Hernias

Question 1

What is a Hernia?

Answer 1

A small sac containing tissue protrudes through an opening in the muscles of the abdominal wall. Also known as a musculofascial defect.

Question 2

What is the technical term for hernia repair?

Answer 2

Herniorrhaphy

Question 3

Where are the weakest places, in relation to hernias?

Answer 3

Inguinal Canals, femoral ring, umbilicus

Question 4

What is the most common type of hernia seen in men? Women?

Answer 4

50% Indirect (male), 3% Femoral (female)

Question 5

Define reducible/nonreducible hernias.

Answer 5

Reducible means contents can be returned to the normal intra-abdominal position

Question 6

Define acquired/congenital hernias.

Answer 6

Acquired hernia - usually a result of consistent heavy lifting
Congenital hernia- Usually seen in children

Question 7

What types of anesthesia is used for hernia repairs?

Answer 7

General Anesthesia (GA) - for patients who are generally healthy
Note: If patient is medically compromised, patient may have a spinal anesthesia

Question 8

What form of medication is used for post-op pain ?

Answer 8

Illio-inguinal nerve block

Local anesthesia to minimize pain

Question 9

What is included in the preoperative assessment?

Answer 9

• 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?

Question 10

Name the 3 sites of hernias in the abdominal wall.

Answer 10

Inguinal canals, Femoral ring, Umbilicus

Question 11

What layer makes up the floor of the inguinal canal? What is this important to know in order to understand inguinal hernia repair?

Answer 11

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.

Question 12

What is the difference between Direct and Indirect inguinal hernias?

Answer 12

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)

Question 13

What type of hernia is easily dissected and occur due to heavy lifting and strenuous activity?

Answer 13

Direct inguinal hernia

Question 14

Define umbilical hernia. Where are these most commonly seen?

Answer 14

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.

Question 15

Define femoral hernia.

Answer 15

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.

Question 16

Why is the mesh avoided in femoral hernia repair?

Answer 16

Due to taking it in place and the proximity to the femoral nerves.

Question 17

Define an epigastric - spontaneous hernia.

What are the symptoms?

Answer 17

Protrusion of fat through abdominal wall defects between xiphoid and umbilicus

Symptoms:

• nausea
• vague abdominal pain
• epigastric pain

Question 18

Define incarcerated hernias.

Answer 18

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.

Question 19

What are the signs of an incarcerated hernia?

Answer 19

• Intestinal obstruction
• vomiting
• abdominal distention

Question 20

What is an immediate danger of an incarcerated hernia?

Answer 20

Strangulation

Question 21

Define non-reducible/ irreducible versus reducible hernias.

Answer 21

Reducible - contents can be returned to normal intra-abdominal position
Non-reducible/ irreducible - contents trapped in the extra-abdominal sac

Question 22

Discuss the advantages for laparoscopic hernia repair.

Answer 22

Can be done for inguinal and abdominal hernia’s using mesh

• Newer technology
• Less pain
• Smaller incisions
• Rapid return to work
• Fewer reoccurences

Question 23

Discuss the disadvantages for laparoscopic hernia repair.

Answer 23

• Initially very expensive
• Need for general anesthesia
• Lack of long term follow up data
• Technical skill ?

Question 24

Nursing Considerations: What instruments/ materials are needed for a herniorrhaphy procedure?

Answer 24

• 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

Question 25

If peritoneum is not entered, what type of count would you complete coming out?

Answer 25

Minor count (coming out)

Question 26

What type of count would you complete going in?

Answer 26

FULL count including sponges, needles, blades, instruments as initial count.

Question 27

What type of suture does the surgeon use to repair a small; to medium sized inguinal hernia?

Answer 27

0 Prolene/ Surgipro - a fairly heavy permanent suture.

Question 28

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?

Answer 28

Absorbable sutures

Question 29

What type of sutures does the surgeon use for mesh plugs?

Answer 29

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.

Question 30

What type of sutures are used to re-approximated the external oblique fascia over the structures?

Answer 30

Running non-absorbable sutures

Question 31

What is another name for incisional hernias?

Answer 31

Ventral hernia

Question 32

What are the etiologies for incisional hernias?

Answer 32

• Obesity
• Prior operations that were contaminated in nature
• Prior wound infection

Question 33

How does the surgeon repair the incisional hernia?

Answer 33

The surgeon does a tight layer by layer closure of the peritoneum, fascia, subcutaneous later, and skin, depending on which later was defective.

Question 34

What do you do if the missing section is too large to be sutured in an incisional hernia repair?

Answer 34

Surgeons will use synthetic mesh.

Question 35

Define the important structure: Inguinal canal

Answer 35

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

Question 36

Define the important structure: Cooper’s ligament

Answer 36

Strong, fibrous band located on the iliopectineal line of superior pubic ramis (this ligament is sometimes used in inguinal repairs.

Question 37

Define the important structure: External inguinal ring

Answer 37

Opening in the external oblique; the ring contains the ilioinguinal nerve (superficial)

Question 38

Define the important structure: Internal ring

Answer 38

Bordered superiorly by internal oblique muscle and inferior medially by the inferior epigastric vessels