CASE STUDY ON INGUINAL HERNIA

BY. JIJO T GEEVARGHESE

STAFF NURSE L5W

DUBAI HOSPITAL

OBJECTIVES

AT THE END OF THE PRESENTATION THE AUDIENCE WILL BE ABLE TO

• Attain knowledge regarding the definition, incidence, etiology, signs and symptoms of hernia

• Understand the surgical correction of inguinal hernia and complications after surgery.

• Identify patients needs , carry out interventions according to the needs and evaluate patients response to care.

DEFINITION

• An inguinal hernia is a protrusion of abdominal cavity contents through the inguinal canal.

INCIDENCE

About 25% of males and 2% of females develop inguinal hernias; this is the most common hernia in males and females

Indirect inguinal hernias are the most common hernias in both men and women; a right-sided predominance exists.

CLASSIFICATION

There are two types of inguinal hernia based on their relationship to inferior epigastric vessels

DIRECT INGUINAL HERNIA

INDIRECT INGUINAL HERNIA

DIRECT INGUINAL HERNIA

Direct inguinal hernias occur medial to the inferior epigastric vessels when abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal, which is formed by the transversalis fascia.

INDIRECT INGUINAL HERNIA

Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring , lateral to the inferior epigastric vessels.

CLINICAL CLASSIFICATIONS 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.

• Irreducible hernias are further classified into

Obstructed hernia-is one in which the lumen of the herniated part of intestine is obstructed but the blood supply to the hernial sac is intact.

Incarcerated hernia-is one in which adhesions develop between the wall of hernial sac and the wall of intestine.

Strangulated hernia- is one in which the blood supply of the sac is cut off, thus, leading to ischemia. the lumen of the intestine may be patent or not.

PATHOPHYSIOLOGY

CONGENITAL

OBESITY

PREGNANCY

DEFECTS IN MUSCULAR

WALL

INCREASED INTRAABDOMINAL

PRESSURE

HERNIA

TRAUMA

ETIOLOGY Increased pressure within the abdomen A pre-existing weak spot in the abdominal wall Straining during bowel movements or urination Heavy lifting Ascites Pregnancy Excess weight Chronic coughing or sneezing Peritoneal dialysis

SIGNS AND SYMPTOMS• A bulge in the area on either side of your pubic bone• A burning, gurgling or aching sensation at the bulge• Pain or discomfort in the groin, especially when bending over, coughing or

lifting• A heavy or dragging sensation in groin• Weakness or pressure in your groin• Occasionally, in men, pain and swelling in the scrotum around the testicles

when the protruding intestine descends into the scrotum• Signs and symptoms in children

Inguinal hernias in newborns and children result from a weakness in the abdominal wall that's present at birth. Sometimes the hernia may be visible only when an infant is crying, coughing or straining during a bowel movement. In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period of time.

INVESTIGATION

• A health care provider can confirm that you have a hernia during a physical exam. The growth may increase in size when you cough, bend, lift, or strain.

• X-ray abdomen/CT Scan in case of strangulated inguinal hernia

CONSERVATIVE MANAGEMENT• Hernias that or not strangulated or incarcerated can be mechanically reduced.• A truss can be placed over the hernia after it has been reduced & left in place

to prevent the hernia from recurring.(truss is a firm pad held in place by a belt)

• The client is taught to apply the truss daily before arising & to inspect the skin underneath for any breakdown.

PICTURE OF TRUSS

SURGICAL MANAGEMENT

Inguinal hernia surgery refers to a surgical operation for the correction of an inguinal hernia. Surgery is not advised in most cases, watchful waiting being the recommended option . In particular, elective surgery is no longer recommended for the treatment of minimally symptomatic hernias, due to the significant risk of chronic pain (Post herniorraphy pain syndrome), and the low risk of incarceration

REPAIR OF INGUINAL HERNIA

OPEN REPAIR (LICHTENSTEIN)

• The most commonly performed inguinal hernia repair today is the Lichtenstein repair. A flat mesh is placed on top of the defect

• It is a "tension-free" repair that does not put tension on muscles

• It involves the placement of a mesh to strengthen the inguinal region.

• Patients typically go home within a few hours of surgery, often requiring no medication beyond Paracetamol.

• Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation.

• Recurrence rate is low, <2%.

LAPROSCOPIC INGUINAL HERNIA REPAIR

LAPROSCOPIC HERNIA REPAIR

• There are mainly two methods of laparoscopic repair: • Transabdominal preperitoneal (TAPP)

• Totally extra-peritoneal (TEP) repair.

• When performed by a surgeon experienced in hernia repair, laparoscopic repair causes less complications than Lichtenstein, and especially half less chronic pain.

SURGICAL MANAGEMENT (CONTD.)

Laparoscopic mesh surgery, as compared to open mesh surgeryADVANTAGES DISADVANTAGES

Quicker recovery Less risk of chronic pain Needs surgeon highly experienced

Less pain during first days

Longer operating time

Fewer postoperative complication of bleeding

Increased recurrence of primary hernias if

surgeon not experienced enough

MESHES PERMANENT MESH Commercial meshes are typically made of prolene (polypropylene) or

polyester.

Mosquito-net mesh-Meshes made of mosquito net clothes, in co-polymer of polyethylene and polypropylene have been used for low-income.

ABSORBABLE MESH Biomeshes are increasingly popular since their first use in 1999. They are absorbable and they can be used for repair in infected

environment, like for an incarcerated hernia. Moreover, they seem to improve comfort.

MESHES USED IN HERNIA REPAIR

COMPLICATION

Pressure on surrounding tissues. Most inguinal hernias enlarge over time if they're not repaired surgically. Large hernias can put pressure on surrounding tissues — in men they may extend into the scrotum, causing pain and swelling.

Incarcerated hernia. This complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall. This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas.

Strangulation. When part of the intestine is trapped in the abdominal wall (incarcerated hernia), blood flow to this portion of the intestine may be diminished. This condition is called strangulation, and it may lead to the death of the affected bowel tissues. A strangulated hernia is life-threatening and requires immediate surgery

COMPLICATIONS Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater

than 3 months after surgery of inguinal hernia.

Hernia recurrence.. Recurrence is the most common complication of inguinal hernia repair, causing patients to undergo a second operation. Hernia recurrence occurs less often when a hernioplasty is performed.

Bleeding. Bleeding inside the incision of hernia repair.It can cause severe swelling and bluish discoloration of the skin around the incision.It is unusual and occurs in

less than 2 percent of patients

Wound infection. The risk of wound infection is small—less than 2 percent,and is more likely to occur in older adults and people who undergo more complex hernia repair.

Injury to internal organs. Although extremely rare, injury to the intestine, bladder, kidneys, nerves and blood vessels leading to the legs, internal female organs, and vas deferens.

COMPLICATION OF MESH REPAIR

Complications are frequent (>10%). They include, but are not limited to: foreign-body sensation chronic pain ejaculation disorders mesh migration mesh folding Infection adhesion formation erosion into intraperitoneal organs

In the long term, polypropylene meshes face degradation, due to heat effects. This increases the risk of stiffness and chronic pain. Persistent inflammation and increased cell turnover at the mesh-tissue interface raised the possibility of cancer transformation.

NURSING MANAGEMENT (GENERAL)

Alteration in comfort pain related to disease conditionAlteration in comfort pain related to surgical interventionNursing interventionsFit the patient with truss/belt when hernia is reduced if orderedEvaluate signs and symptoms of hernia

incarceration/strangulationGive stool softeners as directed

NURSING MANAGEMENTS CONTD.

• Teach about bed rest , intermittent icepacks ,and scrotal elevation to reduce scrotal edema or swelling.• Encourage ambulation as permitted• Advise patient that difficulty in urination is common after surgery , promote elimination to eliminate as necessary

or catheterise the patient.• Teach about bed rest , intermittent ice packs and scrotal elevation to reduce scrotal edema or swelling.• Encourage ambulation as permitted• Advise patient that difficulty in urination is common after surgery,promote elimination to eliminate as necessary

or catheterise the patient.• Preventing infection• Check dressing for drainage &incision for redness and swelling.• Monitor for signs/symptoms of infection• Administer antibiotics if appropriate

PATIENT EDUCATION

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

• Apply ice intermittently• Elevate scrotum,and use scrotal support• Take medication prescribed to relieve discomfort• Teach to monitor self for signs of infection.• Report continued difficulty in voiding• Avoid heavy lifting for 4-6 weeks.Athletics and extremesof exertion to be avoided for 8-

12 weeks post operatively

PATIENTS DETAILS

DEMOGRAPHIC DATA• NAME: XYZ• AGE: 70 YEARS• SEX: Male• NATIONALITY: PAKISTANI• DATE OF ADMISSION: 05-08-2013• DATE OF DISCHARGE: 10-08-2013• DIAGNOSIS: LEFT INGUINAL HERNIA • PROCEDURE: OPEN LEFT INGUINAL HERNIA MESH

REPAIR.

PRESENT SURGICAL HISTORY

Mr. XYZ admitted for Elective inguinal hernia repair on 06/08/13.He had a left groin swelling of one month duration. He is known case of Diabetes mellitus and hypertensive for 10 years and is on regular medications.No significant past surgical history.

GENERAL APPEARANCEHe is moderately built.

Maintains a erect posture and steady gait.

Hygiene and Grooming: Looks cleans and tidy. Maintains his personal hygiene.

MOOD: Calm and Co operative.

FAMILY HISTORY

He is married with five children. He has a good famly support in the home.

SOCIO ECONOMIC STATUS : He is a retired from job. He has middle class socio economis status.

NUTRITIONAL HISTORY

He is a Non-vegetarian. He likes to eat red meat and fried food. He eats three meals per day and snacks in between. He is moderately built.

PHYSICAL EXAMINATION• Groin: A 3 x 4 cm Left Inguinal Swelling that is reducible and non tender on

palpitation associated with scrotal swelling.• All other system review remained normal.

BASELINE DATA• VITAL SIGNS:• TEMPERATURE-36.5 C • BP-138/84 mm of Hg• Pulse:82 Beats/minute• Respiration:24 Breaths/minute• Oxygen saturation:99%(room air)• Height:156cm Weight:68kgs BMI:24• Braden Score:23• Oral Score:7• Fall score:0

DESCRIPTION

VALUE UNIT RANGE

WBC COUNT

8.4 10^3uL 3.6-11.0

RBC COUNT 4.84 10^6uL 4.5-6.00

HGB 17.4 g/dL 13.0-18.0HCT 16.3 % 40.0-52.0

PLATELET 231 10^3uL 150-400CREATININE

1.00 mg/dL 0.7-1.2

UREA 22 mg/dL 12-40P0TASSIUM 4.7 mmol/L 3.3-4.8

SODIUM 138 mmol/L 136-145CHLORIDE 112 mmol/L 98-108

HIV NEGATIVE

HbsAg NEGATIVE

INVESTIGATIONS

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MEDICATIONS

NAME DOSE ROUTE FREQUENCY DURATION

INJ ZINACEF 750MG IV TDS 5DAYS

INJ FLAGYL 500MG IV TDS 5DAYS

INJ PARACETAMOL 1GM IV TDS 5DAYS

INJ TRAMADOL 100MG IM PRN,TDS 1DAYS

Assessment

Diagnosis Objective intervention evaluation

Patient has repeated doubts regarding surgery

Fear and anxiety related to hospitalization.

Patient is free from fear and anxiety

•Assess the anxiety level of the patient•Explain to the patient all procedures in simple terms•Introduce the patient to similar patients who had under gone surgeryDiversion therapy

Patient is relieved of fear and anxiety

NURSING CARE PLAN(PRE-OP)

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Assessment

diagnosis objective intervention evaluation

Patient asks doubts regarding pre op preparation

Knowledge deficit regarding pre and post operative care

Patient gains adequate knowledge regarding pre &postoperative care

•Assess the knowledge level of the patient•Explain to the patient regarding the need for npo,pre operative skin preparation, site marking.•Explain regarding post op pain management, early mobilisation,splinting technique.

Patient verbalized importance of pre op nil by mouth and importance of early mobilisation.

Assessment

Diagnosis Objective Interventions

Evaluation

Patient verbalizes pain over the operated site.Heart rate -100/minute

Alteration in comfort pain related to surgical intervention

Patient gets relief from pain

•Assess the pain level of the patient •Provide comfortable position to the patient•Instruct the patient to splint the surgical site while coughing/moving•Diversion therapy•Administer analgesics as ordered

Analgesics given. advised splinting techniques.patient resting comfortably.

NURSING CARE PLAN (POST OP)

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Assessment Diagnosis Objective Intervention

Evaluation

Patient nil by mouth since previous day midnight.Lips dry.

High risk for fluid volume deficit related to nil by mouth status

Patient maintains normal fluid volume.

•Assess the level of hydration of the patient.•Monitor vital signs•Monitor urine output•Maintain intake output chart•Administer iv fluids as ordered.

Patient maintains normal fluid volume.has adequate urine output.

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Assessment

Diagnosis Objective Interventions

Evaluation

Patient has undergone open hernia repair with meshPatient is having a redivac drain

High risk for bleeding related to surgical intervention

Patient remains free fro bleeding from the surgical site

•Assess the post operative site for any bleeding or oozing•Monitor drain output•Monitor vital signs

Post operative dressing site dry and intactDrain within normal limits

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Assessment

Diagnosis Objective Intervention

Evaluation

Patient has under gone hernia repair with mesh

High risk for infection related to surgical intervention

Patient remains free from infection

•Assess the post operative dressing for any discharge•Assess the post operative site for any redness or oozing•Monitor vital signs•Administer antibiotics as ordered

Patient didn’t developed any post operative infection.

COURSE OF HOSPITAL STAY

• 05-08-13-Admitted electively for left inguinal hernia repair. Site marking and skin preparation done.NPO instructed from mid night.

• 06-08-13-undergone open left inguinal hernia with mesh repair under general anaesthesia. He received Zinacef1.5g intraoperatively. Received with one redivac drain in situ. Received him conscious , coherent. Post operative dressing dry and intact. Post Op orders to start full diet when fully awake. Continue observation.

• 07-08-13 - started on fulldiet , mobilisation, change dressing, mark drain• 08-08-13 - drain marked at 70ml, full diet, pressure dressing.• 09-07-13- antibiotics changed to oral zinacef 500mg BD, mark drain, pressure

dressing.

COURSE OF HOSPITAL STAY (CONTD.)• 10-08-13 - to remove drain and discharge by evening. To continue full diet and

oral antibiotics.• CONDITION AT DISCHARGE:

afebrile, vitally stable, pain free ,clean wound and free of infection.

DISCHARGE MEDICINES:

Tab Zinnat500mg BD*5DAYS

Tab Paracetamol1g TDS PRN

DISCHARGE INSTRUCTIONS

• Avoid heavy lifting and strenuous exercises for 6-8 weeks.• Maintain personal hygiene.• Continue with oral antibiotics and PRN analgesics as ordered.• Monitor for signs of infection and to report to emergency if so.• Encouraged to have vitamin C and protein rich food.

QUESTIONS

• What is inguinal hernia?• What are the signs & symptoms of inguinal hernia?• Which are the two types of hernia repair?• What are the complications after hernia surgery?• What are the discharge instructions to the patient?

CONCLUSION

• An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females. Inguinal hernias may be repaired through surgery. Surgery for inguinal hernia is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient.