HERNIA
It is an abnormal protrusion or projection of an organ or tissue or part of an organ/through the structure that normally contains it.
Causes
Congenital or acquired/weakness of the abdominal wall, increased intra-abdominal pressure from coughing or straining or from an enlarging lesion within the abdomen.
Risk Factors
Increased intra-abdominal pressure, straining of stools, obesity, congenital muscular
Classification
I. Based on Nature
a) Reducible
b) Irreducible
A hernia is referred to a reducible when the protruding mass can be placed back into a abdominal cavity. This can occur when the patient lies down or by manual reduction. A hernia is referred to irreducible when it cannot be reduced or replaced
II. Severity:
a. Strangulated Hernia
b. Incarcerated Hernia
In a strangulated hernia not only are the contents irreducible but the blood and the intestinal flow through the intestine in the hernia ceases completely. This develops when the loop of intestine in the sac becomes twisted or swollen and a constriction is produced at the neck of the sac
Gangrene of the bowel.
Incarcerated Hernia - An irreducible hernia in which the intestinal flow is completely obstructed
III. Site
(a) Inguinal Hernia
1. Indirect
2. Direct
Indirect Inguinal Hernia is due to a weakness of the abdominal wall at the point through which the spermatic cord emerges in the male and the round ligament in the female
Direct Inguinal Hernia pass through the posterior inguinal wall. More common in males. It may be due to hereditary.
(b) Umbilical Hernia results from failure of the umbilical orifice to close. Most common in obese women and in children and with increased intra-abdominal pressure in cirrhosis and ascites. Seen as a protrusion of the umbilicus.
(c) Ventral Incisional Hernia: Occurs because of weakness in the abdominal wall, due to previous operations in which drainage was necessary. Weakened by infection
(d) Femoral Hernia: Appears below the inguinal ligament as a round bulge. More common in women because of changes during pregnancy.
(e) Hiatal or Diaphragmatic Hernia: refer notes.
(f) Parastomal Hernia through the fascial defect around a staua and into the subcutaneous tissue,
Pathophysiology
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Congenital Hernia |
Acquired Hernia |
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Due to decreased muscle strength |
Increased intra-abdominal pressure |
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Protrusion of organ/tissue from its cavity |
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Reducible |
Irreducible |
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Increases the pressure from the hernial ring and cuts off the blood supply to the herniated segment of the bowel |
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Strangulation |
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Ischemia |
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Necrosis |
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Gangrene |
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Clinical Manifestations
1. Bulging over herniated area appears when patient stands on strains and disappears when supine.
2. Hernia tends to increase in size and recurs with intra-abdominal pressure.
3. Strangulated hernia presents with pain, vomiting, swelling of hernial sac, lower abdominal signs of peritoureal irritation, fever.
Diagnostic evaluation
History, Physical examination palpation on affected area, signs and symptoms, increased WBC count due to infection.
Complications
Gangrene, strangulation, recurrence, intestinal obstruction.
Management
1. Mechanical: (Reducible Hernia only)
a. A truss is an appliance with a pad and belt that is held snugly over a hernia to prevent abdominal contents from entering the hernial sac by providing exterior compression over the defect and should be removed at night and reapplied in the morning before patient arises.
b. Conservative measures- no heavy lifting, straining at stool, or other measures that would increase intra-abdominal pressure.
2. Surgical- to correct hernia before strangulation occurs.
Herniorrhaphy removal of hernial sac; contents replaced into the abdomen; layers of muscle and fascia sutured. Laparoscopic herniorrhaphy OP procedure. Hernioplasty involves reinforcement of suturing (often with mesh) for extensive hernia repair.
Strangulated Hernia requires resection of ischemic bowel in addition to repair of hernia.
Nursing Management
1. Apply a truss only after a hernia has been reduced Apply it in the morning before the patient gets out of bed. It should be applied under clothing. Assess the skin daily and apply powder for protection.
2. Watch for signs of incarceration or strangulation Don't try to reduce an incarcerated hernia, doing so may perforate the bowel. A NG tube may be inserted to empty the stomach and relieve pressure on the hernial sac, if ordered.
3. Monitor vital signs and provide routine pre-op preparation.
4. Administer IVF and analgesics for pain, as ordered.
5. Splint the incision site with hand or pillow when o lessen pain and protect site from increased intra-abdominal pressure.
6. Teach about bed rest, intermittent ice packs and scrotal elevation as measures used to reduce scrotal edema or swelling after repair of an inguinal hernia.
7. Encourage ambulation as soon as permitted.
8. Advise patient that difficulty to urinating is common after surgery; promote elimination to avoid discomfort and catheterize if necessary.
9. Check dressing for drainage and incision for redness a.id swelling.
10. Administer antibiotics, if appropriate.
11. Heavy lifting should be avoided for 4-6 weeks. Athletics and extremes of exertion are to be avoided for 8-12 weeks postoperative per provides instructions.
