Management of Right Lower Quadrant Abdominal Hernia
Surgical repair is the definitive treatment for RLQ abdominal hernias, with laparoscopic approach preferred in stable patients, while unstable patients or those with complications require urgent open surgical intervention. 1, 2
Diagnostic Approach
Initial Imaging
- CT scan with contrast is the gold standard for diagnosing abdominal hernias in the RLQ, with sensitivity of 14-82% and specificity of 87% 3, 1
- CT is particularly crucial when clinical diagnosis is uncertain or when differentiating from other causes of RLQ pain (appendicitis, diverticulitis, ureteral stones) 3
- Look for specific CT findings: discontinuity of the abdominal wall, herniated bowel loops, "collar sign" (constriction at the defect), and signs of bowel ischemia (wall thickening, lack of contrast enhancement, pneumatosis) 3
Clinical Assessment
- Examine for palpable bulge or impulse during coughing/straining 4
- Assess for signs of incarceration or strangulation: severe pain, nausea, vomiting, constipation, peritoneal signs 2, 5
- Ultrasonography may be used when diagnosis is uncertain or in specific populations, though CT remains superior 4
Surgical Management Strategy
Stable Patients
- Laparoscopic repair is strongly recommended as it offers lower morbidity, shorter hospital stays, and excellent safety profile (in-hospital mortality 0.14%) 1
- Primary repair using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers 1
Mesh Reinforcement Indications
- Use mesh for defects >3 cm or when primary closure creates excessive tension 1
- Biosynthetic, biologic, or composite meshes are preferred over synthetic due to lower infection risk in emergency settings 3, 1
- Mesh must overlap defect edges by 1.5-2.5 cm 3, 1
- Avoid tackers near vital structures; use transfascial sutures when appropriate 3
Unstable or Complicated Cases
- Immediate open laparotomy is indicated for patients with peritoneal signs, hemodynamic instability, or suspected bowel ischemia 3, 2
- Emergency surgery prevents bowel necrosis and need for extensive resection 2
- Damage control surgery may be necessary in critically ill patients with severely injured organs 3
Special Considerations
High-Risk Elderly Patients
- Percutaneous endoscopic gastrostomy (PEG) or gastrostomy can be considered for patients unsuitable for definitive repair, providing fixation and preventing progression 3, 1
- This approach has very low morbidity and is well-tolerated in frail patients 3
Specific Hernia Types in RLQ
- Spigelian hernias on the right side can mimic appendicitis and require high index of suspicion 5
- Obturator hernias are rare but carry significant morbidity/mortality risk; early CT diagnosis and prompt intervention are critical 2
- Choice between open versus laparoscopic should consider patient comorbidities (e.g., severe asthma may favor open approach) 2
Critical Pitfalls to Avoid
- Do not delay surgery in incarcerated or strangulated hernias - bowel viability deteriorates rapidly 2, 6
- Primary repair alone without mesh has 42% recurrence rate for larger defects 1
- Normal imaging does not exclude hernia in athletes or patients with intermittent symptoms 4
- Urgent surgical consultation is mandatory when bowel ischemia, strangulation, or complete obstruction is suspected 6