CUk LAD CI IA1IMA UNIVLkSI1

kega|ado Ia|rv|ew uezon C|ty

Co||ege of Nurs|ng





INGUINAL nLkNIA




resented by

MUI2 MA IAIMLLI2 MAL G
NCM 103A ] 8SN 31S ] GkCU 19A




resented to

MS MAkIL ANNL A LAI1AN kN MAN
C||n|ca| Instructor



Iu|y 13 2011
INGUINAL nLkNIA

Def|n|t|on
An |ngu|na| hern|a (pronounced /rrqrwrnrl rhrrnlr/) ls a proLruslon
of abdomlnalcavlLy conLenLs Lhrough Lhe lngulnal canal 1hey are very common (llfeLlme
rlsk 27 for men 3 for women) and Lhelr repalr ls one of Lhe mosL frequenLly
performed surglcal operaLlons
ln Lhe case of Lhe female Lhe openlng of Lhe superflclal lngulnal rlng ls smaller
Lhan LhaL of Lhe male As a resulL Lhe posslblllLy for hernlas Lhrough Lhe lngulnal canal ln
males ls much greaLer because Lhey have a larger openlng and Lherefore a much weaker
wall for Lhe lnLesLlnes Lo proLrude Lhrough lL may be a congenlLal or acqulred defecL

D|scuss|on
A dlrecL lngulnal hernla ls less common (2330 of lngulnal hernlas) and usually
occurs ln men over 40 years of age
A AccounLs for 96 Croln
Pernlas (oLher 4 are
femoral)
8 8llaLeral ln 20 of cases
C Cender predlsposlLlon Male
by 9 Lo 1 raLlo
LlfeLlme rlsk of lngulnal
PernlaLlon 10
lngulnal hernlas ln Lurn
belong Lo groln hernlas whlch
also lncludes femoral hernlas A
femoral hernla ls noL vla Lhe
lngulnal canal buL vla Lhe femoral
canal whlch normally allows
passage of Lhe common femoral
arLery and veln from Lhe pelvls Lo
Lhe leg
ln Amyands hernla Lhe conLenL of Lhe hernlal sac ls Lhe vermlform appendlx
ln LlLLres hernla Lhe conLenL of Lhe hernlal sac conLalns a Meckels ulverLlculum

1ypes
1here are Lwo Lypes of lngulnal hernla Jltect and loJltect whlch are deflned by
Lhelr relaLlonshlp Lo Lhe lnferlor eplgasLrlc vessels ulrecL lngulnal hernlas occur medlal Lo
Lhe lnferlor eplgasLrlc vessels when abdomlnal conLenLs hernlaLe Lhrough Lhe superflclal
lngulnal rlng lndlrecL lngulnal hernlas occur when abdomlnal conLenLs proLrude Lhrough
Lhe deep lngulnal rlng laLeral Lo Lhe lnferlor eplgasLrlc vessels Lhls may be caused by
fallure of embryonlc closure of Lhe processus vaglnalls
Descr|pt|on

1ype Descr|pt|on
ke|at|onsh|p
to|nfer|or
ep|gastr|c
vesse|s
Covered
by|nterna|
spermat|c
fasc|a?
Usua|
onset
lndlrecL
lngulnal
hernla
proLrudes Lhrough Lhe lngulnal rlng
and ls ulLlmaLely Lhe resulL of Lhe
fallure of embryonlc closure of Lhe
lnLernal lngulnal rlng afLer
Lhe LesLlclepasses Lhrough lL
LaLeral ?es CongenlLal
dlrecL
lngulnal
hernla
enLers Lhrough a weak polnL ln Lhe
fascla of Lhe abdomlnal wall
(Pesselbach Lrlangle)
Medlal no AdulL



athophys|o|ogy
ln men lndlrecL hernlas follow Lhe same rouLe as Lhe descendlng LesLes whlch
mlgraLe from Lhe abdomen lnLo Lhe scroLum durlng Lhe developmenL of Lhe urlnary and
reproducLlve organs 1he larger slze of Lhelr lngulnal canal whlch LransmlLLed Lhe LesLlcle
and accommodaLes Lhe sLrucLures of Lhe spermaLlc cord mlghL be one reason why men
are 23 Llmes more llkely Lo have an lngulnal hernla Lhan women AlLhough several
mechanlsms such as sLrengLh of Lhe posLerlor wall of Lhe lngulnal canal and shuLLer
mechanlsms compensaLlng for ralsed lnLraabdomlnal pressure prevenL hernla formaLlon
ln normal lndlvlduals Lhe exacL lmporLance of each facLor ls sLlll under debaLe 8ased on
hundreds of observaLlons durlng dlssecLlon Lhe physlologlcal school of LhoughL has
concluded LhaL Lhe rlsk of hernla ls due Lo a physlologlcal dlfference beLween paLlenLs
who suffer hernla and Lhose who do noL namely Lhe presence of aponeuroLlc exLenslons
from Lhe Lransversus abdomlnls aponuroLlc arch
ln women dlrecL lngulnal hernlas usually occur because of a perslsLenL process
vaglnalls As Lhe hernla emerges Lhrough Lhe deep lnLernal rlng lL carrles wlLh lL fasclal
llnlngs of Lhe Llssue lL Lransverses 1he hernla courses along Lhe lngulnal canal laLeral Lo
Lhe eplgasLrlc arLerles and emerges Lhrough Lhe exLernal rlng sllghLly laLeral Lo Lhe publc
Lubercle
ulrecL hernlas are always acqulred and Lherefore unusual ln Lhe young 1hey
Lyplcally affecL mlddleaged or elderly paLlenLs A dlrecL lngulnal hernla occurs because of
degeneraLlon and faLLy changes ln Lhe aponeurosls of Lhe Lransversalls fascla ln Lhe
Pesselbach Lrlangle area 1he Pesselbach Lrlangle ls deflned lnferlorly by Lhe lngulnal
llgamenL laLerally by Lhe lnferlor eplgasLrlc arLerles and medlally by Lhe laLeral border of
recLus abdomlnus
8ecause of Lhe wlde neck of a dlrecL hernla lL rarely sLrangulaLes SLrangulaLlon ls
more common wlLh lndlrecL hernla whlch has a narrow neck As segmenLs of Lhe lnLesLlne
prolapse Lhrough Lhe defecL ln Lhe anLerlor abdomlnal wall Lhey cause sequesLraLlon of
fluld wlLhln Lhe lumen of Lhe hernlaLed bowel 1hls lnlLlally lmpalrs Lhe lymphaLlc and
venous dralnage whlch furLher compounds Lhe swelllng and over Llme Lhe arLerlal supply
becomes lnvolved 1he lncreased lnLralumlnal pressure causes Lhe wall of Lhe affecLed
segmenL Lo become congesLed whlch leads Lo exLravasaLlons of blood lnLo Lhe hernla sac
1he normal plnklsh and shlnlng color of Lhe bowel wall ls losL and replaced wlLh a dull
congesLed bowel segmenL followed by loss of Lone wlLhln Lhe bowel wall 1hls favors
bacLerlal prollferaLlon and subsequenL lnfecLlon of Lhe bloodsLalned fluld ln Lhe hernla
sac Cangrene ensues and lf lefL unLreaLed perforaLlon occurs erlLonlLls occurs lnlLlally
wlLhln Lhe sac and Lhen spreads Lo Lhe perlLoneal cavlLy

C||n|ca| Man|festat|ons
Pernlas presenL as bulges ln Lhe groln area LhaL can become more promlnenL
when coughlng sLralnlng or sLandlng up 1hey are rarely palnful and Lhe bulge commonly
dlsappears on lylng down 1he lnablllLy Lo reduce or place Lhe bulge back lnLo Lhe
abdomen usually means Lhe hernla ls lncarceraLed whlch requlres surgery Lo correcL
SlgnlflcanL paln ls suggesLlve of sLrangulaLed bowel (an lncarceraLed lndlrecL lngulnal
hernla)
As Lhe hernla progresses conLenLs of Lhe abdomlnal cavlLy such as Lhe lnLesLlnes
can descend lnLo Lhe hernla and run Lhe rlsk of belng plnched wlLhln Lhe hernla causlng
an lnLesLlnal obsLrucLlon lf Lhe blood supply of Lhe porLlon of Lhe lnLesLlne caughL ln Lhe
hernla ls compromlsed Lhe hernla ls deemed sLrangulaLed and
guL lschemla and gangrene can resulL wlLh poLenLlally faLal consequences 1he Llmlng of
compllcaLlons ls noL predlcLable Some hernlas remaln sLaLlc for years oLhers progress
rapldly from Lhe Llme of onseL rovlded Lhere are no serlous coexlsLlng medlcal
problems paLlenLs are advlsed Lo geL Lhe hernla repalred surglcally aL Lhe earllesL
convenlence afLer a dlagnosls ls made Lmergency surgery for compllcaLlons such as
lncarceraLlon and sLrangulaLlon carry much hlgher rlsk Lhan planned elecLlve
procedures
ulfferenLlal dlagnosls of Lhe sympLoms of lngulnal hernla malnly lncludes Lhe followlng
poLenLlal condlLlons
2

emoral hernla
LpldldymlLls
1esLlcular Lorslon
Llpomas
lngulnal adenopaLhy (Lymph node Swelllng)
Croln abscess
Saphenous veln dllaLlon called Saphena varlx
Iascular aneurysm or pseudoaneurysm
Pydrocele
Iarlcocele
CrypLorchldlsm (undescended LesLes)
fLen asympLomaLlc (especlally ln dlrecL
hernlas)
aln or dull sensaLlon ln groln
Comp||cat|ons
8owel lncarceraLlon and sLrangulaLlon
Small 8owel bsLrucLlon

Ind|cat|ons

1he causes of hernla are as follows
A CongenlLal or Acqulred muscle weakness
8 lncreased abdomlnal pressure due Lo
O Peavy llfLlng
O beslLy
O regnancy

os|t|on
1 1echnlque ulLrasound ln varlous paLlenL poslLlons
1 Suplne
2 uprlghL
3 Ialsalva maneuver
Co||aborat|ve Management
1 See lngulnal Canal Lxam (for males)
2 alpable defecL or swelllng may be presenL
1 lndlrecL Pernla may bulge aL lnLernal lngulnal 8lng
1 Look for bulge slLe aL mldlngulnal llgamenL
2 ulrecL Pernla may bulge aL LxLernal lngulnal 8lng
1 Look for bulge slLe aL publc Lubercle
2 ccurs [usL above lngulnal llgamenL
3 Seen medlal and lnferlor Lo lndlrecL Pernla bulge
3 ulsLlngulshlng lndlrecL and dlrecL hernlas dlfflculL
1 Lxperlenced cllnlclans are lncorrecL ln 30 of cases
4 lndlrecL lngulnal Pernla palpaLlon dlfflculL ln women
3 lngulnal Pernlas dlfflculL Lo palpaLe ln chlldren
rocedure overv|ew

Surgery Pernlorrhaphy (PernloplasLy)

Med|ca|
1he hernla Lruss ls lnLended Lo conLaln a reduclble lngulnal hernla wlLhln Lhe abdomen
1hls devlce fell ouL of favour wlLh Lhe advenL of hernla surgery lL ls noL consldered Lo
provlde a cure and lf Lhe pads are hard and lnLrude lnLo Lhe hernla aperLure Lhey may
cause scarrlng and enlargemenL of Lhe aperLure ln addlLlon mosL Lrusses wlLh older
deslgns are noL able effecLlvely Lo conLaln Lhe hernla aL all Llmes because Lhelr pads do
noL remaln permanenLly ln conLacL wlLh Lhe hernla 1he more modern varleLy of Lruss ls
made wlLh nonlnLruslve flaL pads and comes wlLh a guaranLee Lo hold Lhe hernla securely
durlng all acLlvlLles AlLhough Lhere ls as yeL no proof LhaL such devlces can prevenL an
lngulnal hernla from progresslng Lhey have been descrlbed by users as provldlng greaLer
confldence and comforL when carrylng ouL physlcally demandlng Lasks A Lruss also
lncreases Lhe probablllLy of compllcaLlonswhlch lnclude sLrangulaLlon of Lhe hernla
aLrophy of Lhe spermaLlc cord and aLrophy of Lhe fasclal marglns1hls allows Lhe defecL Lo
enlarge and makes subsequenL repalr more dlfflculL 1helr popularlLy ls llkely Lo lncrease
as many lndlvlduals wlLh small palnless hernlas are now delaylng hernla surgery due Lo
recenLly publlshed reporLs on Lhe lncldence of posLhernlorrhaphy paln syndrome 1he
elasLlclsed panLs used by aLhleLes also provlde useful supporL for Lhe smaller hernla
Surg|ca|
Surglcal correcLlon of lngulnal hernlas called a hernla repalr ls commonly performed
as ouLpaLlenL surgery 1here are varlous surglcal sLraLegles whlch may be consldered ln
Lhe plannlng of lngulnal hernla repalr 1hese lnclude Lhe conslderaLlon of mesh use Lype
of open repalr use of laparoscopy Lype of anesLhesla approprlaLeness of bllaLeral repalr
eLc uurlng surgery conducLed under local anaesLhesla Lhe paLlenL wlll be asked Lo cough
and sLraln durlng Lhe procedure Lo help ln demonsLraLlng LhaL Lhe repalr ls Lenslon free
and sound ConsLlpaLlon afLer hernla repalr resulLs ln sLraln Lo evacuaLe Lhe bowel causlng
paln and fear LhaL Lhe suLures may rupLure plold analgesla makes consLlpaLlon worse
romoLlng an easy bowel moLlon ls Lherefore lmporLanL and a sub[ecL LhaL few surgeons
glve advlce abouL



er|operat|ve Nurs|ng Cons|derat|ons

lkOlkA1lv cAk
Assess for presence for resplraLory LracL lnfecLlon Sneezlng or Coughlng could weaken Lhe
repalr

lO51OlkA1lv cAk
1 Lncourage Lhe cllenL Lo deep breaLhe buL noL coughlng exerclses
2 lncrease fluld lnLake Lo prevenL consLlpaLlon SLralnlng aL sLool may weaken Lhe repalr
3 MonlLor Lhe bladder dlsLenLlon
4 LlevaLe Lhe scroLum wlLh rolled small Lowel apply lce bag over Lhe scroLum 1o prevenL
edema of Lhe scroLum and mlnlmlze dlscomforL durlng ambulaLlon
3 ulscharge paLlenL Lechnlques
Avold heavy llfLlng pushlng pulllng for abouL 6 weeks
Avold drlvlng cllmblng sLalrs for 2 weeks
SLool sofLeners or bulk laxaLlves as prescrlbed 1o prevenL sLalnlng and defecaLlon
MonlLor lnclslon of slgns of lnfecLlon llke redness swelllng warmLh paln
exudaLes noLlfy physlclan on Lhese slgns and sympLoms
Sexual acLlvlLy may be resumed once heallng ls compleLe and comforL ls assured
usually 3 weeks afLer dlscharge