hernia

1. CLASS PRESENTATION
ON
HERNIA
PRESENTED BY
BHAVYA SHARMA
M.Sc. Nursing First Year.

2. What is Hernia?

3. Definition:
• HERNIA- means ‘To bud’ or ‘To protrude’
• >A bulging of organ or tissue through an abnormal opening.
• >It is a condition in which part of the organ is displaced and protrudes
through the wall of the cavity containing it ( often involving the
intestine at a weak point in the abdominal wall)
• >The most important elements in the development of a hernia are
congenital or muscle weakness and increased of the intra abdominal
pressure.

4. COMPOSITION OF HERNIA
• THE SAC
• THE COVERING OF THE SAC
• THE CONTENT OF THE SAC

5. THE SAC
• Sac is formed by the lining of the abdominal cavity (peritoneum). The
sac comes through a hole or weak area in the strong layer of the belly
wall that surrounds the muscle.

6. THE COVERING
• Covering of a sac are the layers of the abdominal wall through which
the sac passes.

7. CONENT OF SAC
• Depending on the part of abdomen that is herniated eg. small
intestine, appendix, ovary with fallopian tubes, sigmoid colon and
cecum.

8. ARTERIES INVOLVED
• Superior epigastric artery(internal
thorax)
• Inferior epigastric artery(external iliac
artery)
• Deep circumflex iliac artery(pelvis)
• Superficial circumflex iliac artery
(cutaneous branches of femoral
artery)
• Superficial epigastric artery(section of
femoral artery)

10. Superficial circumflex iliac artery
Branch of Femoral Artery, Parallel With inguinal Ligament

11. VARIETIES OF HERNIA
• Reducible: This is the one in which the content of sac reduced
spontaneously or can be pushed back manually. A reducible hernia
impart an expansile impulse on coughing.

12. IRREDUCIBLE HERNIA
1. This is the one whose content cannot be returned to the cavity either
because there are
• >Adhesions between the sac and contents
• >Or because of the narrow neck of the sac.

13. CLASSIFICATION OF HERNIA (SIR HERNIA)

14. CAUSES AND RISK FACTOR
• Ultimately all hernias are caused by a combination of pressure and an
opening or weakness of muscle , the pressure pushes an organ or
tissue through the opening or weak spot.

16. Processus Vaginalis is a Blind Ending sac extending from The peritoneum
to scrotum. If not obliterate can develop hernia.

17. TYPES OF HERNIA

18. A. EXTERNAL HERNIA
(Common)
.INGUINAL(70%)
.FEMORAL
.UMBILICAL(15%)
.INCISIONAL(9%)
(RARE)
.OBTURATOR
.LUMBAR
Gluteal Hernia

19. B. INTERNAL HERNIA
1. DIAPHRAGMATIC HERNIA 2. HITAL HERNIA

20. OTHER HERNIA
SPIEGELIAN HERNIA

21. EXTERNAL HERNIA
INGUINAL CANAL
• The inguinal canals are the two passages in the anterior
abdominal wall of humans which in males convey the
spermatic cords and in females the round ligament of the
uterus. The inguinal canals are larger and more prominent in
males. There is one inguinal canal on each side of the midline.

22. EXTERNAL HERNIA
1. INGUINAL HERNIA/ GROIN HERNIA
• A condition in which soft tissue bulges through a weak point in the
abdominal muscles. The soft tissue is often part of the intestine. Its easy to
see and feel the bulge, although not all are visible by the patient, especially
when obese. The resulting bulge can be painful, especially when you cough
bend over or lift a heavy object. An inguinal hernia isn’t necessarily
dangerous.
• TYPES OF INGUNIAL HERNIA:
• >DIRECT
• >Indirect

23. a. INDIRECT INGUNIAL HERNIA
• Are related to a defect in the lower abdominal wall that is present at
birth. In developing foetus, the inguinal canal have opening inside the
abdomen that typically close before birth. In some cases one or both
openings remain open.
• Content of the abdomen may bulge through this opening, causing a
hernia. While the defect is present may not occur until many year
later.

25. • The direct inguinal hernia occurs slightly to the inside of the
site of the indirect hernia, in an area where the abdominal
wall is naturally slightly thinner.
• It not follow the path of inguinal canal. It rarely will protrude
into the scrotum. Unlike the indirect hernia, which can occur
at any age, the direct hernia tends to occur in the middle
aged and elderly because their abdominal wall weaken as
they age.
b. DIRECT INGUINAL HERNIA

27. B. FEMORAL HERNIA
• It is more common in females. It occurs when tissue pushes through a
weak spot in the muscle wall of the groin or inner thigh.
• It pushes through a weak spot in the surrounding muscle wall
(abdominal wall) into an area called the femoral canal. Common
causes include being overweight and overstanding while coughing,
exercise or passing stool

28. C. Umbilical HERNIA
• A condition in which the intestine protrudes through the abdominal
muscles at the belly button.
• This condition arises when there is weakness or incomplete closure of
the umbilical ring, through which blood vessels had passes during the
fetal life results in a portion of omentum and small intestine passing
through the ring and appearing as soft protrusion, covered with skin

29. D.INCISIONAL/ VENTRAL HERNIA
• An incisional hernia is a type of hernia caused by an incompletely
healed surgical wound.
• It is caused by postoperative wound infection, inadequate nutrition
and obesity. Since median incision in the abdomen are frequent for
abdominal exploratory surgery, ventral incisional hernias are often
also classified as ventral hernias due to their location

30. RARE TYPES OF HERNIA
• OBTURATOR HERNIA:
• OBTURATOR CANAL: IT CONNECTS THE PELVIS TO THE THIGH

31. • An obturator hernia is a rare type of hernia of the pelvic floor in
which pelvic or abdominal content protrudes through the obturator
foramen. Because of difference in anatomy, it is much more common
in women, especially multiparous and older women who have
recently lost a lot of weight.

32. LUMBER HERNIA
• A lumbar hernia is a posterolateral body wall hernia where the bowel,
omentum or pre- peritoneal fat herniates through the lumbar
triangles
•

33. GLUTEAL HERNIA
• Gluteal hernias are extremely uncommon and occurs as a result of
weakness or defect in the GLUTEAL MUSCULATURE.
• It may be due to defect in Levator Ani or arise between the Levator
Ani and Coccygeus Muscles.
• Congenital weakness or opening in the musculature of the lower back
with associated anomalous bony development specially predispose to
such hernia.
• A gluteal hernia passes through the Greater Sciatic Foramen
• If hernia Passes through Lesser Sciatic foramen Then It is Known As
SCIATIC HERNIA.

35. Clinical Picture of Gluteal Hernia

36. INTERNAL HERNIA
A. DIAPHRAGMATIC HERNIA
• It is a birth defect where there is a hole in diaphragm ( the large
muscle that separates the chest from the abdomen). Organs in the
abdomen such as intestine, stomach and liver can move through the
hole in the diaphragm and upwards into a baby’s chest.

37. B. HIATAL HERNIA
• Hiatus Hernia is one of the more common disease of gastro
intestinal old age. It is the problem of displacement of a portion of
the stomach through the opening in the diaphragm through which
the oesophagus passes from the chest to the abdominal cavity. The
oesophagus passes through an opening in the diaphragm called the
hiatus. Hiatus occurs at the oesophageal opening

38. TYPES OF HITAL HERNIA

39. COMPLICATED HERNIA: This is the most complex form of
hiatus hernia. It arise when the whole stomach moves up
into the chest. It leads to a number of symptoms and
difficulties.

40. OTHER TYPES OF HERNIA
• SPIGELIAN HERNIA
• A spigelian hernia is a hernia through the spigelian fascia or layers of
tissue that separates two group of abdominal muscles. The muscles
are called the rectus muscles and the lateral obliques. This type of
hernia is also sometimes called a lateral ventral hernia. Unlike most
hernias, spigelian hernias do not typically develop below layers of fat
but rather between muscles and the fascia- tissue that connects
them.
• It left untreated a spigelian hernia can block a portion of the bowel or
cut off the blood supply to other organs and tissue. This condition can
be life threatening.

42. RICHTER HERNIA
• also know as parietal hernias, ( alternative plural hernia) are an
abdominal hernia where only a portion of the bowel wall is herniated
and comprise 10% of strangulated hernias.
• These hernias progress more rapidly to gangrene than other
strangulated hernias but obstruction is less frequent

44. PATHOPHYSIOLOGY
 Defect or weakness in the muscular wall may be congenital, acquired weakness
or caused by trauma.
 Increased the intraabdominal pressure as a result of any risk factors that
discussed before.
 As a result of weakness of the abdominal wall and increases pressure, the
abdominal content can protrude causing herniation.
 When the content of hernial sac can be replaced into the abdominal cavity by
manipulation the hernia is said to be reducible
 When the pressure from the hernial ring cuts off the blood supply to the
herniated segment of the bowel, it becomes strangulated

45.  Irreducible and incarcerated hernia refers to hernias that cannot be
replaced by manipulation.
 When the pressure from the hernial ring cuts off the blood supply to
the herniated segment of the bowel, it becomes strangulated
 Formation of Hernia

46. CLINICAL MANIFESTATIONS OF HERNIA

47. 1. Bulging and painless swelling at first.
2. Pain: Pain may be:
• Localized Pain: Pain may occur as a result of irritation of damage to area or nerves as a
result of the hernia and its contents pushing into or pinching the nerves.
• Generalized Pain: If the contents of the hernia become trapped or incarcerated, the
intestines blood supply may become compromised or shut off
• REFERRED PAIN: If the hernia irritated, inflames, the pain felt from the hernia may not
be the site of the hernia, but rather at the area to which these nerves are travelling.
• For example: Pain from an inguinal hernia may be felt as discomfort in the back upper
leg and/ or hip area.

48. • Nausea and vomiting: When intestine becomes trapped within the
hernia, the normal flow of food through the intestine become
blocked. This creates a progressive back up within the intestine and
may result in nausea and vomiting.

49. • CONSTIPATION: If the intestine is blocked within the hernia, and
normal flow of food content and feces is blocked the patient may
develop constipation.
• URINARY SYMPTOMS: If the bladder becomes irritated within a
hernia (usually an inguinal hernia). Urinary symptoms such as
frequency, urinary burning, frequent infections, and bladder stones
may all occur.

50.  Pain when lifting heavy object.
 Heart burn occur 30 to 60 minutes after meals.
 Difficulty in swallowing
 Fatigue
 Felling of fullness after eating
 Difficulty of breathing

51.  Chest pain
 Tenderness
 Inability to move your bowels or pass gas
 Hernia bulge that turn red, purple or dark.
 Complete leg pain In case of Gluteal hernia

52. DIAGNOSTIC EVALUATION

53. HEALTH HISTORY
1. Age: Direct hernia typically occur in old age. However at any age indirect
hernias are commoner than direct.
2. Occupation:
3. Duration: Hernia present since childhood are almost always indirect.
4. Onset: Occasionally a hernia may develop suddenly after straining eg.
Lifting heavy weights.

54. Progression: Is it getting larger? Is there sudden increase in size?
Groin hernias typically increase in size slowly. Unexpectedly rapid
growth indicates some other condition for example is there a lymph
node with a metastatic deposit.
Pain: In the beginning hernias are painless. Some patients complain
of dragging aching pain. Strangulated hernias are vey painful and
tender.

55. Systemic symptoms: Frequently straining due to prolonged cough,
constipation, prolonged urinary obstruction are contributory factors
to development of a hernia. Therefore ask about colicky abdominal
pain, vomiting, distension etc.
Past history: Any past surgical history or abdominal cavity.

56. PHYSICAL EXAMINATION
• 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 position

57.  Chest Xray
 Upright/ Standing chest xray film
 USG Abdomen and pelvis
 Blood test
 MRI
 CT Scan
 Barium Swallow X ray. ( diatrizoate meglumine and diatrizoate sodium, Gastrografin)
 Endoscopy

58. ZIEMANS’ TEST/ 3 FINGURE TEST:
• The examiner places his index finger on the deep inguinal ring, middle
finger on the superficial inguinal ring, ring figure over saphenous
opening. The patient is asked to cough or to hold the nose and blow.
• It the impulse is felt at index figure- indirect hernia, middle finger-
direct hernia, ring figure- femoral hernia.

59. Leg Rising Test
•

60. COUGH IMPLUSE
• Ask the patient to stand properly. Then advise him to cough. Once the
patient coughed up the visible and palpable cough impulse may be
visible

61. MANAGEMENT FOR HERNIA

62. GOAL OF MANAGEMENT
 To relieve symptoms
 To reduce the underlying cause.
 To improve the health status of the individual.
 To achieve the Hernia free status of the client.
 To improve the patients functional status and quality of life.

63. Management
• Medical pharmacology treatment
Antibiotic (used if patient have strangulated hernia)
 IV cefoxitin (mefoxin) 1g 6-8 hourly
Cap. Ampicilin 250-500 mg 6 hourly
• H2 receptor blocker
• Suppress the action of Histamine.
(used if the patient with hiatal hernia)
1. tab. Famotidine 40mg daily
2. tab. Rantidine 150mg BD

64. PPI(HIATAL HERNIA)
1 Tab. Iansoprazole (prevacid) 15-30mg dly
2 Cap. Osomeprazole (nexium) 20-40mg dly
3 Cap. Omeprazole (prilosec) 20-40mg dly
4 Tab. Pantaprozole (contoloc) 20-40mg dly
Antianxiety Agents
(indicated for patient who may experience significant anxiety before a
surgery)
1. Tab. Dormicum 7.5-15 mg PRN

65. • NSAIDS:
• ( Block the action of Cyclooxygenase enzyme)
• Example: Asprin, Diclofenac, Ibuprofen.

66. NON PHARMACOLOGICAL MANAGEMENT

67. NON PHARMACOLOGICAL MANAGEMENT

68. SURGICAL MANAGEMENT

69. A. HERNIA REPAIR SURGERY
• Hernia repair is a surgical procedure to return to an organ that
protrudes through a weak area of muscle to its original position.
• There are two types of hernia repair.
A herniorrhaphy (surgical repair of Hernia) is used for simpler
hernias. The intestine are returned to their proper place and the
defect in the abdominal wall is mended.
 A Hernioplasty is used for larger Hernias. In this procedure, plastic or
steel mesh ( Decron) is added to the abdominal wall to repair and
reinforce the weak spot

70. 1. Femoral Hernia Repair:
• This procedure repairs a hernia that occur in the groin where the
thigh meets the abdomen
• An incision is made in the groin area. The tissues are separated from
the Hernia sac, the intestine are returned to the abdomen.
• The area is often reinforced with webbing before it is sewn shut.
• The skin is closed with sutures or metal clips that can be removed in
about one week

71. Inguinal hernia Repair:
• Inguinal hernia repair closes a weakness in the abdominal wall that in
near the inguinal canal.
• An incision is made in the abdomen and then the hernia is located
and repaired.
• The surgeon must be alert not to injure the spermatic cord
• If the hernia is small, it is simply repaired.
• If is large the area is reinforced with mesh to prevent a recurrence.

72. Umbilical Hernia Repair
• An incision is made near the navel
• Hernia is located and the intestines are returned to the abdomen
• The peritoneum is closed and then the large abdominal muscle is
pulled over the weak spot in such a way as to reinforce the area.
• External sutures or skin clips can be removed in about 10 days.

73. HIATAL HERNIA REPAIR/ Nissen Fundoplication
• An incision is made in the abdomen or chest
• The hole or weakness in the diaphragm is located and repaired.
• The top of the stomach is wrapped around the bottom of the
esophagus and they are sutured together to hold the stomach in
place.
• Sometimes the vagus nerve is cut in order to decrease the amount of
acid the stomach produces

74. LAPAROSCOPY
• is a type of surgical procedure that allows a surgeon to access the
inside of the abdomen (tummy) and pelvis without having to make
large incisions in the skin. This procedure is also known as keyhole
surgery or minimally invasive surgery

75. Transabdominal Preperitoneal Repair
• A most common laparoscopic techniques for inguinal hernia repair. In
Transabdominal preperitoneal repair the surgeon goes into the
peritoneal cavity and place a mesh through a peritoneal cavity and
places a mesh through peritoneal incision over possible hernia sites

76. TENSION FREE MESH HERNIA REPAIR
• This can be performed as open or laparoscopic manner and
employs a surgical mesh to cover the defect or hole in the
abdomen
• The mesh is places over the defect essentially creating barrier
• Benefit: The synthetic mesh creates a very strong wall over the
hernia defect.
• As the body’s inflammatory response kicks in, tissue begins to
grown in and around the mesh

77. NON SURGICAL MANAGEMENT:
• TRUSS / HERNIA BELT
• A pad made with firm material that will held in place over the hernia
with belt to help keep the abdominal contents from protruding into
the hernia sac.

78. COMPLICATION
• Post herniorrhaphy pain syndrome.
• Hernia recurrence
• Wound infection
• Ischemia
• Necrosis

81. NURSING ASSESSMENT:
• Age of the patient
• Duration of hernia
• Obesity more risk
• Pain at the hernia place.
• Ask about the previous history
of surgical post operative
complication
• Smoking
• Bowel movement
• Chronic cough
• Family History of hernia.

82. Physical Examination:
 Palpate the bulge area.
 Check for the skin fragile
 Type of hernia

83. NURSING DIAGNOSIS
• PRE-OPERATIVE FOR HERNIA REPAIR
- Fear & anxiety related to undergoing surgery
• POST OPERATIVE FOR HERNIA REPAIR
- Acute pain related to surgical intervention
- Risk of infection related to surgical site
(HIATAL HERNIA)
- Risk for aspiration related to reflux of gastric content

84. NURSING DIAGNOSES- Risk for aspiration related to reflux of
gastric content (HIATAL HERNIA)
• GOAL- Client be able to fully understand and implement ways to prevent
regurgitation and aspiration
1 )Assess patient usual ways after meal to know and possibly correct
improper way that leads to regurgitation
2) Monitor client’s weight under standard condition to know and plan for
necessary weight reduction regime
3) Assess patient routine meal timing and amount to make necessary
adjustment.
4) Teach patient deep breath exercise when feeling nauseated to help
relax the muscle on tension during forceful backing of gastric materials

85. 5) Encourage patient to take high protein and low fat diet to minimize the
episodes of heartburn.eg fish, steam chicken.
6) If patient dependent, assist patient in elevate head of bed during meals
and 30 min to an hour after meal to facilitate movement of food&
prevent possibilities of backflow.
7) Advice patient to take small but frequent meals to facilitate complete
gastric empty.
8) Advice patient to take warm water or soup during meals to promote
flushing of digested material down the alimentary canal
9) Encourage patient to avoid taking meals 2hourbefore sleep. This is to
prevent backflow of the stomach content to the trachea.

86. 10) Encourage to reduce weight to minimize abdominal pressure from
exercise fats.
11) Encourage patient not to wear tight clothes & pants to minimize
abdominal pressure.
12) Administer antacid as ordered by doctor to minimize heartburn, gastric
hyperacidity,& reduce regurgitation. Eg gaviscon 10mls tds.
Evaluation: Client able to understand the ways to prevent regurgitation
and aspiration.

88.  Educate patient to assess for any signs and symptoms of infection such as
redness, severe itchiness and condition at the surgical site
 advise patient come for follow-up to monitor patient progress/condition.
 educate patient to avoid wearing tight clothing to minimize abdominal
pressure
Encourage patient avoid lifting heavy object or doing heavy exercise at
least 6 weeks
 use proper lifting technique
Lose weight
Exercise regularly
 Encourage patient to take high fiber food to prevent constipation.

89. Research Article
• A study on retrospective analysis of inguinal hernia repair by various
methods in a teaching Institute.
• Department of Surgery, GEMS Hospital AP,India,2016
• Aim of the study was to compare the methods of inguinal hernia
repair. This study is to evaluate the all different methods of hernia
repair by observing operative technique, operating time, post
operative pain and complication, long term pain and recurrence.

90. • Sample taken: 160 cases of uncomplicated inguinal hernia with age group 48 year
and above.
• Techniques used:
• > Tissue repair mesh hernioplasty
• >Tension free repair
• > Laparoscopic hernia repair.
• Conclusion: Tension free mesh inguinal hernia repair is a simple , safe, easy to
learn, effective method with low recurrence rate.

91. summary
• It is a protusion of a viscous through an abnormal opening or weakened
area in the wall of the cavity in which normally contained
• Hernia classified by 3 stage
• Reducible,
• Irreducible,
• Strangulated
• Types
• Hiatal
• umbilical
• Inguinal

92. • Femoral
• Incision
• Richert’s hernia
• Spigelian
• Gluteal
• Obturator
• lumbar

94. REFERENCE
 Basavanthappa BT, Textbook of Medical Surgical Nursing, Edition 2, Page
Number 464- 465
 Hinkle JancieL, Cheever Kerry H. Brunner and Suddarth’s ,Textbook of Medical
Surgical Nursing ,Volume-2
 Lippincott Manual”A text book of Medical Surgical nursing” 10th edition,
published by Wolters Kluwer
 Pee Vee A text book of Medical Surgical Nursing 5th edition, Page Number -474-
478
 Sharma Rimple, Essentials of Pediatric Nursing, 2nd Edition, page Number 299-
304
(PDF) Imaging in Gluteal Hernia (researchgate.net)