Hernia

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والجراحي لباطني ا التمريض والجراحي مدرس لباطني ا التمريض مدرس

الحرجة الحرجة والحالت والحالت

التمريض التمريض كلية طنطا – كلية طنطا – جامعة جامعة

HerniaHernia

العبدجيهانديونسحكيم

Definition:

hernia is the protrusion of an organ,

tissue or the part of an organ

through the wall of the cavity that

normally contains it.

Hernia

Weakness of the abdominal muscles.

Increase intra abdominal pressure.

Weakness of containing membranes

or muscles is usually congenital, or

increases with age or due to any risk

factors.

Causes of hernia

Risk Factors

Stretching of muscles during pregnancy.Obese people.Chronic constipation and straining during a bowel movement or urination.Chronic hard coughing Improper heavy weight l i f t ing.

Tight clothing and incorrect posture.

Or because of scars from previous surgery.

Many conditions increase intra-abdominal

pressure, (ascites, COPD, benign prostatic

hypertrophy)

Also, if muscles are weakened due to poor

nutrition, smoking, and overexertion.

1-Hernia may be congenital or acquired:

congenital hernias: occur prenatal or in the

first year of life, and are caused by a

congenital defect.

Acquired hernias: develop later on in life.

2- Hernia may be complete or incomplete: for

example, the stomach may partially or

completely herniate into the chest.

Classification of hernia

3- Hernia may be internal or external:

external ones herniate to the outside

world, whereas internal hernias

protrude from their normal

compartment to another.

4. Hernia may be Reducible or Irreducible:

• Reducible hernia: is one which can be

pushed back into the abdomen by putting

manual pressure to it.

• Irreducible hernia: is one which cannot be

pushed back into the abdomen by applying

manual pressure.

Defect or weakness in the muscular wall may

be congenital, acquired weakness or caused

by trauma.

Increased the intraabdominal pressure as a

result of any risk factors that discussed

before.

As a results of weakness of the abdominal

wall and increased pressure, the abdominal

contents can protrude causing herniation

Pathophysiology of hernia:

When the contents of the hernial sac can be

replaced into the abdominal cavity by

manipulation, the hernia is said to be

reducible.

Irreducible and incarcerated hernia refers to

hernias that cannot be replaced by

manipulation.

When the pressure from the hernial ring cuts

off the blood supply to the herniated

segment of the bowel, it becomes

strangulated.

Hernias can be classified according to their

anatomical location into:

• Abdominal hernias and diaphragmatic hernias.

(1) Inguinal hernia:

• An inguinal hernia is a protrusion of abdominal

cavity contents through the inguinal canal.

Types of hernia:

• -There are two types of inguinal hernia, direct

and indirect.

1-Direct inguinal hernias:

- This hernia passes through the abdominal

Wall in an area of muscular weakness not

through a canal.

- It occur medial to the inferior epigastric

vessels when abdominal contents herniate

through a weak spot in the part of the

posterior wall of the inguinal canal.

2-Indirect inguinal hernias: occur when

abdominal contents protrude through the

deep inguinal ring, lateral to the inferior

epigastric vessels.

• In female, the opening of the superficial

inguinal ring is smaller than that of the male.

As a result, the possibility for hernias

through the inguinal canal in males is

common because they have a larger opening

and a much weaker wall for the intestines to

protrude through it.

•

(2) Femoral hernia:• Femoral hernias occur just below the

inguinal ligament, when abdominal contents

pass into the weak area at the posterior wall

of the femoral canal.

• They can be hard to distinguish from the

inguinal type. Femoral hernias are most

common in women, especially those who are

pregnant or obese.

(3) Umbilical hernia:• It is protrusion of intra abdominal contents

through a weakness at the site of passage of the umbilical cord through the abdominal wall.

• These hernias often resolve spontaneously.

• Umbilical hernias in adults are acquired, and are more frequent in obese or pregnant women. There are three types of umbilical hernia:

1- Para umbilical hernia: a type of

umbilical hernia occurring in adults. It

develop around the area of the

umbilicus.

2- Congenital umbilical hernia

3- Acquired umbilical hernia

(4) Incisional hernia:

• In an incisional hernia, the intestine

pushes through the abdominal wall at

the site of previous abdominal surgery.

• This type is most common in elderly or

overweight people who are inactive

after abdominal surgery.

•

(5) Hiatus hernia:

Diaphragmatic hernia results when part

of the stomach or intestine protrudes

into the chest cavity through a defect in

the diaphragm.

Hiatus hernias may be sliding or rolling

• Sliding hernia: in which the gastroesophageal

junction and upper part of the stomach slides through the defect into the chest.

• Non-sliding : the junction remains fixed while another portion of the stomach moves up through the defect.

• Non-sliding hernias can be dangerous as they may allow the stomach to rotate and obstruct.

• Repair is usually advised.

• Patient with Sliding hernia have

manifestations of reflux and

complications of hemorrhage,

obstruction and strangulation can occur.

• Patient with rolling hernia does not have

manifestations of reflux as the

gastrointestinal sphincter is intact.

• Pathophysiology of haital hernia:

• The diaphragm is a large dome-shaped muscle that separates the chest cavity from the abdomen.

• Normally, the esophagus passes into the stomach through an opening in the diaphragm called the

hiatus.

• Hiatus hernias occur when the muscle tissue

surrounding this opening becomes weak, and the upper part of the stomach bulges up through the

diaphragm into the chest cavity.

• Also, pressure on the stomach may contribute to the

formation of hiatus hernia.

(6) Epigastric hernia:

It is a protrusion of the epigastric

contents through the abdominal wall.

The protrusion occurs between the

linea Alba and the lower part of the rib

cage in the midline of the abdomen.

1) Bulging and painless swelling at first.

2) Pain: Pain may be:

• Localized Pain: Pain may occur as a result of

irritation of or damage to area or nerves as a result

of the hernia and its contents pushing into or pinching the nerves.

• Generalized Pain: If the contents of the hernia

become trapped or incarcerated, the intestine's

blood supply may become compromised or shut off.

Clinical manifestation of hernia:

• Referred Pain:

• If the hernia irritates, inflames, the pain

felt from the hernia may not be at the site

of the hernia, but rather at the area to

which these nerves are traveling.

• For example, pain from an Inguinal Hernia

may be felt as discomfort in the back,

upper leg and /or hip area.

3) Nausea and vomiting:

• When intestine becomes trapped within

the hernia, the normal flow of food

through the intestine becomes blocked.

This creates a progressive back-up

within the intestine and may result in

nausea and vomiting.

4) Constipation:

• If the intestine is blocked within the hernia,

and normal flow of food contents and feces

is blocked, the patient may develop

constipation.

5) Urinary Symptoms:

• If the bladder becomes irritated within a

hernia (usually an Inguinal Hernia). Urinary

symptoms such as frequency, urinary

burning, frequent infections, and bladder

stones may all occur

Heartburn: occur 30 to 60 minutes after

meals

Difficulty in swallowing

Fatigue

Felling of fullness after eating

Difficulty of breathing

Chest pain

Clinical manifestation specific to hiatus hernia

1) Medical treatment:

• Hernias that are not strangulated can be

mechanically reduced.

• Truss (firm pad) held by a belt to keep the

hernia in place or reduced.

• The patient is taught to apply the truss daily.

• Instruct the patient to inspect the skin under

the truss for any manifestation of skin

breakdown.

Treatment

• If patient has preexisting medical conditions that

make surgery unsafe, doctor may not repair hernia

but will watch it closely.

• Some hernias have very large openings in the

abdominal wall, and closing the opening is

complicated because of their large size. These kinds

of hernias may be treated without surgery, using

abdominal binders.

• Some doctors feel that the hernias with large

openings have a low risk of strangulation.

• An attempt to (push back) the hernia will generally

be made, often after giving medicine for pain and

muscle relaxation

2) Surgical treatment:

1) A hernia repair is performed using a

small incision directly over the

weakened area. The intestine is then

returned to the perineal cavity, the

hernial sac excised and the muscle

closed tightly over the area.

2) Hernias in the inguinal region are

usually repaired under spinal or local

anesthesia.

3) Some repair is difficult because there is

insufficient muscle to keep the intestines in

place. So steel mesh grafts are used to

reinforce the area of herniation

4) Clients with difficult repairs are usually

hospitalized for 1 to 2 days to receive

prophylactic antibiotics.

5) If the intestinal contents of the hernia had

the blood supply cut off, the development of

dead (gangrenous) bowel is possible in as

little as six hours.

• The nurse encourages the patient to void

immediately after surgery, because urinary

retention is a common problem.

• Give prescribed medication as ordered.

• The patient should be returned to general

diet as soon as he tolerates food.

• Encourage post operative ambulation as

soon as possible to prevent complications of

immobility.

• Instruct the patient to avoid any risk factors

that facilitate hernial recurrence.

Post operative care

Management of haital hernia:

• Provide small frequent diets that can

pass easily through the esophagus.

• Advise the patient not to sleep for 1

hour after eating to prevent reflux.

• Paraesophageal hernia (Rolling haital hernia) may

require emergency surgery to correct twisting of the

stomach.

Postoperative Outcome:• Patients undergoing elective surgical repair may be

able to go home the same day. However, emergency

repair carries a greater morbidity and mortality rate

and this is directly proportional to the degree of

bowel compromise. Other co-existing medical

conditions also influence outcome.

Complication of hernia:

1. Strangulation: pressure and compromise

blood supply causing venous congestion

ischemia, and later necrosis and gangrene

may occur.

2. Obstruction: for example, when a part of the

bowel herniates, bowel contents can no

longer pass the obstruction. This results in

cramps, vomiting, ileus, and absence of

defecation.

3. Dysfunction: the herniated organ itself, or

surrounding organs, start to malfunction