What is a Hernia?
A small sac containing tissue protrudes through an opening in the muscles of the abdominal wall. Also known as a musculofascial defect.
What is the technical term for hernia repair?
Where are the weakest places, in relation to hernias?
Inguinal Canals, femoral ring, umbilicus
What is the most common type of hernia seen in men? Women?
50% Indirect (male), 3% Femoral (female)
Define reducible/nonreducible hernias.
Reducible means contents can be returned to the normal intra-abdominal position
Define acquired/congenital hernias.
Acquired hernia - usually a result of consistent heavy lifting
Congenital hernia- Usually seen in children
What types of anesthesia is used for hernia repairs?
General Anesthesia (GA) - for patients who are generally healthy Note: If patient is medically compromised, patient may have a spinal anesthesia
What form of medication is used for post-op pain ?
Illio-inguinal nerve block
Local anesthesia to minimize pain
What is included in the preoperative assessment?
- Identify type and location of hernia (left/right)
- TIME OUT procedure - identify the side and MARK the site
- What kind of mesh will the surgeon require
- Does the patient require shaving in the operative site?
Name the 3 sites of hernias in the abdominal wall.
Inguinal canals, Femoral ring, Umbilicus
What layer makes up the floor of the inguinal canal? What is this important to know in order to understand inguinal hernia repair?
The transversalis fascia is the structure that makes up the floor of the inguinal canal. This is closest to the peritoneum - thus any hole in the transveralis fascia in the inguinal area is going to result in an inguinal hernia.
What is the difference between Direct and Indirect inguinal hernias?
Direct - Defect in transveralis fascia, Medial to the deep epigastric blood vessels/ within Hesselbach’s triangle
Indirect - Occurs laterally to the epigastric vessels (defects in the groin through the deep inguinal ring and inguinal canal)
What type of hernia is easily dissected and occur due to heavy lifting and strenuous activity?
Direct inguinal hernia
Define umbilical hernia. Where are these most commonly seen?
Extraperitoneal hernias are small fascial defects UNDER the umbilicus. These are commonly seen in children (may spontaneously disappear by two years of age) and in obese people. They require surgical repairs as they are at high risk for incarceration.
Define femoral hernia.
Defect in the transveralis fascia, but inferior to the inguinal ligament causing an increase of the size of the femoral ring. A bulge is usually present in the upper part of the thigh.
Why is the mesh avoided in femoral hernia repair?
Due to taking it in place and the proximity to the femoral nerves.
Define an epigastric - spontaneous hernia.
What are the symptoms?
Protrusion of fat through abdominal wall defects between xiphoid and umbilicus
- vague abdominal pain
- epigastric pain
Define incarcerated hernias.
Intestine becomes trapped by the abdominal wall. This can be an emergency surgery. It may be a result from adhesions among the contents of the sac.
What are the signs of an incarcerated hernia?
- Intestinal obstruction
- abdominal distention
What is an immediate danger of an incarcerated hernia?
Define non-reducible/ irreducible versus reducible hernias.
Reducible - contents can be returned to normal intra-abdominal position
Non-reducible/ irreducible - contents trapped in the extra-abdominal sac
Discuss the advantages for laparoscopic hernia repair.
Can be done for inguinal and abdominal hernia’s using mesh
- Newer technology
- Less pain
- Smaller incisions
- Rapid return to work
- Fewer reoccurences
Discuss the disadvantages for laparoscopic hernia repair.
- Initially very expensive
- Need for general anesthesia
- Lack of long term follow up data
- Technical skill ?
Nursing Considerations: What instruments/ materials are needed for a herniorrhaphy procedure?
- Minor set
- Something to isolate spermatic cord (Hernia tapes, penrose drain, umbilical tapes)
- Pushers/ Peanuts, sponge on sticks to peel the “sac”
- Electrosurgical unit (ESU)
- Draping body
- 4 square drapes
- Laparotomy sheet
- top of drape clipped to IV pole by anesthetist
- Arms tucked or out on arm boards
If peritoneum is not entered, what type of count would you complete coming out?
Minor count (coming out)
What type of count would you complete going in?
FULL count including sponges, needles, blades, instruments as initial count.
What type of suture does the surgeon use to repair a small; to medium sized inguinal hernia?
0 Prolene/ Surgipro - a fairly heavy permanent suture.
If the defect in the inguinal floor is too large to be repaired by suturing, the surgeon may elect for a permanent mesh or mesh plug instead. What type of suture secures the permanent mesh?
What type of sutures does the surgeon use for mesh plugs?
The surgeon put a few non-absorbable sutures in to tack the plug there with or without its overlay piece. (For example, 2-0 Prolene). The overlay piece of mesh is sutured to itself.
What type of sutures are used to re-approximated the external oblique fascia over the structures?
Running non-absorbable sutures
What is another name for incisional hernias?
What are the etiologies for incisional hernias?
- Prior operations that were contaminated in nature
- Prior wound infection
How does the surgeon repair the incisional hernia?
The surgeon does a tight layer by layer closure of the peritoneum, fascia, subcutaneous later, and skin, depending on which later was defective.
What do you do if the missing section is too large to be sutured in an incisional hernia repair?
Surgeons will use synthetic mesh.
Define the important structure: Inguinal canal
The inguinal canal contains the spermatic cord in males and the round ligament in women, is about 4 cm and runs obliquely parallel and slightly above the groin crease
Define the important structure: Cooper’s ligament
Strong, fibrous band located on the iliopectineal line of superior pubic ramis (this ligament is sometimes used in inguinal repairs.
Define the important structure: External inguinal ring
Opening in the external oblique; the ring contains the ilioinguinal nerve (superficial)
Define the important structure: Internal ring
Bordered superiorly by internal oblique muscle and inferior medially by the inferior epigastric vessels