inguinal hernia(redirected from Direct inguinal hernia)
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Related to Direct inguinal hernia: femoral hernia
A sac formed from the peritoneum and containing a portion of the intestine or omentum, or both, pushes either directly outward through the weakest point in the abdominal wall (direct hernia) or downward at an angle into the inguinal canal (indirect hernia). Indirect inguinal hernia (the common form) occurs more often in males because it follows the tract that develops when the testes descend into the scrotum before birth, and the hernia itself may descend into the scrotum. In the female, the hernia follows the course of the round ligament of the uterus.
Inguinal hernia begins usually as a small breakthrough. It may be hardly noticeable, appearing as a soft lump under the skin, no larger than a marble, and there may be little pain. As time passes, the pressure of the contents of the abdomen against the weak abdominal wall may increase the size of the opening and, accordingly, the size of the lump formed by the hernia. In the early stages, an inguinal hernia is usually reducible—it can be pushed gently back into its normal place. Inguinal hernia usually requires herniorrhaphy.
inguinal herniaSurgery The prolapse of a loop of intestine into a patent inguinal canal
in·gui·nal her·ni·a(ing'gwi-năl hĕr'nē-ă)
inguinal herniaA HERNIA in which, under the influence of intra-abdominal pressure, a sac of PERITONEUM is forced down the inguinal canal, followed by a loop of bowel. In men the inguinal hernia descends alongside the spermatic cord into the scrotum which, in time, may become greatly enlarged by the bulk of its abnormal contents.
|Mean LOS:||4.4 days|
|Description:||MEDICAL: Other Digestive System Diagnoses With CC|
|Mean LOS:||2.4 days|
|Description:||SURGICAL: Inguinal and Femoral Hernia Procedures Without CC or Major CC|
A hernia is a protrusion or projection of an organ or organ part through the wall of the cavity that normally contains it. An inguinal hernia occurs when either the omentum, the large or small intestine, or the bladder protrudes into the inguinal canal. In an indirect inguinal hernia, the sac protrudes through the internal inguinal ring into the inguinal canal and, in males, may descend into the scrotum. In a direct inguinal hernia, the hernial sac projects through a weakness in the abdominal wall in the area of the rectus abdominal muscle and inguinal ligament.
Inguinal hernias make up approximately 80% of all hernias. Repair of this defect is the most frequently performed procedure by both pediatric and adult surgeons. Hernias are classified into three types: reducible, which can be easily manipulated back into place manually; irreducible or incarcerated, which cannot usually be reduced manually because adhesions form in the hernial sac; and strangulated, in which part of the herniated intestine becomes twisted or edematous, possibly resulting in intestinal obstruction and necrosis.
An inguinal hernia is the result of either a congenital weakening of the abdominal wall (when the processus vaginalis fails to atrophy and close) or weakened abdominal muscles because of pregnancy, excess weight, or previous abdominal surgeries. In addition, if intra-abdominal pressure builds up, such as related to heavy lifting or straining to defecate, a hernia may occur. Other causes include aging and trauma.
There may be a genetic contribution to inguinal hernia development and reoccurrence. While patterns of transmission are unclear, autosomal dominant inheritance with incomplete penetrance and sex influence has been suggested.
Gender, ethnic/racial, and life span considerations
A hernia may be detected in both children and adults. Low-birth-weight infants and male infants are at higher risk (8:1) for this defect than female infants or full-term infants. Indirect hernias can develop at any age and are 25 times more common in males than in females. Nearly 90% of all inguinal hernia repairs are performed on males. Approximately 2% of females have an inguinal hernia in their lifetime. No differences in prevalence are noted for various racial and ethnic groups.
Global health considerations
While little is known about the prevalence of inguinal hernias in developing countries, most experts suspect that factors related to anatomy and gender are similar in developing and developed regions of the world.
An infant or a child may be relatively symptom free until she or he cries, coughs, or strains to defecate, at which time the parents note painless swelling in the inguinal area. The adult patient may complain of pain or note bruising in the area after a period of exercise. More commonly, the patient complains of a slight bulge along the inguinal area, which is especially apparent when the patient coughs or strains. The swelling may subside on its own when the patient assumes a recumbent position or if slight manual pressure is applied externally to the area. Some patients describe a steady, aching pain that worsens with tension and improves with hernia reduction.
On inspection, the patient has a visible swelling or bulge when asked to cough or bear down. Another common symptom is achiness radiating into the area of the hernia but no pain or tenderness. If the hernia disappears when the patient lies down, the hernia is usually reducible. In addition, have the patient perform a Valsalva’s maneuver to inspect the hernia’s size. Before palpation, auscultate the patient’s bowel; absent bowel sounds suggest incarceration or strangulation.
You may be able to palpate a slight bulge or mass during this time and when the examiner slides the little finger 4 to 5 cm into the external canal located at the base of the scrotum. If you feel pressure against your fingertip when you have the patient cough, an indirect hernia may exist; if you feel pressure against the side of your finger, a direct hernia may exist. Palpate the scrotum to determine if either a hydrocele or cryptorchidism (undescended testes) is present. Signs of an incarcerated (irreducible hernia that cannot be returned to the abdominal cavity when pushed) hernia include painful engorgement, nausea, vomiting, and abdominal distention.
A delay in seeking health care may result in strangulation of the intestines and require emergency surgery. In the adult population, surgical intervention to correct the defect takes the patient away from home and the work setting and causes anxiety.
General Comments: No specific laboratory tests are useful for the diagnosis of an inguinal hernia. Diagnosis is made on the basis of a physical examination. On rare occasions, computed tomography or ultrasound may be used in diagnosis depending on the patient’s body build.
Primary nursing diagnosis
DiagnosisPain related to swelling and pressure
OutcomesPain: Disruptive effects; Pain level
InterventionsAnalgesic administration; Pain management
Planning and implementation
If the patient has a reducible hernia, the protrusion may be moved back into place and a truss for temporary relief can be applied. A truss is a thick pad with an attached belt that is placed over the hernia to keep it in place. Although a truss is palliative rather than curative, it can be used successfully in elderly or debilitated adult patients who are poor surgical risks or who do not desire surgery.
Collaboration with the surgical team is necessary to prepare the patient and family for surgery. If the hernia is incarcerated, manual reduction may be attempted by putting the patient in Trendelenburg’s position with ice applied to the affected side. Manual pressure is applied to reduce the hernia. Surgery then may occur within 24 to 48 hours. The surgeon replaces hernial contents into the abdominal cavity and seals the opening in a herniorrhaphy procedure. In a hernioplasty, the surgeon reinforces the weakened area with mesh or fascia.
Intravenous fluids are administered to prevent dehydration, especially for the newborn who is prone to fluid shifts. The patient should be able to tolerate small oral feedings before discharge and should be able to urinate spontaneously. Postoperatively, inspect for signs and symptoms of possible peritonitis, manage nasogastric suction, and monitor the patient for the return of bowel sounds. As with any postoperative patient, monitor the patient for respiratory complications such as atelectasis or pneumonia; encourage the patient to use an incentive spirometer or assist the patient to turn, cough, and deep breathe every 2 hours.
|Medication or Drug Class||Dosage||Description||Rationale|
|Antibiotics||Varies with drug||Broad-spectrum||Prevent infection postoperatively|
|Analgesics||Varies with drug||NSAIDs; narcotics||Relieve discomfort caused by hernial pressure or postoperatively|
The nurse explains 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.
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.
Evidence-Based Practice and Health Policy
Zhu, S., Zhang, H., Xie, L., Chen, J., & Niu, Y. (2013). Risk factors and prevention of inguinal hernia after radical prostatectomy: A systematic review and meta-analysis. The Journal of Urology, 189(3), 884–890.
- Development of an inguinal hernia is a significant postsurgical risk following abdominal and genitourinary operations.
- A meta-analysis of 24 trials, which included 12,049 patients treated for prostate cancer, revealed an incidence of postsurgical inguinal hernia development that ranged from 4.4% to 50%.
- Inguinal hernia development was significantly higher in patients who underwent radical retropubic prostatectomy (15.9%; 95% CI, 13.1 to 18.7) compared to patients who underwent laparoscopic radical prostatectomy (6.7%; 95% CI, 4.8 to 8.6) (p < 0.001), and most occurred within the first 2 years following surgery.
- Physical responses: Description of the hernia or incisional site, vital signs, gastrointestinal functioning, breath sounds
- Response to pain management; location, type, and duration of pain
Discharge and home healthcare guidelines
Teach the patient signs and symptoms of infection: poor wound healing, wound drainage, continued incisional pain, incisional 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. Explain that he or she can resume normal activities 2 to 4 weeks after surgery.