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.

IV. Clinical Interventions

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

successful. Recurrence and infection rates for mesh repairs have been shown

in some studies to be lower than with conventional surgeries.

Complications that can occur during surgery include injury to the

spermatic cord structure; injuries to veins or arteries, causing hemorrhage;

severing or entrapping nerves, which can cause paralysis; injuries to the

bladder or bowel; reactions to anesthesia; and systemic complications such

as cardiac arrythmias, cardiac arrest, or death. Postoperative complications

include infection of the surgical incision (less in laparoscopy); the formation

of blood clots at the site that can travel to other parts of the body;

pulmonary (lung) problems; and urinary retention or urinary tract infection.

Surgical repair is recommended for inguinal hernias that are causing pain

or other symptoms and for hernias that are incarcerated or strangulated.

Surgery is always recommended for inguinal hernias in children. Infants and

children usually have open surgery to repair an inguinal hernia.

Open surgery for inguinal hernia repair is safe. The recurrence rate

(hernias that require two or more repairs) is low when open hernia repair is

done by experienced surgeons using mesh patches. Synthetic patches are

now widely used for hernia repair in both open and laparoscopic surgery.

The chance of a hernia coming back after open surgery ranges from 1 to

10 out of every 100 open surgeries done.

1.3 Required instruments, devices, supplies, equipment, and

facilities

Packs/Drapes

Laparotomy pack or minor pack

Four folded towels

Instrumentation

Basic tray or minor tray

Self-retraining retractor

Supplies/ Equipment

Basin set

Suction

Needle counter

Penrose drain

Dissector sponges

Sutures

Solutions – saline, water

Synthetic mesh

Skin closure strips

Standard operating room anesthesia equipment, outfitted for possible

conversion to general anesthesia and endotracheal intubation, is

required.

A standard open surgical tray, including self-retaining retractors, a

Penrose drain, and different size meshes, should be available on

standby.

Mesh: The mesh must be a permanent material large enough to

produce a wide overlap beyond the defects edges. A polypropylene or

polyester mesh (5 X 10 cm to 7 X 15 cm) is generally used. Recently,

manufacturers have shifted toward lighter, more porous constructions

that maintain the strength of the repair but putatively reduce the

inflammatory response. Different mesh configurations may be chosen,

primarily based on surgeon preference and training. None have been

shown to be better at preventing recurrence.

The question of absorbable versus permanent sutures to secure the

mesh is based on surgeon preference; to date, no evidence supports

one over the other. A theoretical advantage of absorbable suture is

that, if nerve impingement is inadvertently caused, the suture material

disappears with time. The authors prefer to use absorbable (2-0

polyglactin) suture for mesh fixation.

Laparoscopic inguinal hernia repair (LH) requires similar scar size to

traditional open repair. To perform LH with minimal access, finer

instruments were used. A 5-mm laparoscope was inserted from the

umbilicus, and surgical instruments were inserted through 5- and 3-

mm trocars to perform LH by the transabdominal preperitoneal

approach. Polyester mesh was placed over the hernia orifice and the

peritoneum was closed with 3-0 silk sutures. Sixteen patients

underwent smaller access LH and 24 had standard LH. Although

smaller access LH took longer (105.7 versus 83.9 min), significantly

fewer patients required analgesia after smaller access LH than after

standard LH (12.5 versus 70.8%), and the postoperative hospital stay

was shorter (4.6 versus 5.6 days). In addition, a better cosmetic

outcome was obtained with smaller access LH. In conclusion, access

was minimized by using fine-caliber instruments and polyester mesh,

making LH less invasive and improving the cosmetic outcome.

Blacksmith surgical Set

Blacksmith Surgical has a set of instruments – Hernia/Hydrocoelectomy

Set –that is primarily used by surgeons to perform herniorrhaphy and

hydrocoelectomy.

The comprehensive Hernia/Hydrocoelectomy Set by Blacksmith

Surgical is composed of forty-four (44) instruments. Included are the

scissors: Mayo scissors for cutting heavy fascia and sutures; Metzenbaum

scissors for cutting delicate tissues; and dressing scissors. A wide variety of

forceps are present too: tissue forceps for controlling tissues during surgery,

especially during suturing; artery forceps for grasping and compressing an

artery; Allis forceps for grasping tissues; and different dissecting forceps.

There are three types of retractors for separating the edges of a surgical

incision or wound, or holding back underlying organs and tissues, so that

body parts under the incision may be accessed; these are Farabeuf,

Langenbeck, and Senn-Miller. Blacksmith Surgical incorporate a surgical

blade handle, needle holders and other miscellaneous items.

The performance of the medical practitioners in any area of the hospital is

highly affected by the quality of the equipment they use during their

operations. Blacksmith Surgical knows this information; that is why the

company ventures into providing only the best items and instruments for

diagnostic, medical and surgical purposes. As we all know, operative

procedures such as herniorrhaphy and hydrocoelectomy warrant efficient

execution. That is the reason why Blacksmith Surgical’s

Hernia/Hydrocoelectomy Set provides the best quality instruments for the

goal of helping the doctors perform the surgical procedure better. Customer

satisfaction is achieved through quality, efficiency, fastest delivery on

competitive prices. Instruments are nicely arranged in quality packaging.

S.No. Set Description of item Qty32 Hernia/Hydrocoelectomy

SetContents:

Forceps, Sponge Holding, 180mm 2Towel Clip, Backhaus, 90mm 4Handle For Surgical Blade No3 1Scissors, Mayo, Straight, 140mm 1Scissors, Mayo, Curved, 140mm 1Scissors, Metzenbaum, Curved, 180mm 1Scissors, Dressing, Straight 145mm 1Forceps dissecting slender pattern 1          5cm

1

Forceps, Dissecting, Straight, Plain, 145mm

1

Forceps, Dissecting, Straight, Plain, 145mm

1

Forceps, Dissecting, Straight, 1/2 Teeth, 145mm

1

Forceps, Dissecting, Straight, 1/2 Teeth, 180mm

1

Forceps, Tissue, Allis, 4x5 Teeth, 155mm

1

Forceps, Artery, Straight, 125mm 1Forceps, Artery, Curved, 140mm 4Forceps, Artery, Straight, 135mm 6Forceps, Artery, Straight, Kocher, 1/2teeth, 160mm

1

Forceps, Artery, Straight, Kocher, 1/2teeth, 185mm

1

Forceps, Mikulicz peritoneum 205mm 1Forceps, Mikulicz peritoneum 205mm 1Needle Holder, Mayo, 150mm 1Needle Holder, Mayo, 200mm 1Director, 1          5cm 1Probe, Myrtle leaf, 1          5cm 2

diameter         5cmRetractor, fine pattern 1 sharp prong 2Retractor, Senn-Miller baby, sharp 1Retrators, Set of Farabeuf 2Retractor, Langenbeck, 28 x 10mm 2

1.4 Perioperative tasks and responsibilities of the Nurse

Responsibilities of a Circulating & Scrub Nurse

Circulating and scrub nurses are two of the most important healthcare

workers in an operating room. Together, they are responsible for anticipating

and meeting the needs of the surgeon and patient. During a surgery, each

performs her own duties, but they work together to make the procedure as

successful as possible.

Responsibilities of the Circulating Nurse

Role

The circulating nurse plays a number of roles before, during and after

surgery. A circulating nurse ensures the sterility of the operating room

before and during surgery. These nurses supervise the technicians that clean

and sterilize the operating room (OR) and any tools, equipment and supplies

needed to perform a surgical procedure. Circulating nurses also coordinate

schedules with physicians, anesthesiologists and other nurses to make sure

that all participants understand the procedure being performed and arrive on

time. A circulating nurse acts on behalf of the patient during a procedure;

she may make decisions for the patient by proxy and ensures that the

patient receives proper care before, during and after a procedure.

Pre-surgery

Circulating nurses assess operating room conditions and ensure that all

necessary surgical tools are available. They inspect the room to ensure its

sterile to prevent patient infections. They also assist doctors in scrubbing up

and donning sterile gowns and gloves.

Conditions

Circulating nurses work primarily in hospitals, as part of trauma units and in

other facilities that perform surgery. During surgery, these nurses may stand

for long periods of time, some of which involves handling supplies and

positioning a patient to receive anesthesia. These nurses work directly with

patients in surgical and non-surgical settings. They also oversee staff that

includes other nurses and technicians. This position requires that a nurse

combine communication, team work, problem-solving and leadership skills

with nursing knowledge. Circulating nurses take courses, seminars and

certifications to continually update their knowledge base with the latest

surgical practices and procedures.

Patient Preparation

Since circulating nurses work as patient advocates, they must understand

specific patient's needs before surgery. They'll do a check on patient vital

signs prior to surgery and make sure patients aren't wearing anything, such

as jewelry, that can interfere with the surgical process. They also speak with

patients and answer any questions they have about the surgery.

During Surgery

Circulating nurses help put patients to sleep for surgery. When the surgery

starts, they remain in a non-sterile function, meaning they may venture

outside the operating room if there's a need to get supplies. They also open

packaging as necessary so doctors can grab the sterile supplies inside

without infecting their gloves or gowns.

Patient Advocate

During most surgeries, patients are anesthetized, so they can't make

decisions for themselves. The circulating nurse must serve the role of patient

advocate to ensure the operating room remains sterile and all procedures

are being followed.

Post-Surgery

After surgery, circulating nurses must account for all surgical instruments

used during the procedure and make sure nothing was left inside the patient.

Circulating nurses also do follow-up health checks on patients in the Post-

Anesthesia Care Unit to ensure their vitals are good.

Emergency Preparation

During surgery, there's always a risk of complications with which the

circulating nurse must be able to assist. Patients' vital signs can crash during

surgery, so emergency procedures take place to save their lives. Circulating

nurses, who operate between surgical teams and the rest of the hospital,

must coordinate getting supplies and other doctors and staff to patients

during emergencies.

Responsibilities of the Scrub Nurse

The scrub nurse has an important role during surgery. As a part of a

team of trained professionals, a scrub nurse will be sure that sterile

techniques are used throughout the surgery and advocate patient safety.

They may be a surgical technologist or registered nurse and are trained to

assist the surgeon and help provide an optimal outcome to the procedures.

The scrub nurse interacts with the patient prior to the surgery. She

explains the procedure to the patient and family members, in addition to

obtaining consent forms. She also washes, shaves and disinfects incision

sites and later transports the patient to the operating room. There, the

surgical technician helps to move the patient onto the surgical table and

covers the patient in sterile surgical drapes. The scrub technician oversees

the patient's vital signs and uses the patient's chart to verify all the steps

that will be undertaken. The duties and responsibilities of a scrub nurse do

not end when the procedure begins. A technician sometimes delivers

specimens to testing labs, while a scrub nurse who also is an RN assists with

suturing at the conclusion of the operation.

Preparation and Organization

Organization is important to all things in medicine and the operating

room is not any different. The scrub nurse goes into the operating room to

set the room up and set up the sterile field before the procedure begins. The

room is set up differently according to the specific surgery. Correct

instruments and materials are placed in the room by the scrub nurse so that

leaving the operating room during the procedure and potentially breaking

the sterile field is avoided. They also check that needed equipment is in good

working condition for a smooth process.

Before Surgery

The scrub nurse’s duties begin far before the start of the operation. He

ensures the operating room is clean and ready to be set up, then prepares

the instruments and equipment needed for the surgery. He counts all

sponges, instruments, needles and other tools and preserves the sterile

environment by “scrubbing in,” which requires washing his hands with

special soaps and putting on sterile garments, including a gown, gloves and

face mask. When the surgeon arrives, the nurse helps her with her gown and

gloves before preparing the patient for surgery.

During Surgery

Another duty of the scrub nurse is to identify all instruments to be used in

the operating room. She is responsible for passing the appropriate

instruments to the surgeons during surgeries and other procedures. The

nurse's knowledge and understanding of each instrument's function will help

ensure that the procedure will run smoothly and finish on time. It is also part

of the scrub nurse's duties to make sure that surgeons can comfortably and

efficiently perform their procedures. They must be keen observers and must

immediately notice if the surgeon's needs.

After Surgery

After the operation, the scrub nurse again counts all instruments, sponges

and other tools and informs the surgeon of the count. He removes tools and

equipment from the operating area, helps apply dressing to the surgical site

and transports the patient to the recovery area. He also completes any

necessary documentation regarding the surgery or the patient's transfer to

recovery.

1.5 Expected outcomes of surgical treatment performed

These guidelines are intended for Claims and Clinical Staff as general

guides for the direction, timing, expected outcomes for post-surgical

rehabilitation patients/clients. These guidelines have been developed

through an evidence-base process. The guideline may also vary on the

institute or surgeon preference.

*Without post-operation complication*

1.6 Medical management of physiologic outcomes

Wound Healing and Systemic Implications of Inguinal Hernia

Whether the hernia repair involves tissues alone, or a prosthetic graft, the

normal healing process involves a cascade of activities. Platelets are

released and surround the traumatized tissue. Macrophages and neutrophils

move in to clean the area of debris and bacteria, and to elaborate soluble

substances vital to the healing process. A fibrin matrix is deposited that

becomes polymerized and oriented into an ideal cross-linking configuration

forming reliable collagen. Work by Peacock and Maddenon defective cross-

linking and the imbalance of collagen metabolism, as well as the

observations by Read regarding the correlation of groin hernia disease with

arterial aneurysm and nicotine consumption in smokers suggest that some

metabolic factors, including collagenolysis and elastase, contribute to the

clinical eventuality of a inguinal hernia.

Hernia repair site

The hernia repair site must be kept clean and any sign of swelling or

redness reported to the surgeon. Patients should also report a fever, and

men should report any pain or swelling of the testicles. The surgeon may

remove the outer sutures in a follow-up visit about a week after surgery.

Activities may be limited to non-strenuous movement for up to two weeks,

depending on the type of surgery performed and whether or not the surgery

is the first hernia repair. To allow proper healing of muscle tissue, hernia

repair patients should avoid heavy lifting for six to eight weeks after surgery.

The postoperative activities of patients undergoing repeat procedures may

be even more restricted.

The surgery drugs commonly used before, during and after procedures vary

widely from patient to patient. The drugs you will receive are based upon the

type of surgery you are having, the anesthesia you will be receiving and

other variables, including any medical conditions you may have.

Surgery drugs are sometimes prescribed before and after the procedure, to

prevent problems after surgery. For example, you may be prescribed an

antibiotic before your surgery to prevent infection after your procedure.

Surgery Drugs:

Antibiotics

Antibiotics are a category of drugs used to combat bacteria that cause

infection. Antibiotics can be given orally, in pill form, or intravenously, or

through an IV. While in the hospital, antibiotics are most commonly given

through an IV, but the vast majority of home antibiotics are prescribed as

pills. The selection of the antibiotic depends on the type of surgery and the

risk of infection by certain types of bacteria. Examples include:

Amoxicillin

Ampicillin

Ancef (Cefazolin)

Keflex (Cephalexin)

Levaquin (Levofloxacin)

Linezolid

Maxipime (Cefepime)

Piperacillin

Rifampin

Rocephin (Ceftriaxone)

Vancomycin

Analgesics-Pain Relievers

Analgesics, or pain medications, are used to control pain before and after

surgery. They are available in a wide variety of forms, and can be given as

an IV, in pill form, as a lozenge, a suppository, as a liquid taken by mouth

and even as an ointment where the medication is absorbed through the skin.

The strength of individual pain medications varies widely, just as the dosage

prescribed by a physician can be different from one patient to another. For

this reason, the medication prescribed will depend greatly on the condition

for which it is prescribed. Most post-operative analgesics contain opioids,

either purely or in combination with acetaminophen or NSAIDs.

The following are examples of commonly prescribed choices:

Codeine

Darvocet

Demerol(Meperidine)

Dilaudid (Hydromorphone)

Fentanyl

Lortab (Hydrocodone)

Morphine

Percocet (Oxycodone)

Ultram (Tramadol)

Vicodin (Hydrocodone)

IV Fluids

Intravenous fluids, or IV fluids, are given to patients for two primary reasons,

to replace fluids they have lost through illness or injury, or to provide fluids

when they are unable to drink as they normally would. The solution that is

used is selected based on the patient’s needs and can change periodically

during a hospital stay.

Half-Normal Saline (.45 NaCL)

Normal Saline (.9 NaCl)

Lactated Ringer’s

5% Dextrose (D5)

Electrolytes

Electrolytes are compounds in the blood that can conduct an electrical

charge and help the body complete essential functions, including helping the

heartbeat. Too many electrolytes, or too few electrolytes, can cause

disruptions in the heart’s function or other serious problems.

To prevent complications from electrolyte imbalances, supplements can be

given, orally or through an IV.

Calcium Chloride

Magnesium Chloride

Potassium Chloride

Phosphorous (Potassium Phosphate)

Anticoagulants

Anticoagulants are a category of medications that slow the clotting of the

blood. This is important after surgery as one of the risks of surgery is blood

clots, especially deep vein thrombosis, which often occur in the legs.

To prevent blood clots from forming and causing complications such as a

stroke or pulmonary embolus, anticoagulants are given through an IV, an

injection, or in a pill form.

Argatroban

Coumadin (Warfarin)

Heparin

Lovenox (Enoxaparin)

Diuretics

Diuretics are medications that increase the rate of urination. They can be

used to stimulate kidney function and are also used to help control high

blood pressure.

Lasix (Furosemide)

Hydrochlorothiazide (HCTZ)

Anesthesia Drugs/Paralytics

There are several types of medication that are used to provide anesthesia for

patients having surgery. To keep patients calm immediately before the

procedure, a barbiturate may be used. During surgery, a combination of

paralytics-drugs that paralyze the muscles of the body, and drugs that cause

unconsciousness are used together.

Isoflurane

Nitrous Oxide

pancuronium

Propofol

Succinylcholine

Vecuronium

Barbiturates/Benzodiazepines

Barbiturates and benzodiazepines, commonly known as “downers” or

sedatives, are two related classes of prescription medications that are used

to depress the central nervous system. They are sometimes used with

anesthesia to calm a patient prior to surgery.

Because of side effects, barbiturates have basically been replaced by benzos

to treat anxiety and can be used to relieve symptoms of insomnia and

prevent seizure activity.

Ativan (Lorazepam)

Librium (Chlordiazepoxide)

Pentobarbital

Valium (Diazepam)

Versed (Midazolam)

Phenobarbital

Seconal (Secobarbital)

Antacids

Antacids are common part of recovery from surgery. Even if you aren’t

feeling well enough to eat or drink, your stomach continues to produce

stomach acids. To prevent nausea, vomiting, or other complications from

acid being produced but not used, antacids are given.

Pepcid (Famotidine)

Tagamet (Cimetidine): Used as both a mouth swish and to treat ulcers

Mouth Care

Mouth care is very important after surgery, especially for patients who are on

a ventilator. Studies have shown that good mouth care, including rinsing the

mouth with a solution that helps kill bacteria, can help prevent ventilator

acquired pneumonia, which is when pneumonia develops in a patient who

has been intubated and placed on a ventilator.

Mouth care is also important after dental surgeries, helping prevent infection

in the gums and the areas where surgery was performed.

Chlorhexidine

Lidocaine HCl (oral solution)

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

http://www.surgeryencyclopedia.com/Fi-La/Inguinal-Hernia-Repair.html#ixzz2YKSEVnvR

http://www.nursingdirectorys.com/2011/01/nursing-care-plan-for-inguinal-hernia.html

http://www.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73635/all/inguinal_hernia

http://fitsweb.uchc.edu/student/selectives/Luzietti/hernia_inguinal_indirect.htm

http://www.intelihealth.com/IH/ihtIH/EM/35320/75768/1369341.html?d=dmtHMSContent

http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/#diagnosis

http://www.mayoclinic.com/health/inguinal-hernia/DS00364/DSECTION=symptoms