Hernia Surgery RPN20231 PDF

MODULE 10: Hernia Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 13 ORNAC Standards 2023 Learning Outcomes Define and differentiate the terms: direct hernia, indirect hernia,...

MODULE 10: Hernia Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 13 ORNAC Standards 2023 Learning Outcomes Define and differentiate the terms: direct hernia, indirect hernia, reducible hernia, non-reducible hernia, and incarcerated hernia, strangulated hernia, incisional and umbilical. Understand relevant anatomy and pertinent details of hernia surgeries for a novice perioperative nurse. Explain the rational for full instrument counts in hernias surgeries. A hernia is an abnormal protrusion of a peritoneum-lined sac through a defect in the layers of the abdominal wall. It is composed of covering tissues, a peritoneal sac, and any contained viscera. The technical name for the operation that repairs a hernia is called a Herniorrhaphy. Hernias are congenital or acquired. Hernia surgeries are normally unilateral are require pre- operative site marking. Hernia Anatomy Inguinal Canal - The inguinal canal contains the spermatic cord in males and the round ligament in women, is about 4 cm long and runs obliquely parallel and slightly above the groin crease. Cooper's Ligament - Strong, fibrous band located on the iliopectineal line of superior public ramus. (*This ligament is sometimes used in inguinal repairs). External Inguinal Ring (Superficial) - Opening in the external oblique; the ring contains the ilioinguinal nerve. Internal Ring - Bordered superiorly by internal oblique muscle and inferior medially by the inferior epigastric vessels. Module 10: Hernia  Types of Hernias There are three types of hernias: femoral hernias, abdominal hernias, and direct and indirect inguinal hernias. Depending on the defect location, hernias are classified as direct inguinal, indirect inguinal, femoral, incisional, umbilical, or epigastric. Inguinal Hernia - the transversalis fascia is the structure that makes up the floor of the inguinal canal. The hole in the transversalis fascia in the inguinal area is going to result in an inguinal hernia. The sac is formed when the contents in the abdominal cavity is pushing through the weakened area or defect in the transversalis fascia. The sac or peritoneum is stretched and is pushing through the defect. Contents of Inguinal Canal Male - the spermatic cord Female - the round ligament (runs parallel and slightly the groin crease Inguinal Hernia Direct – Protrusions that occur through an area of weakness, such as the Hasselbach triangle. Typically, are a result of heavy lifting or other strenuous activities. Indirect - Outside the Hasselbach triangle, lateral to the deep epigastric vessels. Abdominal Hernias Incisional Hernia – Defect through inadequately healed surgical repair Umbilical – Congenital defect in the muscle. Module 10: Hernia Femoral Hernia – Defect protrudes from the groin below the inguinal ligament into the thigh. Reducible - Visceral contents can be pushed back to the normal intra-abdominal position. Irreducible – Contents are trapped into the extra abdominal sac (peritoneum) and become INCARCERATED. This may result in necrosed bowel and thus bowel surgery. Perioperative Nursing Considerations Nursing Assessment The hernia patient is often concerned with the time it will take to return to their normal level of activity. Another concern may be risk for urinary retention in the adult male patient. Patient Positioning The surgical procedure determines the patient’s intraoperative position. Typically, a patient undergoing a laparoscopic hernia repair will be placed in the supine position. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. The perioperative nurse ensures that the patient return electrode pad is applied and the safety strap secured. Instrumentation and Counting A minor Instrument tray is required for all hernia surgeries. If there is bowel involved as in a strangulated hernia, bowel instruments will be added. A major count is conducted at the beginning of all cases. In the event that peritoneum is opened, a full closing count will be required, in addition to a minor final count. Initial Count (major) → Closing Count (major) → Final Count (minor) If the peritoneum is not opened, a minor closing count is indicated. Initial Count (major) → Closing Count (minor) → Final Count (minor) Permanent suture used for repair (Prolene, Surgipro) Something to isolate spermatic cord (ie. Hernia Tapes, Penrose drain, umbilical tapes, Pushers. Sponge on stick to peel the “sac” Module 10: Hernia Procedural Considerations The incision is made down through skin, subcutaneous layers, and the inguinal canal is opened by incising the inguinal ligament. The spermatic cord or round ligament is gently moved out of the way. Usually, a Penrose drain is slipped around the spermatic cord (or Round Ligament- female) and secured with a Kelly. Sharp instruments and retractors are avoided. The hernia sac and its contents is opened up and checked for bowel contents. If it is clear, then the sac is excised. Once excised, the surgeon must repair the hole in the inguinal canal floor. The repair must be permanent. The surgeon will use something like 0 Prolene/ Surgipro, a fairly heavy permanent suture. Once this is completed the wound is closed using absorbable sutures or staples for the skin incision. If the defect in the inguinal floor is too large to be repaired with suturing, a permanent mesh may be indicated; secured using an absorbable suture. The surgeon then gently replaces the spermatic cord or round ligament and closes up the superficial layers with absorbable sutures. Inguinal and Femoral Mesh Plug Repairs Procedural Considerations Femoral Hernias are also caused by a defect in the transversalis fascia, but inferior to the inguinal ligament causing an increase of the size of the femoral ring. Femoral hernias are often incarcerated or strangulated, and therefore require immediate surgery. They can be repaired with similar methods as inguinal hernias. For an inguinal hernia repair, an innovation known as a mesh-plug has shown to be very useful. In this procedure a special type of mesh is used for the repair. This mesh-plug or PerFix plug is placed into the hernia defect. Using this method, there is less dissection, resulting in decreased post-operative pain, faster recovery time, less recurrence of hernias. Non absorbable sutures are used to secure the plug with or without its overlay piece. The overlay piece of mesh is sutured to itself. The spermatic cord structures are placed on top of this flat portion of permanent mesh. The external oblique fascia is approximated over the structures with a “running NON absorbable” suture. Ventral (Abdominal) Hernia Ventral hernias occur on the abdominal wall outside of the inguinal area, and can appear either spontaneously (epigastric and umbilical hernias) or after previous operations (incisional hernias). Incisional Hernias Etiologies are often obesity, prior wound infections, or previous operations that Module 10: Hernia  involved a potential for contamination, such as that for acute perforate ulcer or other perforated abdominal viscera. If the missing section is too large to be sutured, synthetic meshes can be used. Umbilical Hernia Extra peritoneal hernias are small fascial defects under the umbilicus. They are common in children and often spontaneously disappear by two years of age They can occur in obese people. They require simple repair approximating the overlying fascia Epigastric Hernia Protrusions of fat through defects in the abdominal wall Symptoms include: nausea, vague abdominal pain, or epigastric pain Surgical repair is simple and very successful. Module 10: Hernia