apparent only when standing or straining. They may be asymptomatic for years before enlarging to the point of causing pain, functional limitation, or risk of bowel incarceration.

Spigelian Hernia

Spigelian hernias are relatively rare and occur through the Spigelian fascia — the aponeurotic layer lateral to the rectus muscle, at or below the level of the arcuate line. They are unique in that they are often interparietal (meaning the hernia sac passes between layers of the abdominal wall) rather than subcutaneous, making them difficult to see or feel on exam.

Spigelian hernias most commonly present with lateral abdominal wall pain — often mistaken for a muscular strain or other musculoskeletal complaint. Because they may not produce an obvious bulge, diagnosis often requires CT imaging. Despite their rarity, they carry a relatively high risk of incarceration due to the nature of their defect.

Obturator Hernia

Obturator hernias are uncommon and occur through the obturator canal — a small opening in the obturator membrane of the pelvis through which the obturator nerve and vessels pass. They occur almost exclusively in elderly, thin women and are frequently misdiagnosed because they produce no visible external bulge. The classic presentation is medial thigh pain aggravated by hip flexion and rotation (Howship-Romberg sign), along with bowel obstruction. Obturator hernias are often diagnosed on CT scan obtained for a bowel obstruction workup.

Complications of Untreated Hernias

Incarceration

A hernia becomes incarcerated when its contents become trapped in the defect and cannot be reduced back into the abdominal cavity. The bowel or omentum is caught in the hernia sac and cannot be manually pushed back. An incarcerated hernia causes persistent, non-positional pain and a firm, tender bulge that does not decompress when lying down.

Strangulation

Strangulation occurs when the blood supply to incarcerated hernia contents is compromised. This is a surgical emergency. The compromised bowel will progress to ischemia and necrosis — and if not corrected urgently, sepsis, perforation, and death can result. Strangulated hernias present with severe pain, fever, nausea, vomiting, and an acutely tender, erythematous bulge. Immediate surgical intervention is required.

The risk of strangulation is not equal across hernia types. Femoral hernias, small umbilical hernias, and obturator hernias carry relatively high strangulation risks. Large, wide-necked ventral hernias are generally at lower strangulation risk — though they carry greater risks of chronic bowel symptoms and difficulty of eventual repair.

Diagnosis

The diagnosis of most hernias is clinical — based on history and physical examination. A careful exam performed with the patient standing and straining (cough impulse) can identify the location, size, and reducibility of the hernia.

When clinical findings are equivocal — as in suspected Spigelian, obturator, or occult inguinal hernias — or when preoperative planning requires detailed anatomy (as in complex incisional hernias), imaging is valuable:

CT scan of the abdomen and pelvis — the most useful imaging modality for hernia evaluation; defines defect size, hernia contents, and surrounding tissue quality
Ultrasound — can be useful for dynamic assessment of groin hernias and may identify hernias not obvious on static imaging
MRI — occasionally used for groin hernias when CT findings are inconclusive

When Is Hernia Repair Necessary?

Symptomatic Hernias

Any hernia causing pain, limitation of activity, or progressive enlargement warrants surgical consultation. Symptoms do not reliably predict which hernias will incarcerate — but consistently symptomatic hernias have a lower quality of life impact and a legitimate surgical indication.

Inguinal Hernias in Men

Watchful waiting is an accepted option for minimally symptomatic inguinal hernias in men — studies have shown that approximately 70 to 80% of asymptomatic or minimally symptomatic inguinal hernias can be safely observed, with crossover to surgery driven by symptom development. However, most patients develop symptoms within two to five years, and the cumulative risk of acute incarceration (approximately 0.3% per year) adds up. For active men — especially those with physically demanding jobs or lifestyles — early repair is often the preferred strategy.

Femoral Hernias

Femoral hernias should be repaired promptly after diagnosis regardless of symptoms, due to their significantly elevated strangulation risk.

Umbilical and Epigastric Hernias

Repair is generally recommended for umbilical and epigastric hernias that are symptomatic, enlarging, or have a small defect diameter (which paradoxically increases incarceration risk). Asymptomatic umbilical hernias in the setting of active liver disease with ascites may be managed medically first, with surgical repair deferred until the ascites is controlled.

Incisional Hernias

Incisional hernias are repaired when symptomatic, enlarging, or when they threaten the integrity of the abdominal wall. Because they tend to grow over time and become progressively more complex to repair, earlier intervention is generally preferred when the patient is a good surgical candidate.

Emergency Situations

Incarcerated hernias that cannot be reduced require urgent surgical repair. Strangulated hernias require emergent intervention and may necessitate bowel resection if necrosis has occurred.

Hernia Repair at Sulphur Surgical Clinic

Our surgeons at Sulphur Surgical Clinic have decades of experience managing every type of abdominal wall hernia — from routine inguinal repairs to complex incisional hernia reconstructions. We take time to understand each patient’s symptoms, anatomy, activity level, and goals before recommending a repair strategy.

Part 2 of our Hernia Series covers the surgical techniques used to repair hernias — including laparoscopic approaches, open repair, and the role of mesh — in detail.

Continue Reading: The SSC Hernia Series

Part 2: Hernia Repair — Laparoscopic and Open Surgical Techniques

To schedule a hernia consultation at Sulphur Surgical Clinic, call (337) 527-6363 or visit sulphursurgicalclinic.com. We serve patients throughout Southwest Louisiana, at two convenient locations: 914 Cypress Street, Sulphur LA 70663 and our new Lake Charles office at 1920 W Sale Rd, Lake Charles LA 70605.