I. Introduction General description of disease condition requiring surgical procedure. About 75% of all hernias are classified as inguinal hernias, which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. Because humans stand upright, there is a greater downward force on the lower abdomen, increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinal hernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia). According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men. Hernias are divided into two categories: congenital (from birth), also called indirect hernias, and acquired, also called direct hernias. Among the 75% of hernias classified as inguinal hernias, 50% are indirect or congenital hernias, occurring when the inguinal canal entrance fails to close normally before birth. The indirect inguinal hernia pushes down from the abdomen and through the inguinal canal. This condition is found in 2% of all adult males and in 1–2% of male children. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushes folds of genital tissue into the inguinal canal opening. In fact, women will more likely have an indirect inguinal hernia than direct. Direct or acquired inguinal hernias occur when part of
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Transcript
I. Introduction
General description of disease condition requiring surgical
procedure.
About 75% of all hernias are classified as inguinal hernias, which are
the most common type of hernia occurring in men and women as a result of
the activities of normal living and aging. Because humans stand upright,
there is a greater downward force on the lower abdomen, increasing
pressure on the less muscled and naturally weaker tissues of the groin area.
Inguinal hernias do not include those caused by a cut (incision) in the
abdominal wall (incisional hernia). According to the National Center for
Health Statistics, about 700,000 inguinal hernias are repaired annually in the
United States. The inguinal hernia is usually seen or felt first as a tender and
sometimes painful lump in the upper groin where the inguinal canal passes
through the abdominal wall. The inguinal canal is the normal route by which
testes descend into the scrotum in the male fetus, which is one reason these
hernias occur more frequently in men.
Hernias are divided into two categories: congenital (from birth), also
called indirect hernias, and acquired, also called direct hernias. Among the
75% of hernias classified as inguinal hernias, 50% are indirect or congenital
hernias, occurring when the inguinal canal entrance fails to close normally
before birth. The indirect inguinal hernia pushes down from the abdomen
and through the inguinal canal. This condition is found in 2% of all adult
males and in 1–2% of male children. Indirect inguinal hernias can occur in
women, too, when abdominal pressure pushes folds of genital tissue into the
inguinal canal opening. In fact, women will more likely have an indirect
inguinal hernia than direct. Direct or acquired inguinal hernias occur when
part of the large intestine protrudes through a weakened area of muscles in
the groin. The weakening results from a variety of factors encountered in the
wear and tear of life.
Inguinal hernias may occur on one side of the groin or both sides at the
same or different times, but occur most often on the right side. About 60% of
hernias found in children, for example, will be on the right side, about 30%
on the left, and 10% on both sides. The muscular weak spots develop
because of pressure on the abdominal muscles in the groin area occurring
during normal activities such as lifting, coughing, and straining during
urination or bowel movements, pregnancy, or excessive weight gain. Internal
organs such as the intestines may then push through this weak spot, causing
a bulge of tissue. A congenital indirect inguinal hernia may be diagnosed in
infancy, childhood, or later in adulthood, influenced by the same causes as
direct hernia. There is evidence that a tendency for inguinal hernia may be
inherited.
Relevant and current statistical evidences or critical findings
An indirect inguinal hernia may develop at any age, is more common in
males, and is especially prevalent in infants younger than age 1. According
to the American academy of pediatrics about 5 out of 100 children have
inguinal hernias. The incidence is also high among clients 50 to 60 years of
age and then gradually decreases in older age groups. These hernias can
become extremely large and often descend into the scrotum. Indirect
inguinal hernias typically cause a bulge in the groin (at the top of or within
the scrotum) and usually with increased abdominal pressure. The bulge may
or may not be painful. By palpating the inguinal canal and asking the patient
to cough while standing, one can usually elicit the hernia. In fact, one can
often times palpate an inguinal hernia without invaginating the scrotum (as
is typically taught in medical school). Rather, by placing one's fingers over
the inguinal canal and asking the patient to cough, one can often feel the
bulge against the lower abdominal wall. As indirect and direct hernias are
unreliably differentiated by physical exam alone, the need to invaginate the
scrotum to feel into the inguinal canal is often more uncomfortable to the
patient, than revealing to the physician. Rarely, palpation is not even
necessary, as the hernia is large enough to be visualized.
Indirect inguinal hernias are the most common type of hernia
encountered. Virtually any patient under the age of 25 presenting with
hernia will have an indirect hernia. They are more prevalent in men (the
male to female ratio being about 9:1). This is because, during their descent,
the testicles and blood vessels pass through the inguinal canal, making the
opening from the abdomen less likely to close completely.
Recent trends, refinements, and/ or innovations in treatment
The first hernia repair, or herniorrhaphy, took place in 1887. For
nearly 100 years, surgeons simply used sutures to bring the separated
tissues together. But this puts the tissues under tension and they pull apart
in up to 7% of patients. The hernia may then come back. Surgeons use
only two types of surgeries to repair groin hernias.
Tension-free repair
In the early 1980s, Dr. Irving Lichtenstein developed a way to repair
hernias without putting tissues under tension. Surgeons close the defect with
a sheet of mesh. It can be done as outpatient surgery under local or spinal
anesthesia. Because patients experience less pain and there is a lower risk of
the hernia returning, tension-free repair has quickly became the favored
operation.
Laparoscopic surgery
This newer rival burst onto the scene in the early 1990s. Whereas open
repairs require a four- to six-inch incision in the groin, the laparoscopic repair
requires only three half-inch incisions in the abdomen. First, the surgeon
inflates the abdomen with carbon dioxide. Next, he inserts a thin fiber-optic
tube (laparoscope) through the incisions. While watching through a video
camera, he then inserts instruments that he uses to pull the intestinal
contents back into place and to staple a mesh patch over the defect.
Inflating the abdomen is painful, so laparoscopic surgery requires general
anesthesia. It also requires specialized equipment and extra training, so it is
more expensive than open surgery.
General or Local Anesthesia?
It's the simplest of the three questions. If you have a laparoscopy, you'll
need general anesthesia. Open surgery can be done with local, spinal or
general anesthesia. However, randomized clinical trials report that local
anesthesia produces less post-operative pain and fewer problems with
urination. Still, if you and your doctors have a reason to choose general or
spinal anesthesia, they are also reasonable options.
Implications of the above information for nurses as a productive
member of society
The nurse can explain what to expect before, during, and after the
surgery. Parents, especially those of a newborn, are anxious because their
child requires general anesthesia for the procedure. If possible, use
preoperative teaching tools such as pamphlets and videotapes to reinforce
the information. Allow as much time as is needed to answer questions and
explain procedures.
The nurse also instructs patients and parents on the care of the
incision. Often, the incision is simply covered with collodion (a viscous liquid
that, when applied, dries to form a thin transparent film) and should be kept
clean and dry. Encourage the patient to defer bathing and showering and
instead to use sponge baths until he or she is seen by the surgeon at a
follow-up visit. Explain how to monitor the incision for signs of infection.
Infants or young children who are wearing diapers should have frequent
diaper changes, or the diapers should be turned down from the incision so as
not to contaminate the incision with urine. Teach the patient or parents
about the possibility of some scrotal swelling or hematoma; both should
subside over time.
Hernia surgery pain is centered on the abdomen. The muscles that
have been sewn together are active and healing, and when they pull on the
stitches, it causes pain. In addition, the incisions are healing, so doing
anything but resting that area of the body can cause a sharp shooting pain.
Certain pain is normal after a hernia surgery, but other forms of
discomfort may be a sign of infection or complication. According to the
Society of American Gastrointestinal and Endoscopic Surgeons, patients
should see their doctors if they have a persistent fever of more than 101
degrees F, bleeding or swelling in the groin.
Other symptoms that require immediate medical attention include
nonstop nausea or vomiting, stubborn pain, inability to urinate, chills,
coughing, shortness of breath, pus, and growing redness near the incision,
and the inability to eat or drink.
If the patient does not have surgery, teach the signs of a strangulated
or incarcerated hernia: severe pain, nausea, vomiting, diarrhea, high fever,
and bloody stools. Explain that if these symptoms occur, the patient must
notify the primary healthcare provider immediately. If the patient uses a
truss, she or he should use it only after a hernia has been reduced. Assist the
patient with the truss, preferably in the morning before the patient arises.
Encourage the patient to bathe daily and to apply a thin film of powder or
cornstarch to prevent skin irritation.
II. Anatomy and Physiology
A useful learning tool in gaining a
working knowledge of the inguinal
region is visualizing it as it is surgically
approached in the open technique.
The inguinal region is part of the
anterolateral abdominal wall, which is
made up of 9 layers. These layers,
from superficial to deep, are the skin,
the Camper and Scarpa fascia, the
external oblique aponeurosis, the
internal oblique and transversus
muscles, the transversalis fascia, the
preperitoneal fat, and the peritoneum.
o The first layers encountered upon dissection through the subcutaneous
tissues are the Camper and Scarpa fascia. Contained in this space are the
superficial branches of the femoral vessels, namely, the superficial
circumflex and the epigastric and external pudendal arteries, which can be
safely ligated and divided when encountered.
o The inguinal canal can be visualized as a tunnel traveling from lateral to
medial in an oblique fashion. It has a roof facing anteriorly, a floor facing
posteriorly, a superior (cranial) wall and an inferior (caudal) wall, as shown
below. The canal contents (cord structures in men or the round ligament in
women) are the traffic that traverses the tunnel.Anatomy of the inguinal
canal.
The external oblique aponeurosis serves as the roof of the inguinal canal
and opens just lateral to and above the pubic tubercle. This is the
superficial inguinal ring, which allows the cord structures egress.[5]
The floor of the canal is composed of the transversus abdominus muscle
and the transversalis fascia. The entrance to the inguinal canal is through
these layers, and this entrance comprises the internal or deep ring.
The inferior wall is the inguinal (Poupart) ligament. The inguinal ligament is
formed by the lower edge of the external oblique aponeurosis and extends
from the anterior superior iliac spine to its attachments at the pubic
tubercle and fans out to form the Lacunar ligament (Gimbernat
ligament). The inguinal ligament folds over itself to form the shelving edge.
This folded-over sling of external oblique aponeurosis is the true lower wall
of the inguinal canal.
The superior wall consists of a union of the internal oblique and transversus
muscles aponeurosis, which arches from its attachment at the lateral
segment of the inguinal ligament over the internal inguinal ring, ending
medially at the rectus sheath and coming together inferomedially to insert
on the pubic tubercle, thus forming the conjoined tendon.
The cord structures include the vas deferens, testicular artery, artery of the
ductus deferens, cremasteric artery, pampiniform plexus, and genital
branch of the genitofemoral nerve, parasympathetic and sympathetic
nerves, and lymph vessels.
Nerves of the groin
Since the widespread acceptance of meshed-based repairs and the
significant reduction of inguinal hernia recurrence, the most vexing
complication of herniorrhaphy is chronic groin pain. Causalgia syndromes of
each of the 3 nerves of the groin are well described. Controversy exists as to
whether to section the nerves or to preserve them. Current
recommendations are nerve identification (nerves are depicted in image
below) and preservation.
Ilioinguinal nerve: The ilioinguinal nerve
runs medially through the inguinal canal
along with the cord structures traveling
from the internal ring to the external
ring. It innervates the upper and medial
parts of the thigh, the anterior scrotum,
and the base of the penis.
Iliohypogastric nerve: The
iliohypogastric nerve runs below the
external oblique aponeurosis but cranial to the spermatic cord, then
perforates the external oblique cranial to the superficial ring. It innervates
the skin above the pubis.
Genital branch of the genitofemoral nerve: This branch travels with the
cremasteric vessels through the inguinal canal. It innervates the cremaster
muscle and provides sensory innervation to the scrotum.
Some variations remain in the anatomical distribution of these nerves, eg,
the occasional absence of an ilioinguinal nerve.
External Inguinal Ring
The external inguinal ring or the superficial ring is an anatomical structure in the anterior wall of the human abdomen. It is a triangular opening that forms the exit of the inguinal canal, which houses the ilioinguinal nerve, the genital branch of the genitofemoral nerve, and the spermatic cord (in men) or the round ligament (in women). At the other end of the canal, the deep inguinal ringforms the entrance.
It is found within the aponeurosis of
the external oblique, immediately above
the crest of the pubis, 1 centimeter above
and medial to the pubic tubercle. It
has medial and lateral crura. It is at the
layer of the aponeurosis of the obliquus
externus abdominis.
Internal Inguinal Ring
The internal inguinal ring or the deep inguinal ring is the entrance to
the inguinal canal. Its surface markings are 1 to 1.5cm superior to the mid-
inguinal point. Its borders are:
superolateral: internal oblique and transversus abdominis muscles
medial: inferior epigastric vessels and interfoveolar ligament
inferior: inguinal ligament
It lies lateral to the inferior epigastric vessels as they pass upwards from the
external iliac artery and vein. It is the point at which the spermatic cord or
round ligament push through the transversalis fascia.
Inguinal Canal
Is the oblique passage through the
lower abdominal wall. In males it is the
passage through which the testes descend
into the scrotum and it contains the
spermatic cord, in women the round
ligament. The inguinal canal is larger and
more prominent in men. Each person has
two, on the left and right sides of the
abdomen.
Scrotum
The scrotum is a part of a male's
body located behind the penis. The
scrotum is the sac (pouch) that contains
the testes, blood vessels, and part of the
spermatic cord.
It is also a dual-chambered
protuberance of skin and muscle,
containing the testicles and divided by
a septum. It is an extension of the
perineum, and is located between the penis and anus. In humans and some
other mammals, the scrotum becomes covered with pubic hairs at puberty.
Small Intestine
Where much of the digestion and
absorption of food takes place. It
receives bile juice and pancreatic juice
through heptopancreatic duct,
controlled by Spincter of oddi.
In invertebrates such as worms, the
terms "gastrointestinal tract" and "large
intestine" are often used to describe the
entire intestine. This article is primarily about the human gut, though the
information about its processes is directly applicable to most placental
mammals. The primary function of the small intestine is the digestion,
absorption of nutrients and minerals found in food.
It is also a tubular structure within the abdominal cavity that carries the food
in continuation with the stomach up to the colon from where the large
intestine carries it to the rectum and out of the body via the anus.
It is divided into the duodenum (the first section of the small intestine in
most higher vertebrates.), jejunum (middle section of the small intestine and
usually defined as the Duodenojejunal flexure), and ileum (final section of
the small intestine).
Perineum
Is a region of the body including the perineal body and surrounding
structures. There is some variability in how the boundaries are defined, but
the term generally includes the genitals and anus.
III. The Patient and his Illness
A. Schematic diagram
Incarcerated organs become
intertwined
Etiology:It is considered mainly to be a
congenital lesion. It is denoted
“indirect” because the bowel and
peritoneum do not herniate
directly through a
weakness in the abdominal
wall.
Precipitating Factors:
Emphasize high-fiber foods
Maintain a healthy weight
Avoid heavy lifting altogether
Stop smoking
Predisposing Factors:
Smoking Life-threatening
condition ( i.e. cystic fibrosis)
Poor knowledge about proper nutrition
Prolonged hospitalization or residence in a nursing home
Obesity
Book-Based Pathophysiology
An organ, intestine, or tissue from your abdomen falls into
the inguinal canal
Indirect inguinal hernias in infants and children are congenital and
result from an arrest of embryologic development, failure of obliteration of
the processus vaginalis, rather than an acquired muscular weakness. The
pertinent developmental anatomy of congenital indirect inguinal hernia
relates to development of the gonads and descent of the testis through the
internal ring and into the scrotum late in gestation. The gonads develop
near the kidney as a result of migration of primitive germ cells from the
Intestines become incarcerated
Decrease or complete deprivation of blood flow to
the protrusion
Abdomen become painful and tender
Accompanied by nausea, vomiting, fever, inflammation, bowel obstruction and the appearance of blood in stool
Swollen skin in your groin that is red, gray, or blue
Lump or swelling in your scrotum
Indirect Inguinal Hernia
yolk sac to the genital ridge, which is completed by 6 wk of gestation.
Differentiation into testis or ovary occurs by 7 or 8 wk of gestation under
hormonal influences. The testes descend from the urogenital ridge in the
retroperitoneum to the area of the internal ring by about 28 wk of
gestation. The final descent of the testes into the scrotum occurs late in
gestation between weeks 28 and 36. The testis is preceded in descent to
the scrotum by the gubernaculum and the processus vaginalis. The
processus vaginalis is present in the developing fetus at 12 wk of gestation
as a peritoneal outpouching that extends through the internal inguinal ring
and accompanies the testis as it exits the abdomen and descends into the
scrotum.
The gubernaculum testis forms from the mesonephros (developing kidney),
attaches to the lower pole of the testis, and directs the testis through the
internal ring and inguinal canal and into the scrotum. The testis passes
through the inguinal canal in a few days but takes about 4 wk to migrate
from the external ring to the scrotum. The cordlike structures of the
gubernaculum occasionally pass to ectopic locations (perineum or femoral
region), resulting in ectopic testes.
In the last few weeks of gestation or shortly after birth, the layers of the
processus vaginalis normally fuse together and obliterate the patency from
the peritoneal cavity through the inguinal canal to the testis. The
processus vaginalis also obliterates just above the testes, and the portion
of the processus vaginalis that envelops the testis becomes the tunica
vaginalis. In girls, the processus vaginalis obliterates earlier, at about 7 mo
of gestation. Failure of the processus vaginalis to close permits fluid or
abdominal viscera to escape the peritoneal cavity and accounts for a
variety of inguinal-scrotal abnormalities seen in infancy and childhood. The
ovaries descend into the pelvis from the urogenital ridge but do not exit
from the abdominal cavity. The cranial portion of the gubernaculum in girls
differentiates into the ovarian ligament, and the inferior aspect of the
gubernaculum becomes the round ligament, which passes through the
internal ring and attaches to the labia majora. The processus vaginalis in
girls extends into the labia majora through the inguinal canal and is also
known as the canal of Nuck.
Androgenic hormones, adequate end-organ receptors, and mechanical
factors such as increased intra-abdominal pressure influence complete
descent of the testis through the inguinal canal. The testes and spermatic
cord structures (spermatic vessels and vas deferens) are located in the
retroperitoneum but are affected by increases in intra-abdominal pressure
as a consequence of their intimate attachment to the processus vaginalis.
The genitofemoral nerve also has an important role: It innervates the
cremaster muscle, which develops within the gubernaculum, and
experimental division or injury to both nerves in the fetus prevents
testicular descent. Failure of regression of smooth muscle (present to
provide the force for testicular descent) might have a role in the
development of indirect inguinal hernias. Several studies have investigated
genes involved in the control of testicular descent for their role in closure
of the patent processus vaginalis, for example, hepatocyte growth factor
and calcitonin gene-related peptide. Unlike in adult hernias, there does not
appear to be any change in collagen synthesis associated with inguinal
hernias in children
B. Synthesis of the disease
B.1 Definition of the disease
An indirect inguinal hernia follows the tract through the inguinal
canal. This results from a persistent process vaginalis. The inguinal
canal begins in the intra-abdominal cavity at the internal inguinal ring,
located approximately midway between the pubic symphysis and the
anterior iliac spine. The canal courses down along the inguinal
ligament to the external ring, located medial to the inferior epigastric
arteries, subcutaneously and slightly above the pubic tubercle.
Contents of this hernia then follow the tract of the testicle down into
the scrotal sac.
B.2 Predisposing / Precipitating factors
o Family History: There is an increased risk of hernia with a close
family history
o Certain Medical Conditions: Cystic fibrosis, or conditions
associated with a chronic cough increase the risk of developing a
hernia
o Smoking: Like cystic fibrosis, a chronic cough increases risk
o Excess Weight & Pregnancy: Increases risk by weakening and
placing stress on lower abdominal muscles
o Inherited gene: Having one hernia puts you at risk of having
another
B.3 Signs and symptopms with rationale
Hernia symptoms in children
o In infants, a hernia may bulge when the child cries or moves
around.
o Strangulated hernias, in which part of the intestine becomes
trapped in the hernia, are more common in infants and children
than in adults. They can cause nausea and vomiting. An infant with
a strangulated hernia may cry and refuse to eat. Astrangulated
hernia is a medical emergency that requires immediate surgery.
In adults
o A bulge in the groin or scrotum. The bulge may appear gradually
over a period of several weeks or months, or it may form suddenly
after the patient has coughed, bent, strained or laughed because of
the protrusion of the intestine on the sac. Many hernias flatten
when the patient lie down.
o Groin discomfort or pain. The discomfort may be worse when the
patient has bend or lift. Although he/she may have pain or
discomfort in the scrotum, many hernias do not cause any pain.
o You may have sudden pain, nausea, and vomiting if part of the
intestine becomes trapped (strangulated) in the hernia.
Other symptoms of a hernia include:
o Heaviness, swelling, and a tugging or burning sensation in the area
of the hernia, scrotum, or inner thigh. Males may have a swollen
scrotum, and females may have a bulge in the large fold
of skin (labia) surrounding the vagina.
o Discomfort and aching that are relieved only when the patient lie
down. This is often the case as the hernia grows larger.
1.1 Description of prescribed surgical treatment performed
A hernia is usually because of weakness in an individual’s abdominal
wall, which allows the inner tissue or organs to protrude as a bulge on the
skin. Most often, hernias are found in the abdomen or in the groin area. A
herniorrhaphy procedure repairs a hernia by making an incision on the skin,
pushing the protrusion back into its place and suturing the edges of healthy
muscle tissues together. This works when the hernias are small or when the
tissues are healthy and the stitches would not add to the strain on the
tissue. The herniorrhaphy technique used may use a traditional incision or a
laprascopic surgery.
In hernia cases involving trapped tissues which run the risk of having
their blood supply cut off, leading to tissue death, surgery is usually urgently
required. In males, before they are born, the testicles descend into the
scrotum through the inguinal canal in the abdomen. Usually the inguinal
canal closes before birth or by the age of two. In some cases, it may remain
open well into adult life. In such cases, tissue from inside the abdomen may
bulge through it, leading to indirect inguinal hernia. An inguinal
herniorrhaphy procedure in children is usually an open surgery requiring
about four weeks for recovery.
Herniorrhaphy protocol in some cases may involve the use of synthetic
material as patches. These patches are sewn over the weakened area of the
abdominal wall after the hernia is pushed backed into its place, so that there
is no recurrence. These patches are used both in open and laparascopic
surgeries to ensure that the stress on the weakened wall is minimal. This
procedure is also called hernioplasty. Open surgery for small children with
hernias on one side or both sides of the groin is in most cases found to be
quite a safe procedure. An inguinal hernia needs to be treated and will not
disappear on its own. Incarcerated hernias in children need to be repaired
because there is a risk of strangulation of blood supply to the tissue or
intestine.
Tension-free Hernioplasty (Open Surgery)
Using this technique, the hole in the muscle of the abdominal wall is not
closed by pulling the edges together, but rather the defect is bridged by the
This patient has an indirect inguinal hernia (A). To repair it, the surgeon makes an incision over the area and separates the muscle and tissues to expose the hernia sac (B). The sac is cut open (C), and the contents are replaced into the abdomen (D). The neck of the hernia sac is tied off (E), and the muscles and tissues are sutured (F). (Illustration by GGS Inc.)
mesh which covers the hole. Because of the combination of safety and
excellent success rate in preventing recurrence of the hernia, the tension-
free hernioplasty technique is now recommended.
Permanent polypropylene mesh, which is a well-tolerated biologically
safe and very strong tissue substitute, is sutured to strong tissues in the
groin to close the gap in the inguinal canal. The hernia mesh is inserted in
the preperitoneal space (above the abdominal cavity, but below the muscle
layer) to afford the strongest mechanical advantage. Placing the mesh in this
location allows it to incorporate into the patient’s tissues more rapidly. It is
important that the surgeon avoid pulling the edges of the hole together and
causing tension, as tension causes swelling and pain, and may cause the
sutures to tear out leading to a recurrent hernia.
Any foreign body inserted into human tissue may become infected and
need to be removed. To improve the chances of acceptance, the mesh is
An 8-centimeter incision is made for an open surgery. Laparoscopic repair would begin with two 5-millimeter and one 10-millimeter holes for the ports.
soaked in an antibiotic solution prior to implantation, and prophylactic
(preventive) antibiotics are administered intravenously to reduce the risk of
infection. Any infections that may occur generally happen within the first two
weeks after surgery.
After the hernia is repaired, the remaining layers are closed with
absorbable sutures, dressings are applied and the patient is transferred to
the recovery room. Surgery takes 1 to 1-1/2 hours with a recovery room time
of approximately 3 hours. Following surgery, patients are not restricted or
bedridden, though they must avoid very heavy lifting for 30 days. They are
given a prescription for pain medication, and encouraged to gradually return to
full activities as tolerated. The surgical dressings are waterproof, and bathing is
allowed.
Shouldice/Canadian Repair (Open Surgery)
Developed during World War II by Dr. E. E. Shouldice, a Canadian surgeon,
this technique is widely used as a non-mesh option for hernia repair. Two
permanent, continuous back-and-forth sutures are used close the hole in the
abdomen wall.
A completed tension-free hernia repair
By sliding four layers of tissue together, this technique is considered a
more secure closure of the hole in the abdominal wall than the single-layer
Bassini repair. In addition, the Shouldice technique uses the deepest layers
of muscle while the Bassini repair uses more superficial layers.
This technique has a high success rate and low rate of recurrence.
However, tension in the closure of the incision can lead to swelling and
patient discomfort lasting several weeks.
Laparoscopic Repair
Laparoscopic surgery is performed using general anesthesia. The
surgeon makes several small incisions in the lower abdomen and inserts a
laparoscope—a thin tube with a tiny video camera attached to one end. The
camera sends a magnified image from inside the body to a monitor, giving
the surgeon a close-up view of the hernia and surrounding tissue. While
viewing the monitor, the surgeon uses instruments to carefully repair the
hernia using synthetic mesh. Laparoscopic repair is less invasive than an
open approach. It uses three ports, or trocars, inserted into the area of the
surgery through which a TV camera and instruments are placed to allow
surgeons to visualize the anatomy, define the hernia defect, and implant the
mesh.
People who undergo laparoscopic surgery generally experience a
somewhat shorter recovery time. However, the doctor may determine
laparoscopic surgery is not the best option if the hernia is very large or the
person has ha d pelvic surgery.
Outline/Illustration of the process: (Open surgery)
o Confirm and mark the correct surgical site preoperatively in the
holding area.
o Position the patient supine, comfortably securing the upper
extremities.
o For large defects, slight Trendelenburg positioning may help exposure
by reducing the visceral contents into the abdomen.
o Shave the surgical site with electric clippers.
o Prepare and drape the surgical site in standard surgical fashion,
exposing only the intended operative groin site
A Microscopic view of meshLaparoscopic surgery
After final verification of the correct side of surgery and the infiltration of
local anesthesia (described in Anesthesia), make an oblique skin incision (or
along the Langer lines) approximately 2 finger breadths (2 cm) superior to
and parallel to the thigh crease, and extend it 5 cm toward the anterior
superior iliac spine, starting from just lateral to the pubic tubercle. In thin
patients, the external ring can actually be palpated just lateral and slightly
above the pubic tubercle and should be the medial starting point of incision,
as shown below.
Marking of the incision site
Continue the dissection deeper through the subcutaneous tissue until the
aponeurosis of the external oblique is identified. During dissection, take note
of the superficial vessels that can be ligated and divided when encountered.
Identify the external oblique aponeurosis. The following 3 landmarks must
also be identified before incising the external oblique:
Firstly, the Scarpa fascia can mimic the external oblique, as it is well
developed and thickened in some patients. Avoiding this mistake,
especially in patients who are overweight, can be accomplished if the
fibers of the external oblique aponeurosis are always visualized, since
the Scarpa fascia does not have these fibers.
Secondly, the inguinal canal should be entered at its apex. To correctly
identify the apex of the canal, identify the lower wall of the canal,
which is where the external oblique aponeurosis disappears into the fat
of the thigh. Approximately one finger breadth above this point is a
good entry site into the canal.
Thirdly, the external ring must be identified. This is important because
the external ring is ultimately the end point of the division to be made
in the external oblique aponeurosis and defines the orientation of this
cut.
Once the external oblique aponeurosis is identified, thoroughly expose it and
make a gentle stab incision in its mid-portion along the orientation of its
fibers. Extend this incision superiorly, and medially downward, through the
superficial ring, thus exposing the inguinal canal and the cord structures, as
shown below.
Division of the external oblique aponeurosis
Circumferentially mobilize the cord structures off the floor of the canal by
working on the pubic tubercle as a fulcrum as shown below. With blunt
dissection of the index finger in a sweeping and medially encircling fashion,
the cord is sufficiently freed, so that the cord structures can be surrounded
by a Penrose drain for convenient retraction. This allows exposure of the
inguinal floor and protects the cord structures.
Next, examine the anteromedial aspect of the cord for an indirect
component of the hernia. Separating the cremasteric muscle along its fibers
often facilitates this. The cremasteric muscle fibers must be dissected
Cord structures and hernia sac encircled by a
Penrose drain
carefully with slow electrocautery coagulation, as the cut muscle fibers tend
to bleed.
If an indirect hernia is present, dissect the sac off the cord structures, down
toward its base at the internal inguinal ring, until it is comfortably
invaginated into the preperitoneal space as shown below. This is preferably
achieved without division of the sac. However,
If necessary, as with certain large hernias, the sac can be entered carefully
and examined for visceral contents, and then divided with a high ligation (ie,
proximal).
Closure of the defect and buttressing of the inguinal canal floor can now be
performed. This can be done using a prosthesis, as in the Lichtenstein repair,
or primarily with native tissue, as in the McVay and Bassini repairs. Possible
closure methods are detailed below.
Lichtenstein repair: In the Lichtenstein repair, a mesh is positioned and
trimmed as necessary so that its medial rounded edge comfortably
overlaps the pubic tubercle by approximately 2 cm. The rounded lower
edge of the mesh is fixed to the lacunar ligament with 3-0 Prolene
suture and continued inferolaterally in running fashion along the
inguinal ligament and beyond the internal ring. A slit is cut in the
superior portion of the mesh in the shape of an inverted T, so that its 2
tails can be draped over and then loosely reapproximated around the
exiting cord, thus fashioning an artificial internal ring. The
superomedial aspect of the mesh is secured with interrupted sutures to
the rectus sheath and to the conjoint tendon at its upper portion.
Plug and patch: This adds a polypropylene plug shaped as a cone,
which can be deployed into the internal ring following indirect sac
reduction. The plug then acts as a toggle bolt to reinforce this defect.
Hernia sac separated from the cord
structures
Prolene hernia system (PHS): This system consists of an anterior oval
polypropylene mesh connected to a circular posterior component.
The anterior portion is then laid out with a cut made to recreate the internal ring, as depicted as shown in
the image above
The posterior component is deployed in a bluntly created preperitoneal space, as shown in the image
above
The following repairs are not simply of historical interest. Surgeons must
know and understand these repairs so that they can be used when needed.
Specifically, cases that involve a contaminated field such as necrotic or
perforated bowel secondary to hernial strangulation are not amenable to
prosthetic repair. In such cases, either a primary tissue repair or biologic
implant repair is necessary.
McVay repair: The conjoined tendon is sutured with interrupted
nonabsorbable sutures to the inguinal ligament.
Bassini repair: The conjoined tendon is sutured to the Cooper ligament
with a transition stitch onto the inguinal ligament over the femoral
vessels. In addition, a relaxing incision is made to the anterior rectus
sheath.
Recent reports using an acellular dermal implant (eg, AlloDerm) in
cases of a contaminated surgical field have appeared in the literature,
but long-term results are not yet available.
The anterior portion is then sutured above to the conjoined tendon and below to the shelving edge of the inguinal ligament and is tucked behind the
external oblique, as shown above
Follow this with reapproximation of the Scarpa fascia with interrupted 3-0
polyglactin suture and then a running subcuticular closure of the skin with 3-
0 poliglecaprone suture, shown below.
Skin closure
Clean the operative site and apply sterile dressing.
Reapproximate the external oblique aponeurosis with a running 3-0 polyglactin suture as shown below; be
mindful of the underlying ilioinguinal nerve. Closure of the external oblique aponeurosis
1.2 Indication of prescribed surgical treatment
Indication:
The existence of an inguinal hernia has been reason enough for
operative intervention. However, recent studies have shown that the
presence of a reducible hernia is not, in itself, an indication for surgery
and that the risk of incarceration is less than 1%
Symptomatic patients (with pain or discomfort) should undergo repair;
however, up to one third of patients with inguinal hernias are
asymptomatic. The question of observation versus surgical intervention in
this asymptomatic or minimally symptomatic population was recently
addressed in 2 randomized clinical trials. The trials found similar results,
namely that after long-term follow-up, no significant difference in hernia-
related symptomology was noted, and that watchful waiting did not
increase the complication rate.
In one study, the substantial patient crossover from the observation
group to the surgery arm led the authors to conclude that observation
may delay but not prevent surgery. This reasoning holds particularly true
in the younger patient population. Thus, even an asymptomatic patient, if
medically fit, should be offered surgical repair. After a long-term follow-
up, one study determined that most patients with a painless inguinal
hernia will develop symptoms over time, and therefore, surgery is
recommended for medically fit patients.
Koch et al found that recurrence rates were higher in women and that
recurrence in women was 10 times more likely to be of the femoral
variety than in men. This has led some to the conclusion that repairs that
provide coverage of the femoral space (eg, laparoscopic repair) at the
time of initial operation are better suited for women as a primary repair.
Contraindication:
Inguinal hernia repair has no absolute contraindications. Just as in any
other elective surgical procedure, the patient must be medically
optimized. Any medical issues, whether acute (eg, upper respiratory tract
or skin infection) or exacerbations of underlying medical conditions (eg,
poorly controlled diabetes mellitus), should be fully addressed and the
surgery delayed accordingly.
Risk Vs. Benefit
Hernia surgery is considered to be a relatively safe procedure, although
complication rates range from 1–26%, most in the 7–12% range. This means
that about 10% of the 700,000 inguinal hernia repairs each year will have
complications. Certain specialized clinics report markedly fewer
complications, often related to whether open or laparoscopic technique is
used. One of the greatest risks of inquinal hernia repair is that the hernia will
recur. Unfortunately, 10–15% of hernias may develop again at the same site
in adults, representing about 100,000 recurrences annually. The risk of
recurrence in children is only about 1%. Recurrent hernias can present a
serious problem because incarceration and strangulation are more likely and
because additional surgical repair is more difficult than the first surgery.
When the first hernia repair breaks down, the surgeon must work around
scar tissue as well as the recurrent hernia. Incisional hernias, which are
hernias that occur at the site of a prior surgery, present the same
circumstance of combined scar tissue and hernia and even greater risk of
recurrence. Each time a repair is performed, the surgery is less likely to be
1.7 Nursing management of physiologic, physical, and psychosocial
outcomes
III. Conclusion
What has been learned from the clinical experience and correlation of facts and practices featured in your report?
We have learned that indirect inguinal hernia during assessment there will be an obvious swelling in the inguinal area. And that there are many method in relieving the patient’s condition by means of nursing interventions such as proper positioning. Positioning plays a vital role pre-operative and
post-operative. Also in determining the diagnosis, Indirect hernias, the more common form, can develop at any age but are especially prevalent in infants younger than age 1. This form is three times more common in males. Because it is more common in young infant males it’s very hard to tell if they have the condition. Inguinal hernia is a common congenital malformation that may occur in males during the seventh month of gestation. Normally, at this time, the testicle descends into the scrotum, preceded by the peritoneal sac. If the sac closes improperly, it leaves an opening through which the intestine can slip, causing a hernia.
IV. References / Bibliography
Books:
Joyce M. Black, Jane Hokanson Hawks Medical-Surgical Nursing Clinical Management for Positive Outcomes 8th Edition page 710
Lippincott Williams and Wilkins Professional guide to diseases 9 th edition page 278
Maddern, Guy J. Hernia Repair: Open vs. Laparoscopic approaches. London: Churchill Livingstone, 1997.
Others:
"Focus on Men's Health: Hernia." MedicineNet Home Jan. 2003. http://www.medicinenet.com .
"Inguinal Hernia." Healthwise, Inc. February 2001. http://www.laurushealth.com/library