A hernia occurs when an internal body part such as the small intestine pushes through weak muscle or surrounding tissue. Hernia repair is ideally performed so as to avoid complications.
REDUCIBLE HERNIA: intestines push through muscle or tissue but can still be pushed back in.
IRREDUCIBLE / INCARCERATED HERNIA: intestines push through muscle or tissue and cannot be pushed back into their original position.
STRANGULATED HERNIA: intestines push through muscle or tissue, become stuck and result in impaired blood supply, causing it to become necrotic. This requires an emergency procedure where the intestines require to be resected before the hernia is repaired.
Inguinal Hernia
An inguinal hernia is the most common type of hernia, mostly presenting in men due to the testicle descent at birth. It is located in the lower abdomen above the leg crease or close to the pubic area. Inguinal hernias are most common with ageing since the abdominal muscles become weaker with age.
In the case of girls, ovarian herniation of the canal of Nuck, which can occur at any age, is most common in childhood. Early diagnosis is vital since incarceration of the ovary can lead to ovarian necrosis.
INDIRECT INGUINAL HERNIA: a natural defect known as the ‘internal inguinal ring’ which is caused by testicles not descending before birth does not seal properly, and eventually develops into a hernia. This usually reaches the scrotum. It is very common in children.
DIRECT INGUINAL HERNIA: acquired by continuous exertion on the muscles. Presents as a forward protrusion and is found in adults.
Hernia Risk Factors
WEAKENED TISSUE: caused by ageing, surgical wounds, smoking, steroids, immunosuppresive drugs and collagen disorders.
EXERTED TISSUE: caused by heavy lifting, coughing, constipation, pregnancy, muscle strain.
Hernia Signs and Symptoms
- swelling which may or may not be painless which may worsen when standing or straining, and improve when lying down.
- burning sensation in the bulging area
- weakness or pressure in the groin
Immediate action should be taken if an inguinal hernia causes pain as well as nausea and vomiting, or swelling that feels firm and tender.
Hernia Repair – Surgical Approaches
HERNIOTOMY: removal of the hernia sac.
HERNIORRHAPHY: removal of the hernia sac AND inguinal canal posterior wall repair. Repair is performed using the patient’s own tissue, and sutures cause tension on both sides to keep it closed. Unfortunately this conventional method of hernia repair can cause pain and discomfort, and has an unfavourable recurrence rate.
HERNIOPLASTY a.k.a. Lichtenstein Repair: removal of the hernia sac AND inguinal canal posterior wall repair with a synthetic mesh. This is one of the most commonly used methods of hernia repair that poses no tension, and in which the mesh is sutured over the defect. The mesh is made out of polypropylene. It is thin, flexible and lightweight, and helps reduce the risk of pain and foreign body sensation, acting as a base for new tissue growth that eventually incorporates it into the area.
Laparoscopic Hernia Repair
Laparoscopic hernia repair is especially indicated in the case of bilateral inguinal hernia or when diagnosis is not clear enough. This type of hernia repair is free of tension and is completed with the use of a mesh. CO2 is used to inflate the abdominal cavity to allow easy access for surgery. Laparoscopic hernia repair allows the patient to return to normal in less time than when an open surgery is performed.
Perioperative Nursing Care
Preoperative Care:
- Assess pulmonary risk (if patient has a cold, coughing may exacerbate pain post-surgery).
- Assess psychosocial patient needs including fear of anesthesia, fear of pain, fear of disruption of normal daily life.
- Make sure patient is not given a gastrointestinal cleanser (laxative) in the case of an obstructed hernia.
- Assure patient that pain relief will be given post-surgery as required. This may help alleviate any pain-management related worry.
- Talk to the patient about what to expect to see post-surgery, eg. incision location and size, closure type, dressings, drains, tubes (including a NG tube, oxygen, IV and drains so the patient will feel prepared.
- Monitor normal state of health, posture and other physical factors of the patient so as to be able to notice any important differences post-surgery.
- Removal of hair is done with electric clippers and not blades, so as to minimise incisions (more infections risk).
- Patient should fast for 6 hours from food or milk and 2 hours for clear fluid.
- Sedatives may be administered to help reduce anxiety associated with surgery.
Intraoperative Care:
- Correct positioning of patient on surgical table prior to surgery ensures patient comfort.
- Avoid friction burns, shearing and damage to soft tissue of the patient.
- Apply preventative measures against deep vein thrombosis by administrating Low Molecular Weight Heparin, using intermittent pneumatic compression devices and graduated compression stockings.
- Use forced air warming blankets, warm IV fluids, irrigation and skin preparation fluids to prevent inadvertent hypothermia.
- All swabs, instruments, needles and other surgical tools need to be accounted for and documented.
Postoperative Care:
- Airway must be patent and clear, not with blood-tinged mucus.
- Assist in supine or on the side to increase ventilation.
- Monitor SP02.
- Ensure bilateral even movement of the chest.
- Respiratory changes may be a sign of respiratory or cardiac arrest.
- Inspect wounds and drains for signs of haemorrhage.
Postoperative Complications:
Infection indicators include fever, erythema (superficial reddening of the skin), increased exudate and/or change in its colour, malodour, localised heat and/or pain, delayed healing. A well-balanced diet high in Vitamin C and protein may help reduce wound infection and quicker healing.
Fluid deficiency may lead to hypovolaemia (low blood volume) and hypotension (low blood pressure). Monitor blood pressure and pulse, intake and output, and note urine colour and concentration. Inspect mucous membranes, skin turgor (pinching up a small portion of skin and assessing whether it remains raised or not after letting go), and capillary refill (monitors amount of blood flow to the tissue).
Read more perioperative nursing care considerations here.
Below you can find a collection of videos that can help provide a more visual approach to hernia locations, types, risk factors, symptoms and hernia repair.
What is a Hernia?
Hernia Symptoms
Inguinal Hernia
Inguinal Hernia Symptoms & Hernia Repair
WARNING! GRAPHIC CONTENT! Paediatric Open Herniotomy
WARNING! GRAPHIC CONTENT! Robotic Inguinal Herniorrhaphy Surgical Video
WARNING! GRAPHIC CONTENT! Inguinal Hernia Repair With Mesh
Hernia Repair Complications
Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Buck Parker MD, Howard County General Hospital, drgursev : The Pediatric Surgery Specialist, Plexus Surgical Video Productions, Gajendra Singh, MD and California Hernia Specialists: Specialty Care for Hernia Repair.
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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