What Is a Hernia?

A hernia occurs when an organ pushes

through an opening in the muscle or
tissue that holds it in place. For example,
the intestines may break through a
weakened area in the abdominal wall.
Hernias are most common in the
abdomen. However, they can also appear
in the upper thigh, belly button, and groin
regions. Though the majority of hernias
are not immediately life threatening, they
will not go away on their own and will
require surgical correction to prevent
potentially dangerous complications.

Inguinal
Inguinal hernias are the most common type of hernia. They make up about 70 percent of
all hernias, according to the British Hernia Centre (BHC).
hiatal
A hiatal hernia occurs when part of stomach protrudes up through the diaphragm into
the chest.
Umbilical
Umbilical hernias occur in babies and children under six months of age if their intestines
bulge through the abdominal wall near the bellybutton.

incisional
Incisional hernias can occur after have abdominal surgery. Your
intestines may push through the incision scar or the surrounding,
weakened tissue.

Femoral
Femoral hernias occur just below the inguinal ligament , when abdominal contents
pass into the weak area at the posterior wall of the femoral canal.

 What is an inguinal hernia?

An inguinal hernia happens when contents of the abdomen
usually fat or part of the small intestinebulge through a weak
area in the lower abdominal wall. The abdomen is the area
between the chest and the hips. The area of the lower abdominal
wall is also called the inguinal or groin region.
Two types of inguinal hernias are
indirect inguinal hernias, which are caused by a defect in the
abdominal wall that is congenital, or present at birth
direct inguinal hernias, which usually occur only in male adults
and are caused by a weakness in the muscles of the abdominal
wall that develops over time
Inguinal hernias occur at the inguinal canal in the groin region.

ETIOLOGICAL FACTORS
Males are much more likely to develop inguinal
hernias than females. About 25 percent of
males and about 2 percent of females will
develop an inguinal hernia in their lifetimes
People of any age can develop inguinal
hernias. Indirect hernias can appear before age
1 and often appear before age 30; however,
they may appear later in life. Premature infants
have a higher chance of developing an indirect
inguinal hernia.

 Direct hernias, which usually only occur in

male adults, are much more common in
men older than age 40 because the muscles
of the abdominal wall weaken with age.
People with a family history of inguinal
hernias are more likely to develop inguinal
hernias. Studies also suggest that people
who smoke have an increased risk of
inguinal hernias.

TYPES
indirect inguinal hernias, which are
caused by a defect in the abdominal wall
that is congenital, or present at birth
direct inguinal hernias, which usually
occur only in male adults and are caused
by a weakness in the muscles of the
abdominal wall that develops over time

TYPES
Reducible hernia: is one which can be pushed back into
the abdomen by putting manual pressure to it.
Irreducible/Incarcerated 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.
Strangulated hernia: is one in which the blood supply of
the hernia contents is cut off, thus, leading to ischemia.
The lumen of the intestine may be patent or not.

PATHOPHYSIOLOGY
Indirect inguinal hernias. A defect in the abdominal wall that
is present at birth causes an indirect inguinal hernia.
During the development of the fetus in the womb, the lining
of the abdominal cavity forms and extends into the inguinal
canal. In males, the spermatic cord and testicles descend out
from inside the abdomen and through the abdominal lining to
the scrotum through the inguinal canal. Next, the abdominal
lining usually closes off the entrance to the inguinal canal a
few weeks before or after birth. In females, the ovaries do not
descend out from inside the abdomen, and the abdominal
lining usually closes a couple of months before birth. 1
female children, occurring in less than 1 percent.3

 Sometimes the lining of the abdomen does not

close as it should, leaving an opening in the
abdominal wall at the upper part of the inguinal
canal. Fat or part of the small intestine may slide
into the inguinal canal through this opening,
causing a hernia. In females, the ovaries may also
slide into the inguinal canal and cause a hernia.
Indirect hernias are the most common type of
inguinal hernia.2 Indirect inguinal hernias may
appear in 2 to 3 percent of male children; however,
they are much less common in

 Direct inguinal hernias. Direct inguinal

hernias usually occur only in male adults
as aging and stress or strain weaken the
abdominal muscles around the inguinal
canal. Previous surgery in the lower
abdomen can also weaken the
abdominal muscles.

SIGNS AND SYMPTOMS

The first sign of an inguinal hernia is a
small bulge on one or, rarely, on both
sides of the grointhe area just above
the groin crease between the lower
abdomen and the thigh. The bulge may
increase in size over time and usually
disappears when lying down.

 Other signs and symptoms can include

discomfort or pain in the groinespecially when
straining, lifting, coughing, or exercisingthat
improves when resting
feelings such as weakness, heaviness, burning, or
aching in the groin
a swollen or an enlarged scrotum in men or boys
Indirect and direct inguinal hernias may slide in and out of the
abdomen into the inguinal canal. A health care provider can
often move them back into the abdomen with gentle massage .

 extreme tenderness or painful redness in

the area of the bulge in the groin
sudden pain that worsens quickly and
does not go away
the inability to have a bowel movement
and pass gas
nausea and vomiting
fever

DIAGNOSIS
medical and family history. Taking a medical and family
history may help a health care provider diagnose an
inguinal hernia. Often the symptoms that the patient
describes will be signs of an inguinal hernia.
Physical exam. A physical exam may help diagnose an
inguinal hernia. During a physical exam, a health care
provider usually examines the patients body. The health
care provider may ask the patient to stand and cough or
strain so the health care provider can feel for a bulge
caused by the hernia as it moves into the groin or scrotum.
The health care provider may gently try to massage the
hernia back into its proper position in the abdomen.

 Abdominal x ray. An x ray is a picture

recorded on film or on a computer using
a small amount of radiation.
Computerized tomography (CT) scan. CT
scans use a combination of x rays and
computer technology to create images.
Abdominal ultrasound.

MANAGEMENT
Trusses, corsets, or binders can hold
hernias in place by placing pressure on the
skin and abdominal wall.
Herniotomy (removal of the hernial sac only)
Herniorrhaphy (herniotomy plus repair of
the posterior wall of the inguinal canal)
Hernioplasty (herniotomy plus
reinforcement of the posterior wall of the
inguinal canal with a synthetic mesh)

 The Lichtenstein tension-free mesh repair, which is an example of

hernioplasty and is currently one of the most popular open inguinal
hernia repair techniques, includes the following components:
Opening of the subcutaneous fat along the line of the incision
Opening of the Scarpa fascia down to the external oblique
aponeurosis and visualization of the external inguinal ring and the
lower border of the inguinal ligament
Opening of the deep fascia of the thigh and exposure of the femoral
canal to check for a femoral hernia
Division of the external oblique aponeurosis from the external ring
laterally for up to 5 cm, safeguarding the ilioinguinal nerve
Mobilization of the superior (safeguarding the iliohypogastric nerve)
and inferior flaps of the external oblique aponeurosis to expose the
underlying structures

 Mobilization of the spermatic cord, along with the cremaster, including the
ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels; all
of these structures may then be encircled in a Penrose drain or tape
Opening of the coverings of the spermatic cord and identification and
isolation of the hernia sac
Inversion, division, resection, or ligation of the sac, as indicated
Placement and fixation of mesh to the edges of the defect or weakness in
the posterior wall of the inguinal canal to create a new artificial internal
ring, with care taken to allow some laxity to compensate for increased
intra-abdominal pressure when the patient stands
Resection of any nerves that are injured or of doubtful integrity
In males, gentle pulling of the testes back down to their normal scrotal
position
Closure of spermatic cord layers, the external oblique aponeurosis,
subcutaneous tissue, and the skin

 Other approaches to open inguinal hernia repair include the following:

Plug-and-patch repair - This adds a polypropylene plug shaped as a cone,
which can be deployed into the internal ring after reduction of an indirect
sac
Prolene Hernia System (PHS) - This consists of an anterior oval
polypropylene mesh connected to a posterior circular component
McVay repair - In this approach, the conjoined (transversus abdominis and
internal oblique) tendon is sutured to the inguinal ligament with
interrupted nonabsorbable sutures
Bassini repair - This approach involves suturing the transversalis fascia
and the conjoined tendon to the inguinal ligament behind the spermatic
cord, as well as placing a vertical relaxing incision in the anterior rectus
sheath
Shouldice repair - This is a four-layer procedure in which transversalis
fascia is incised from the internal ring laterally to the pubic tubercle
medially, upper and lower flaps are created and then overlapped with two
layers of sutures, and the conjoined tendon is sutured to the inguinal
ligament (again in two overlapping layers)
Darn repair - This is a pure-tissue tensionless technique that is performed
by placing a continuous suture between the conjoined tendon and the
inguinal ligament without approximating the two structures

COMPLICATIONS
Incarcerated hernia. If the omentum or a loop of
intestine becomes trapped in the weak point in the
abdominal wall, it can obstruct the bowel, leading
to severe pain, nausea, vomiting, and the inability
to have a bowel movement or pass gas.
Strangulation. An incarcerated hernia may cut off
blood flow to part of your intestine. This condition
is called strangulation, and it can lead to the death
of the affected bowel tissue. A strangulated hernia
is life-threatening and requires immediate surgery.

Post operative complications

Recurrence (most common)
Inability to urinate
Wound infection
Fluid build-up in scrotum (called hydrocele
formation)
Scrotal hematoma (bruise)
Testicular damage on the affected side (rare)

NSG DIAGNOSIS
Activity intolerance
Acute pain
Ineffective tissue perfusion: Gastro
Intestinal
Risk for infection
Risk for injury

HEALTH EDN
Tell the postoperative patient that he'll probably be able to
return to work or school and resume all normal activities
within 2 to 4 weeks.
Explain that he or she can resume normal activities 2 to 4
weeks after surgery.
Remind him to obtain his physician's permission before
returning to work or completely resuming his normal
activities.
Before discharge, Instruct him to watch for signs of
infection (oozing, tenderness, warmth, redness) at the
incision site. Tell him to keep the incision clean and
covered until the sutures are removed.

 Inform the postoperative patient that the risk of

recurrence depends on the success of the surgery, his
general health, and his lifestyle.
Teach the patient signs and symptoms of infection:
poor wound healing, wound drainage, continued
incision pain, incision swelling and redness, cough,
fever, and mucus production.
Explain the importance of completion of all antibiotics.
Explain the mechanism of action, side effects, and
dosage recommendations of all analgesics.
Caution the patient against lifting and straining.