Nursing care of Inguinal Hernias

An inguinal hernia is a protrusion of the abdominal contents through the inguinal canal, often into the groin or scrotum. They are a very common problem and patients may complain of pain or discomfort when coughing, exercising or during bowel movements. Inguinal hernias are so common, they are often one of the first surgical procedures postgraduate surgical residents are trained in​[NO_PRINTED_FORM]​. The protrusion may not be visible, particularly in overweight patients, however, a bulging area may occur in the area of the hernia, and may become markedly bigger when the patient is asked to bear down​[NO_PRINTED_FORM]​.

Classifications of Hernias

There are two classifications of Inguinal hernias, direct and indirect. A direct inguinal hernia occurs medial to the inferior epigastric vessels when the abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal. An indirect inguinal hernia occurs when the abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels.

Hernias in general are divided into three categories depending on their nature and severity.

1. Strangulated: Strangulated hernias are the most serious category, and are categorised by part of the herniated organ becoming twisted or edematous, leading to serious complications. Strangulated hernias may result in necrosis the affected area if not treated promptly. A strangulated hernia is considered a medical emergency and requires prompt surgical intervention.
2. Reducible hernias: A hernia may be deemed reducible if it can be easily manipulated into place. This can often be done with non-invasive procedures.
3. Irreducible hernias: Also known as an incarcerated hernia, they can not be reduced manually due to adhesions of the hernia sac. This type of hernia is symptomatic of long-term herniation, or lack of treatment. Surgical intervention may be required in serious cases.

Organ Involvement

Inguinal hernias by definition involve the protrusion of the abdominal contents, but will generally involve a section of the small intestine or bowel protruding through the herniated site. It is important to note that any abdominal organs and structures can be involved including the bladder^​1​, ovaries and uterus^​2​.

Medical Management

Surgical correction is always recommended for inguinal hernias in children​[NO_PRINTED_FORM]​.

Until recently, surgical correction of inguinal hernias has been recommended, and as a result, there is no current medical recommendations about how to treat inguinal hernias in adults^{​​3​​​​4​​}. Surgical repair is still recommended as the current approach in the majority of cases, whereas surgical intervention is not recommended in asymptomatic or minimally symptomatic in favour of monitoring the condition for progression^{​​5​​}. Hernia repair surgery is commonly performed as an outpatient procedure and is not considered a complex procedure. The methods of surgical repair, and surgical techniques vary greatly, but may include the use of a mesh, either synthetic or biological to repair the herniated site. The surgery may be performed through an open surgical site, laparoscopy, and may be performed under either a general or local anaesthesia.

The use of a hernia truss administered to retain the hernia within the abdominal cavity is recommended, however, this is not intended to be a curative measure. A truss also increases the risk of complications including strangulations and atrophy of the fasical margins. This could allow the hernia to enlarge and make subsequent surgical repair difficult^​6​. For this reason, surgical repair is recommended if the hernia progresses^​5​.

Differential Diagnosis

Hydrocoele

Risk Factors^​7​

Inguinal hernias are most common in men, although up to 5% of newborn children present with inguinal hernias. Although women can still develop an inguinal hernia, they are at a much greater risk of developing one during pregnancy.

• Smoking
• Obesity
• Peritoneal Dialysis
• Previous Appendectomy
• COPD
• Pregnancy
• Collagen Vascular Disease

Diagnostic Tests:

There are no specific laboratory tests for inguinal hernias. Often they can be objectively observed through physical examination, and such physical examination is often sufficient for accurate diagnosis^​8​. Large hernias may present as obvious swelling in the inguinal or groin area. In males, the hernia may extend into the scrotum. Smaller hernias may present as a fuller appearance to the inguinal area. Inguinal hernias are noted to be more prevalent on the right side than the left.

In the case of a suspected inguinal hernia, the area can be auscultated, which should reveal prevalent bowel sounds^​8​ indicating the presence of an inguinal hernia.

Suspected bowel obstructions require an imaging scan and associated WBC, which would be expected to be elevated.

Nursing Outcomes:

• The patient will perform ADL’s within the confines of the disease process.
• The patient will express feelings of comfort
• The patients bowel function will return to normal
• The patient will remain free of sign and symptoms of infection
• The patient will avoid any complications.

Nursing Interventions^{​8​​9​}:

• Place the patient in the Trendelenburg’s position to reduce pressure on the hernia site.
• Apply truss only after the hernia has been reduced. For best results, apply it in the morning before the patient gets out of bed.
• Assess the skin daily and apply powder to prevent irritation.
• Watch for and immediately report signs of incarceration and strangulation.
• Closely monitor vital signs and provide routine preoperative preparation.
• Administer IV fluids and analgesics for pain as ordered.
• Control fever with acetaminophen as ordered.

Postoperative interventions:

• Provide routine postoperative care.
• Do not allow the patient to cough.
• Encourage deep breathing and frequent turning.
• Apply ice bags to the scrotum to reduce swelling and relieve pain; elevating the scrotum on rolled towels may also help to alleviate swelling.
• Administer analgesic as prescribed.
• In males, a jock strap or suspensory bandage may be used to provide support.

Last Reviewed: 14th March, 2018