Hernia PDF

# Hernia ## Definition: A hernia is the protrusion of an organ or part of an organ through the wall of the cavity that normally contains it. ### Incidence Rate of Hernia: - Abdominal wall hernia is the most frequently encountered surgical condition that affects all age groups regardless of sex....

# Hernia ## Definition: A hernia is the protrusion of an organ or part of an organ through the wall of the cavity that normally contains it. ### Incidence Rate of Hernia: - Abdominal wall hernia is the most frequently encountered surgical condition that affects all age groups regardless of sex. - Globally, the prevalence of abdominal wall hernia was 1.7% for all ages. - Abdominal wall hernias are accounting for 15%-18% of all surgical procedures, and annually more than 20 million hernias are operated worldwide. - The most common hernias (up to 75% of all abdominal hernias) are inguinal hernias. Worldwide, inguinal hernia repair is one of the most common surgeries, being performed in more than 20 million people annually. ## Types of Hernia: - Hiatal hernia. - Abdominal hernias. ### Hiatal Hernia: - The esophagus enters the abdomen through an opening (hiatus opening) in the diaphragm and empties at its lower end into the upper part of the stomach. - Normally, the opening in the diaphragm encircles the esophagus tightly, and the stomach lies completely within the abdomen. - In a condition known as hiatus (or hiatal) hernia, the hiatus opening becomes dilated and part of the upper stomach tends to move up into the lower portion of the thorax. ### Risk Factors: - Hiatal hernia occurs more often in females than males (poor eating habits). - Risk factors include sedentary life style, poor eating habits, stress and smoking. **Types of Hiatal Hernia:** 1. **Sliding, or type I, hiatal hernia** occurs when the upper stomach and the gastroesophageal junction (GEJ) are displaced upward and slide in and out of the thorax, it is more common. About 95% of patients with esophageal hiatal hernia have a sliding hernia. 2. **Paraesophageal hernia** occurs when all or part of the stomach pushes through the diaphragm beside the esophagus. ### Clinical Manifestations: - The patient with a sliding hernia may have heartburn, regurgitation, and dysphagia, but at least 50% of patients are asymptomatic. Sliding hiatal hernia is often leads to reflux. - The patient with a paraesophageal hernia usually feels a sense of fullness after eating or may be asymptomatic. Reflux usually does not occur, because the gastroesophageal sphincter is intact. - The complications are hemorrhage, obstruction, and strangulation. ### Diagnosis: - History of operations, medication, diet history, smoking...etc. - Physical examination of manifestations and other associated symptoms. - Diagnostic studies: x-ray studies, barium swallow, and fluoroscopy. ### Management: - Small frequent meals easy digested. - The patient is advised not to lying down for one hour after eating, to prevent reflux or movement of the hernia (fowler's position is preferred). - Elevate the head of the bed to prevent the hernia from sliding upward. - Surgical repair of the dilated opening is optional. However, paraesophageal hernias may require emergency surgery to correct torsion (twisting) of the stomach or other body organ that may leads to strangulation. ## Abdominal Hernia: - Abdominal hernia means protrusion of loop of intestine through the weak abdominal wall. - Certain areas in the abdominal wall are weaker than other areas and more vulnerable to the development of a hernia, these areas include the inguinal ring, the femoral ring and the umbilicus. - If the protruding structures can be replaced in the abdominal cavity, it is a reducible hernia. - It can be reducible (returnable) or irreducible (unreturnable) hernia. ### Management: - Placing the client in a supine position and applying gentle manual pressure over the area may reduce the hernia. - An irreducible hernia is one in which the intestine cannot be replaced in the abdominal cavity because of edema of the protruding segment and constriction of the muscle opening. - If the process continues without treatment, the blood supply to the trapped segment of bowel can be cut off, leading to gangrene. This development is referred as a strangulated hernia. ### Pathophysiology and Etiology: - Inguinal hernias the most common type and more prevalent in men than women. - Umbilical and femoral hernias are more frequent in female than male. - A hernia develops when intra-abdominal pressure increases as in: - Straining: - Lift something heavy. - Passing hard stool during defecation. - Coughing or sneezing forcefully. - Stress, screaming, crying...etc. - Ascites. - Pregnancy. - Poor suture technique. - Poor post-operative exercise. - Obesity. - When abdominal pressure increases, a segment of the intestine moves through a weak area of abdominal muscle. - In the areas that are naturally predisposed to weakness, the abdominal wall may be thin or stretched from an inadequate amount of collagen. - Such a condition may be present at birth or develop as a result of aging, abdominal surgery, or obesity. ## Types of Hernias: 1. **Inguinal**: Protrusion of the hernial sac contains the intestine at the inguinal opening. Its types are: - **Direct:** Hernia extends through inguinal ring; it follows spermatic cord in males and round ligament in females. - **Indirect:** Protrusion follows the posterior inguinal wall; it often descends into the scrotum in males.  2. **Umbilical**: Hernia occurs in the umbilical region, through which the hernial sac protrudes. This type occurs in children when the umbilical orifice fails to close shortly after birth. It may occur in obese adults who have prolonged abdominal distention. 3. **Femoral**: Intestines descend through the femoral ring where the femoral artery passes into the femoral canal, below the inguinal ligament. Incidence of strangulation is high. 4. **Incisional:** it occurs through the scar of a surgical incision when healing is impaired. Careful surgical technique, particularly prevention of wound infection, can prevent it. Obese, older, or malnourished clients are prone to the development of incisional hernias. At first, the defect in the abdominal wall is small. As the hernia persists and the organs continue to protrude, the defect grows larger. Eventually the bowel becomes trapped in the weakened pouch. If blood supply to the bowel is compromised, it becomes gangrenous. ## Diagnosis: **A. Health History:** - Surgical and medical history and recurrence. - Stress and strain history, daily living activities ...etc. **B. Physical examination of manifestations of hernia:** - A hernia initially causes swelling on the abdomen with no other symptoms. - When the client coughs or bears down, the protrusion is more obvious. - Sometimes the swelling is painful, but the pain subsides when the hernia is reduced. ### Management: **A. Medical:** - Usually conservative treatment is not the best option. It is used to decrease the risk of complications until surgical repair occur. - Wearing a truss (an apparatus that presses over the hernia) and prevents protrusion of the bowel (as abdominal belt). - The client also may lie supine while gentle manual pressure is applied over the protruding area to reduce the hernia periodically. Some clients learn to do these themselves. **B. Surgical:** - A herniorrhaphy, the surgical repair of a hernia, is the recommended treatment. It is done by repositioned the protruding intestine in the abdominal cavity and the defect in the abdominal wall is repaired. - Herniorrhaphy is performed under local, spinal, or general anesthesia. Some types of hernias can be treated using a laparoscopic or surgical approach. - Hernioplasty: Obese people who have delay surgical repair for a prolonged period are especially prone to recurrence of the hernia. The weakened area is reinforced with wire, fascia, or mesh. The obese client usually is advised to lose weight before the surgery to decrease the possibility of recurrence. - Strangulation is an acute emergency. - Once blood flow to the intestine is impaired; necrosis (gangrene) occurs. - The gangrenous part must be excised then anastomosis is done. ## Nursing Management: - If the client is managed by conservative treatment, teach him: - How to avoid constipation (diet, fluid, mobility, bowel-training program). - Control a cough and support hernia during it even by hand. - Weight control. - Proper body mechanics. - Avoid heavy lifting. - Danger signs of irreducible strangulation of the hernia (severe pain, irreducible hernia, hotness, dark color of herniated part, nausea and vomiting, and colicky abdominal). - The nurse teaches the client how to wear a truss and observe for and treat skin irritation from friction caused by continuous rubbing. - Advising the client to keep the skin clean and dry. - The nurse also explains that compression from a truss may produce localized edema from interference with lymphatic and venous blood flow. - When surgery is scheduled, general pre and post-operative care is done with teaching patients preoperatively how to manage cough, constipation, strain and stress. - Male patient may experience swelling of the scrotum with femoral or inguinal hernia repair. Ice packs and elevation of the scrotum may be ordered to reduce the swelling - Items of conservative treatment should be done all the time to reduce risk of strangulation and recurrence. ## Nursing Diagnosis of Hernia: - Pain (its characteristic) - Disturbed body image - High risk for ineffective tissue perfusion (strangulation) - Diarrhea/ Dysfunctional Gastrointestinal Motility/ Risk for Electrolyte Imbalance - Aniexty - High risk for recurrence - Knowledge deficit **1- Pain (its characteristics...) (site of hernia)** Related to: - irreducible herniated intestinal segment - surgical incision As evidenced by : - pt. verbalized that he has pain & uncomfortable facial expression. Nursing goal: (patient will be) - Mentioned before. **2- Disturbed body image:** Related to: - protrusion of intestinal Segment from an abdominal cavity and being trapped in a weakened pouch ((hernia sac). As evidenced by : - verbalization of hopeless - fear of rejection from others - negative feeling about the body Nursing goal: (patient will be) - implement new Coping pattern and verbalize acceptance of his appearance. ## Complications of hernia: - Inflammation - Hydrocele of the hernial sac - An irreducible hernia may become strangulated if the blood and intestinal flow are completely cut off. - Strangulation leads to an intestinal obstruction and possibly gangrene and bowel perforation. ## Reference: - Hinkle JL, Cheever KH, Hinkle JL. In: Brunner & Suddarth's textbook of Medical-Surgical Nursing. Philadelphia: Wolters Kluwer; 2018. - Lemone P. Medical-surgical nursing: critical thinking for person-centred care. 3rd ed . Pearson Australia, 2017. - Pamela B, Lynn MSN, RN.Clinical Nursing Skills - A Nursing Process Approach. 5th Edition, 2019.