Hernia : Types, Diagnosis, management, Complications

Hernia:

A hernia is a protrusion of an organ, tissue or structure through the wall of the cavity in which it is normally contained.

Etiology:

1.     Congenital weakness of the abdominal valve

2.     Acquired causes  (traumatic injury, aging)

3.     Increased intra-abdominal pressure due to heavy lifting, obesity, pregnancy, straining and chronic coughing

Types of hernia:

1.     Reducible: The protruding mass can be placed back into the abdominal cavity.

2.     Irreducible: The protruding mass cannot be moved back into the abdomen.

3.     Incarcerated: An irreducible hernia in which the intestinal flow is completely obstructed.

4.     Strangulated: An irreducible hernia in which the blood and intestinal flow are completely obstructed. Develops when the loop of intestine in the sac becomes twisted or swollen and a constriction is produced at the neck of the sac.

Classification of hernia by site:

1. Inguinal hernia:

Hernia into the inguinal canal (more common in males.)

Indirect inguinal hernia: Due to weakness of the abdominal wall at the point through which the spermatic card emerges in the male and the round in the female.

Through this opening the hernia extends down, the inguinal canal and often into the scrotum or the labia.

Direct inguinal hernia: Passes through the posterior inguinal wall.

2.Femoral hernia:

Hernia into two femoral canals appearing below the inguinal ligament that is below the groin.

3. Umbilical hernia:

Protrusion of part of the intestine at the umbilicus due to failure of umbilical orifice will close. Occurs most often in obease women, in children and in patients with increased intra abdominal pressure from cirrhosis and ascites

4. Ventral (or) incisional hernia:

Hernia through the weak abdominal wall may occur after impaired healing of incision due to infection.

5. Diaphragmatic (or) hiatus hernia (or) oesophageal hernia:

It is the protrusion of a part of the stomach that slides or follows the normal path of the esophagus and enters into the thoracic cavity through an enlarged hiatal opening.

Signs and symptoms:

1.    Bulging over herniated area when patient stands or strains, and disappears when supine.

2.     Hernia tends the increase in size and recurs with intra abdominal pressure.

3.     Strangulated hernia presents with pain, vomiting, swelling of hernial sac, peritoneal irritation and fever.

4.     In hiatus hernia the patient complaints of heart burn after large meals and during the night, food may be regurgitated

Diagnosis:

1.     Based on signs and symptoms.

2.     Abdominal X-rays: Reveals abnormally high level of gas in the bowel.

3.     Laboratory studies: Complete blood count and electrolytes may show haeconcentration (increased hematocrit), dehydration (increased or decreased sodium) and leucocytosis.

Management:

1.Mechanical:

A truss is an appliance with a pad and belt that is holding snugly over a hernia to prevent abdominal contents from entering the hernia sac.

Surgical management:

Recommended to correct hernia before strangulation.

Strangulation of hernia is an emergency condition that necessitates emergency laparotomy.

2.Herniorrhaphy:

Removal of hernial sac, contents replaced into the abdomen, layers of muscle and fascia sutured.

Laparoscope Herniorrhaphy is a possibility is often performed on outpatient basis.

3. Hernioplasty:

Involves reinforcement of suturing (often with mesh) for extensive hernia repair.

c. Strangulated:

Strangulated hernia requires resection of ischemic bowel in addition to repair of hernia.

Nursing management:

1.Achieving comfort of the patient:

Fit patient with truss or belt when hernia is reduced, if ordered.

Trendelenburg' s position may reduce pressure on hernia, when appropriate.

Emphasize patient to wear truss under clothing and to apply before getting out of the bed when hernia is reduced.

2. Post operative care:

·  Encourage the patient to splint the incision site with hand or pillow when coughing to lessen pain and protect the site from increased intra-abdominal pressure and wound dehiscence.

1.     Administer analgesics as ordered.

2.     Teach about bed rest, intermittent ice packs. Scrotal elevation is done with T bandage to reduce scrotal edema or swelling after repair of an inguinal hernia.

3.     Encourage ambulation as soon as permitted.

4.     Advise patient that difficulty in urinating is common after surgery; promote  elimination  to  avoid discomfort,  and catheterise if necessary.

3. Prevention of infection:

1.     Monitor the vital signs

2.     Check dressings for drainage and incision for redness and swelling.

3.     Monitor for other signs and symptoms of infections; fever, chills, malaise, diaphoresis.

4.     Administer prescribed antibiotics.

4. Patient education on discharge:

1.     Advise that pain and scrotal swelling may be present for 24 to 48 hours after repair of an inguinal hernia.

2.     Apply ice intermittently.

3.     Elevate scrotum by using scrotal support.

4.     Take prescribed medication to relieve discomfort.

5.    Inform that heavy lifting should be avoided for 4-6 weeks.

6.    Athletics and extremes of extension are to be avoided for 8 to 12 weeks postoperatively.

Complications:

1.     Bowel obstruction.

2.     Gangrene formation

3.     Wound dehiscence