CARE OF PATIENT WITH ABDOMINAL HERNIA

 Descriptive Definition of Abdominal Hernia

·         A hernia is a pouch of lining membrane protruding itself through a weak point in the covering structures

·         The most common site of a hernia is the abdominal wall.

Sites of hernia

·         The weak points in the musculature of the abdomen are the canals through which certain structures normally run so  the hernias are named according to the particular sites as follows:

• Inguinal
• Femoral
• Umbilical (paraumbilical in adults)
• Epigastric
• Incisional through a scar (known as ventral if arising on the anterior abdominal wall)
• Obturator
• Hiatus
• Diaphragmatic

Pathophysiology of Abdominal Hernias

Pathophysiology

·         A hernia develops when intra-abdominal pressure increases such as with straining to lift something heavy, while having a bowel movement, or during forceful coughing or sneezing and a segment of intestine moves into a weak area of abdominal muscle.

·         There are areas that are naturally weak but the abdominal wall may be thin or stretched due to an inadequate amount of collagen, a condition that may be present at birth or that develops as a result of aging, abdominal surgery and obesity.

·         At first the defect is small but if the hernia persists the defect grows larger. 

·         Eventually the bowel may become trapped within the weakened pouch.

·         If the blood supply to the bowel is compromised it may become gangrenous

Signs and Symptoms of Abdominal Hernia

Symptoms and signs of uncomplicated hernia

·         They are noticed after coughing or standing

·         A swelling with a slight dragging ache is the commonest complaint

·         The skin over a large hernia may be in folds which tend to become eczematous as a result of friction

·         On examination there is an abnormal swelling with an expansile impulse on coughing

·         The swelling disappears or can be reduced on lying down

Symptoms and signs in complicated hernia

·         Irreducibility of the contents occurs in long standing hernias

·         Strangulation;  the blood supply to the contents of the hernia usually a loop of bowel or piece of omentum is cut off and in addition to the local symptoms and signs of obstruction may be present

·         There is no impulse on coughing and the hernia is irreducible and tender

·         If it is not relieved the strangulated loop of bowel become gangrenous

·         Progression that is increase in size is usual

·         Intertrigo of the skin that is abrasion due to two folds of skin rubbing together

Management of a Patient with Abdominal Hernia

Treatment

·         Operative repair is the treatment of choice

• The sac is excised after the contents have been reduced to the abdomen
• Weakness is repaired by suture muscles or by introduction of special suture material if the muscles are weak.
• The patient is kept in bed for only one day but in large recurrent hernias 3-4 days in bed are advisable
• Advise against heavy lifting for 3 months

Definitions of terms used in hernia operations

·         Herniotomy means opening of the sac

·         Herniorrhaphy refers to the repair of the defect in the musculature

·         Hernioplasty is a Herniorrhaphy in which extra material such as monofilament nylon or implants of Teflon are introduced for wide deficiencies

·         The following conditions if present must be treated before operation:

• Enlargement of the prostate
• A urethral stricture
• Constipation
• A persistent cough

Conditions when a patient is temporary unfit for operation are:

·         In an infant the operation is undertaken at 3 months or even earlier

·         During pregnancy provided the hernia is reducible operation is best deferred until after parturition

·         After a severe illness such as pneumonia

·         Chronic bronchitis with an acute exacerbation

Conditions where patient is unfit for operation

·         Severe cardiac or pulmonary disease

·         Extreme age

·         In all these conditions a truss is advisable

·         No truss for femoral hernia

·         In babies an umbilical hernia is reduced by supporting with strapping

Special advice to a patient wearing a truss

·         Careful washing and powdering of the skin

·         The pad must be maintained in good repair

·         Renew the spring before it becomes too weak

·         Wear the truss while in bed after reduction of the hernia

The care of the patient for a hernia operation

Preoperative care

·         Careful shaving of the suprapubic area and cleaning of the skin are essential

·         Avoid even slight cuts-which may give rise to infection

·         The rest of the care is as for any abdominal operation

Post operative care

·         Abdominal exercise should be commenced on the day following operation

·         Relieve any retention of urine

·         Avoid abdominal distension by passing a flatus tube

·         The rest of care is as for any abdominal operation

·         If the patient is very fat advise to reduce his weight before the operation

·         In case a patient has two large hernias they should be operated one at a time to avoid cardio-respiratory embarrassment

Complications after Operation of a Patient with Hernia

·         Recurrence in inguinal hernia is in the order of 5-10% and main causes are:

• Faulty technique (failure to remove the sac)
• Infection
• Straining
• Coughing
• Heavy lifting

·         Scrotal swelling-apply a scrotal suspensory support

·         Pain –give analgesic before ambulation