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INGUINAL HERNIA and Umbilical hernia
nursing management on inguinal and umbilical hernia, and also its signs and s...
From Kath
HERNIASGeneral features common to all herniasDefinition
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Abnormal protrusion of intra-abdominal tissue (aviscus or part of a viscus) through a fascial defect(abnormal opening) in the abdominal wall.
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The external abdominal hernia is the commonest form, themost frequent varieties being the inguinal, femoral andumbilical, respectively, 75, 8.5 and 15 per cent.
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The rarer forms comprise 1.5 per cent, excluding incisionalhernias.
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Most often, a hernial mass consists of covering tissues(skin, subcutaneous tissues, etc.), a peritoneal sac, andany contained viscera.
→
Groin hernias
(indirect inguinal, direct inguinal, femoral)are the most common (about 75% of cases), followed by
incisional
and
ventral hernias
(10%),
umbilical
(3%),and
others
(3%).
→
Reducible hernia
is one where the contents of the sacmay spontaneously or with pressure return to theabdomen.
→
Irreducible (incarcerated) hernia
is one whose contentscannot be returned to the abdomen.
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A strangulated hernia is one where there is compromise tothe blood supply of the contents of the sac leading toischemia and gangrene.
→
Hiatus hernia:
protrusion of the stomach above thediaphragm.
Aetiology
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Any condition which raises intra-abdominal pressure, suchas a powerful muscular effort, may produce a hernia.
→
Whooping cough
is a predisposing cause in childhood,whilst a
chronic cough, straining on micturition or straining on defecation may precipitate a hernia in anadult
.
→
Hernias are more common amongst
smokers
, which maybe the result of an
acquired collagen deficiency
increasing an individual’s susceptibility to the developmentof hernias.
→
It should be remembered that the appearance of a herniain an adult can be a
sign of intra-abdominalmalignancy.
→
Stretching of the abdominal musculature because of an increase in contents,
as in
obesity
, can be another factor.
→
Fat acts to separate muscle bundles and layers,weakens aponeurosis and favours the appearance of paraumbilical, direct inguinal and hiatus hernias.
→
A
femoral hernia
is rare in nulliparous women and men,but more common in
multiparous
women owing tostretching of the pelvic ligaments.
→
An indirect hernia may occur in a congenital preformedsac — the remains of the processus vaginalis.
→
Peritoneal dialysis
can cause the development of ahernia from a previously occult weakness or enlargementof a patent processus vaginalis.
→
Congenital defect
. Indirect inguinal hernia.
Results frompersistent process vaginalis
→
Postoperative complication (incisional hernia
).
→
Resultant breakdown of surgical fascial closure andHerniation through surgical fascia
→
abnormal muscular structures around umbilical cord(umbilical hernia); common in newborns
→
weakness in the fascial margin of the internal inguinal ring(indirect inguinal hernia)
→
weakness in fascia floor of the inguinal canal (directinguinal hernia)
Composition of a hernia
→
As a rule, a hernia consists of three parts — the
sac
, the
coverings
of the sac and the
contents
of the sac.
1.The sac
→
The sac is a diverticulum of peritoneum consisting of mouth, neck, body and fundus.
→
The neck is usually well defined, but in some directinguinal hernias and in many incisional hernias there is noactual neck.
→
The diameter of the neck is important becausestrangulation of bowel is a likely complication where theneck is narrow, as in femoral and paraumbilical hernias.
2.The body of the sac
→
The body of the sac varies greatly in size and is notnecessarily occupied.
→
In cases occurring in infancy and childhood the sac isgossamer thin.
→
In long-standing cases the wall of the sac may becomparatively thick.
3.The covering
→
Coverings are derived from the layers of the abdominalwall through which the sac passes.
→
In long-standing cases they become atrophied fromstretching and so amalgamated that they areindistinguishable from each other.
Contents
These can be:
→
Omentum = omentocele (syn. epiplocele);
→
Intestine = enterocele. More commonly small bowel, butmay be large intestine or appendix;
→
a portion of the circumference of the intestine Richter’shernia;
→
a portion of the bladder (or a diverticulum) may constitutepart of or be the sole contents of a direct inguinal, a slidinginguinal or a femoral hernia;
→
ovary with or without the corresponding fallopian tube;
→
a Meckel’s diverticulum = a Littre's hernia;
→
Fluid — as part of ascites or as a residuum thereof.
Classification
→
Irrespective of site, a hernia can be classified into fivetypes.
→
Classification of hernias1.Reducible2.Irreducible3.Obstructed
JUDY WAWIRA GICHOYA YR 2007
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4.Strangulated (complication of irreducible hernias)5.Inflamed
1.Reducible
→
The hernia either reduces itself when the patient liesdown, or can be reduced by the patient or the surgeon.
→
The intestine usually gurgles on reduction and thefirst portion is more difficult to reduce than the last.
→
Omentum, in contrast, is described as doughy and thelast portion is more difficult to reduce than the first.
→
A reducible hernia imparts an expansile impulse oncoughing.
2.Irreducible hernia
→
Here the contents cannot be returned to the abdomen,but there is no evidence of other complications.
→
It is usually due to adhesions between the sac and itscontents or from overcrowding within the sac.
→
Irreducibility without other symptoms is almost diagnosticof an
omentocele
, especially in femoral and umbilicalhernias.
→
Note: any degree of irreducibility predisposes tostrangulation.
3.Obstructed hernia
→
This is an irreducible hernia containing intestinewhich is obstructed from without or within, but thereis no interference to the blood supply to the bowel.
→
The symptoms (colicky abdominal pain and tendernessover the hernia site) are less severe and the onset moregradual than is the case in strangulation, but more oftenthan not the obstruction culminates in strangulation.
→
Usually there is no clear distinction clinically betweenobstruction and strangulation, and the safe course is toassume that strangulation is imminent and treataccordingly.
→
Incarcerated hernia. The term ‘incarceration’ is often usedloosely as an alternative to obstruction or strangulation,but is correctly employed only when it is considered thatthe lumen of that portion of the colon occupying a hernialsac is blocked with faeces.
→
In that event the scybalous contents of the bowel shouldbe capable of being indented with the finger, like putty.
4.Strangulated hernia
→
A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contentsischaemic.
→
Gangrene may occur as early as 5—6 hours after theonset of the first symptoms.
→
Although inguinal hernia may be 10 times more commonthan femoral hernia, a femoral hernia is more likely tostrangulate because of the narrowness of the neck and itsrigid surrounds.
→
Pathology. The intestine is obstructed and its blood supplyimpaired.
→
Initially, only the venous return is impeded, the wall of theintestine becoming congested and bright red with thetransudation of serous fluid into the sac.
→
As congestion increases, the wall of the intestine becomespurple in colour.
→
The intestinal pressure increases distending the intestinalloop and impairing venous return further.
→
As venous stasis increases, the arterial supply becomesmore and more impaired.
→
Blood is extravasated under the serosa and is effused intothe lumen.
→
The fluid in the sac becomes blood stained and theshining serosa dull due to a fibrinous, sticky exudate.
→
At this stage the walls of the intestine have lost their toneand become friable.
→
Bacterial transudation occurs secondary to the loweredintestine viability and the sac fluid becomes infected.
→
Clinical features. Sudden pain at first situated over thehernia is followed by generalised abdominal pain, colickyin character and often located mainly at the umbilicus.
→
Nausea and subsequently vomiting ensue.
→
The patient may complain of an increase in hernia size.
→
On examination, the hernia is tense, extremely tender andirreducible, and there is no expansile cough impulse.
→
Unless the strangulation is relieved by operation, thespasms of pain continue until peristaltic contractionscease with the onset of ischaemia when paralytic ileus(often the result of peritonitis) and septicaemia develop.
→
Spontaneous cessation of pain must be viewed withcaution as this may be a sign of perforation.
Richter’s hernia
→
Richter’s hernia is a hernia in which the sac contains onlya portion of the circumference of the intestine (usuallysmall intestine).
→
It usually complicates femoral and, rarely, obturator hernias.
Strangulated Richter’s hernia
→
Strangulated Richter’s hernia is particularly noteworthy asoperation is frequently delayed because the clinicalfeatures mimic gastroenteritis.
→
The local signs of strangulation are often not obvious, thepatient may not vomit and, while colicky pain is present,the bowels are often opened normally or there may bediarrhoea; absolute constipation is delayed until paralyticileus supervenes.
→
For these reasons, gangrene of the knuckle of bowel andperforation have often occurred before operation isundertaken.
Strangulated omentocele
→
The initial symptoms are in general similar to those of strangulated bowel.
→
Vomiting and constipation may be absent as omentum,unlike intestine, can exist on a very meager blood supply.
→
The onset of gangrene is therefore delayed, occurring firstin the centre of the fatty mass.
→
Unrelieved, a bacterial invasion of the ischaemic contentsof the sac will occur and an abscess eventually develops.
→
In an inguinal hernia, infection usually terminates as ascrotal abscess, but extension from the sac to the generalperitoneal cavity is always a possibility.
5.Inflamed hernia.
→
Inflammation can occur from inflammation of the contentsof the sac (e.g. acute appendicitis or salpingitis) or fromexternal causes (e.g. the trophic ulcers which develop inthe dependent areas of large umbilical or incisionalhernias).
→
The hernia is usually tender but not tense, and theoverlying skin red and oedematous.
→
Treatment is based on treatment of the underlying cause.
INGUINAL HERNIASAnatomy of inguinal area
JUDY WAWIRA GICHOYA YR 2007
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Inguinal ligament
−
The Inguinal ligament is formed by the lower border of theexternal oblique aponeurosis which is thickened andfolded backwards on itself.
−
The inguinal ligament extends from the anterior superior iliac spine to the pubic tubercle and lies beneath the foldof the groin.
−
Its lateral half is rounded and oblique.
−
Its medial half is grooved upwards and is more horizontal.
−
It is convex downwards.
−
It is placed at the junction of the anterior abdominal wallwith the front of the thigh.
−
Relations:
The upper grooved surface of the medial half of the inguinal ligament forms the floor of the inguinalcanal and lodges the spermatic cord or round ligament of the uterus.
Conjoint Tendon or Falx Inguinalis
→
The conjoint tendon is formed by fusion of the lowestaponeurotic fibres of the internal oblique and of thetransversus muscles, and is attached to the pubic crestand to the medial part of the pecten pubis.
→
Medially, it is continuous with the anterior wall of therectus sheath.
→
Laterally, it is usually free.
→
Sometimes it may be continuous with an inconstantligamentous band, named the interfoveolar ligament,which connects the lower border of the transversusabdominis to the superior ramus of the pubis.
→
The conjoint tendon strengthens the abdominal wall at thesite where it is weakened by the superficial inguinal ring
Inguinal canal
−
Definition:
This is an oblique passage in the lower part of the anterior abdominal wall, situated just above the medialhalf of the inguinal ligament.
−
Length and direction:
It is about 4 cm (1.5 inches) long,and is directed downwards, forwards and medially.
−
The inguinal canal extends from the deep inguinal ring tothe superficial inguinal ring.
−
The deep inguinal ring is an oval opening in the fasciatransversalis, situated 1.2 cm above the midinguinal point,and immediately lateral to the stem of the inferior epigastric artery.
−
The superficial inguinal ring is a triangular gap in theexternal oblique aponeurosis.
−
It is shaped like an obtuse angled triangle.
−
The base of the triangle is formed by the pubic crest.
−
The two sides of the triangle form the lateral or lower andthe medial or upper margins of the opening. It is 2.5 cmlong and 1.2 cm broad at the base.
−
These margins are referred to as crura.
−
At and beyond the apex of the triangle, the two crura areunited by intercrural fibres.
BoundariesThe anterior wall is formed by the following.
a)In its whole extent:
1.
Skin;
2.
Superficial fascia; and
3.
External oblique aponeurosis.b)In its lateral one-third: The fleshy fibres of the internaloblique muscle
The posterior wall is formed by the following.
a)In its whole extent:1.The fascia transversalis,
2.
The extraperitoneal tissue,
3.
The parietal peritoneum.b)In its medial two-thirds:1.The conjoint tendon;
2.
At its medial end by the reflected part of theinguinal ligament,
3.
Over its lateral one-third by the interfoveolar ligament.
Roof:
It is formed by the arched fibres of the internal obliqueand transversus abdominis muscles
Floor:
It is formed by the grooved upper surface or theinguinal ligament; and at the medial end by the lacunar ligament.
Sex Difference:
The Inguinal canal is larger in males than infemales.
Structures Passing through the Canal
a.
The spermatic cord in males, or the round ligamentof the uterus in females, enters the inguinal CanaIthrough the deep Inguinal ring and passes outthrough the superficial ingulnal ring.
b.
The
ilioinguinal nerve
enters the canal throughthe interval between the external and internaloblique muscles and passes out through thesuperficial inguinal ring
Constituents of the Spermatic Cord1. Structures
1.The ductus deferens
2.
Remains of the processus vaginalis.
3.
Cremaster muscle
2. Arteries
1.The testicular arteries2.Cremasteric arteries3.The artery of the ductus deferens.
3. Veins
1.The pampiniform plexus of veins
4. Lymphatics
1.Lymph vessels from the testis.
5. Nerves
1.The genital branch of the genitofemoral nerve2.The plexus of sympathetic nerves around the arteryto the ductus deferens.
6. Coverings of Spermatic Cord
1.The internal spermatic fascia, derived from the fasciatransversalis: it covers the cord in its whole extent.
2.
The cremasteric fascia is made up of the muscleloops constituting the cremaster muscle, and theintervening areolar tissue. It is derived from theinternal oblique and transversus abdominis muscles,and therefore covers the cord below the level of thesemuscles.
3.
The external spermatic fascia is derived from theexternal oblique aponeurosis. It covers the cordbelow the superficial inguinal ring.
Mechanism of Inguinal Canal
JUDY WAWIRA GICHOYA YR 2007
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HERNIAS General Features Common to All Hernias Definition → →
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is this copied from Bailey & love's short practice of surgery?