1

General surgery
Hernia surgery
GROUP 1
CASSANDRA
DK
NORHAFIZAH
MIKE
Learning outcome 2

 Explain definition, types and classification of Hernia.

 Explainanatomy of inguinal region, femoral region and
abdominal wall.
 Explain all types of Hernias
 Describe specific requirement and instrument for laparoscopic
Hernia
 Explain how perioperative nurse assist and anticipate in hernia
repairs.
 Explainnursing care regarding scrotal oedema, seroma or
haematoma formation
Hernia
3
 DEFINITION 4

 Hernia is the protrusion of an organ or part of an organ through a

defect in the supporting structures that normally contain it.

 May be congenital, acquired, or traumatic.

 Canoccur in any body cavity, and include intracranial hernias,

spinal disk hernias, and internal hernias of the abdominal cavity.
 Hernia consist of 3 part 5
1. Sac
 Consist of diverticulum of peritoneal

2. Contents
 Omentum, small or large intestine, urinary bladder, ovaries,
malignant noduls, or ascetic fluid.

3. Covering
 Derived from the layers of abdominal wall
Hernia consist of 3 part 6
Type of hernia
7
8
9
10
 Direct Inguinal Hernia 11
 Protrudesthrough a weakness in the abdominal wall in the
region between the rectus abdominis muscle and inguinal
ligament and medial to the inferior epigastric artery.

 An acquired weakness of the lower abdominal wall, a direct

inguinal hernia often results from straining, such as heavy
lifting, chronic coughing, or straining to urinate or defecate.
12
 Indirect Ingunial Hernia 13

 The peritoneal sac containing intestine protrudes

through the internal inguinal ring and passes down
the inguinal canal outside Hesselbach’s triangle.

 It directs laterally to the inferior epigastric vessels.

It may descend all the way into the scrotum.
14
 Femoral Hernia 15

Repairing the defect in the transversalis

fascia below the inguinal ligament and
removing the peritoneal sac protruding
through the femoral ring.
 16

Hernia where its

commonly occur?
Hernia where its commonly occur? 17
Let learn more about hernias.. 18

1.Anatomical 2. Clinical

Classification of
Hernias

4. According 3. Congenitial or
Extend Acquired
Explain Hernia…. 19

 Can be classified by;

a. Anatomical (indirect, direct)
b. Clinical (reducible, irreducible, obstructed, strangulated,
incarcerated & inflammed)
c. According to extend
d. Congenital and Acquired
Anatomical Hernia 20
1. Inguinal hernias
 Inguinal hernias occur when bowel tissue or fatty tissue protrudes
into the groin area at the top of the thigh. These hernias make up
75% of all abdominal hernias and mainly affect men.

2. Femoral hernia
 These also occur when abdominal contents protrude through to
the groin area. However, these hernias tend to be more rounded
than inguinal hernia and mainly occur in women rather than men.
 Cont.. 21

3. Umbilical hernia
 Here, intra-abdominal tissue pokes through the abdomen, near
the naval area. These hernias are more common among
pregnant women and obese people.

4. Hiatus hernia
 A hiatushernia occurs when part of the stomach or intestine
protrudes into the chest area through a hole in the diaphragm.
 Cont.. 22
5. Less common hernias
 Less common hernias that are also classified according to their location in the
body include:
i. Epigastric hernia: Fatty tissue protrudes through the abdomen in the area
between the belly button and the breast bone.
ii. Spigelian hernia: A bowel part protrudes through the abdomen, below the
belly button and at the side of the abdominal muscle.
iii. Muscle hernia: A piece of muscle pokes through the abdomen.
iv. Incisional hernia: These occur when a piece of tissue protrudes through a
surgical wound that has not healed properly.
Anatomical Hernia 23

Anatomical
Direct Indirect
Hernia
Direct Inguinal Hernia 24
bulges through the inguinal (
Hesselbach's) triangle
directly through abdominal wall
through the external inguinal
ring
medial to inferior epigastric
artery
covered only by external
spermatic fascia
 most commonly in older men
Hesselbach’s Triangle 25
Indirect Inguinal Hernia  travels the entire length of the inguinal
26
canal following descent path of the testes
 enters internal inguinal ring lateral to
inferior epigastric artery and exits external
inguinal ring
 may enter scrotum
 covered by all 3 layers of spermatic fascia
 most commonly seen in male infants
 due to patent processus vaginalis
peritoneal connection between inguinal canal
and tunica vaginalis
27
Clinical Manifestation’s Classification 28
29
No Clinical Explanation
Classification
30
1 Reducible is a hernia with a bulge that flattens out when you lie down or
push against it gently using simple manipulation.

2 Irreducible also known as an incarcerated hernia - is a hernia that cannot

be pushed back, manually, through the opening in the
abdomen
3 Obstructed Bowel contents may no longer be able to pass through an area
of herniated bowel, leading to cramps and vomiting.

4 Strangulated The contents of the hernia become pressured and blood supply
is compromised leading to cell death and gangrene.

5. Inflamed Content of Sac have became imflammed

Reducible, irreducible and strangulated Hernia 31
32
Obstructed Hernia 33
34
Strangulated Hernia 35
 Strangulated Hernia 36
 Serious impairment of blood supply of the content with or without
obstruction.
 Ischemic may occurred if not treated within 5-6 hours and cause gangrene.
 In strangulated venous impairment occurs first.
 Then intestinal congestion and oedema.
 Become worse and more congestion and oedema.
 Next arterial impairment occurs, tissue become ischemia.
 Exudation of blood into sac and bacterial transudation through the wall
occurs. (infection/inflammation)
 Content such as bowel may gangrene and perforation occurs.
Also can be classified by.. 37

1.Congenital Hernia
Occurred in prenatal or in the first year of life and caused
by congenital defect.
E.g; Inguinal, umbilical, Diaphragmatic Hernia
38
39
Cont.. 40

2. Acquired Hernia
Developed later on after life
E.g; Postoperative, artificial, Primary,
Traumatic, degeneration, hiatal hernia.
41
Hiatal Hernia 42

A hiatal hernia occurs when the upper part of the stomach pushes
through an opening in the diaphragm and into the chest cavity.
Caused of Hiatal Hernia 43
 Acquired Hernia: Incisional Hernia 44

 An incisional hernia is a type of hernia caused by an incompletely-healed

surgical wound.
 Since median incisions in the abdomen are frequent for abdominal
exploratory surgery, ventral incisional hernias are often occurs.
Ventral incisional hernias also classified as 45

ventral hernias due to their location…

A ventral hernia is any protrusion of viscera through anterior
abdominal wall (a bulge of tissues).
 Categorized as spontaneous or acquired.
 Many are called incisional hernias because they form at the
healed site of past surgical incisions.
 Here abdominal wall layers have become weak or thin, allowing
for abdominal cavity contents to push through.
46
External Hernia Vs Internal Hernia 47

 External Hernia
-Occur through a body wall producing a visible and palpable
swelling covered by skin.
-example; Umbilical H, Inguinal H, Scrotal H, Perennial H,
Ventral H.
 Internal Hernia
-it occur within the abdominal cavity
-example; Diaphragmatic H.
Classification according to extent 48
49
 50

Preparation of
Standard
Requirement and
Instrument for
Laparoscopic Hernia.
 Instrument or Set for surgery
51
 Herniatomy Set
1. Dissecting and cutting instrument
 BP handle with blade size 11
 Mayo scissor straight & curved

2. Clamping and occluding instruments.

 Crile artery x 2 - 4

3. Retracting and exposing instrument

 Small langenback x 2
cont.. 52
4. Grasping and holding instrument
 Dissecting forceps :- Toothed & non-toothed
 Sponge forcep

5. Others
 Kidney dish
 Gallipot
 Non peforated towel clip
 Miscellaneous 53

1. Sutures ( vicryl 2/0 or

3/0, prolene 3/0, ethilon
3/0 )

2. Steri strip - for incision

site.
 Miscellaneous
3. Mesh 54

 Used to provide permanent reinforcement to the repaired

hernia.
 Mesh place over the hernia site, it will be sutures, tacks or
use surgical glue to hold the mesh in place.
 Tissue should grow into the small pores in the mesh and
strengthen the muscle wall.
 This creates scar tissue that strengthens the hernia site.
55
56
 8 Element of Endoscopy
57
Element Indication
Access portal Natural orifice or percutaneous puncture
Working space Fluid , gas or positional expansion to accommodate
instrumentation.
Illumination Fiberoptic or incandescent bulb.
Vision Direct or indirect viewing with lens or camera.
Manipulation Tissue grasping, debulking and dissection.
Capture Collection of specimen.
Evacuation Remove gases, plume or fluid
Closure Suturing, stapling or minimize the access portal.
 Laparoscopic Instrument / Equipment
58

1. Access Portal

 Variety of access port

 E.g :- Trocar and

cannula size 10mm x 1
and 5mm x 2
 Laparoscopic Instrument / Equipment59
2. Working Space /
Insufflation equipment

 Carbon dioxide gas

 Gas Tubing

 Verres Needle
 Laparoscopic Instrument / 60

Equipment
3. Illumination

 Light source machine

 Light source cable

 Laparoscopic Instrument / Equipment61
4. Vision

 Monitor system

 Camera

 Telescope ( 0° / 30° )
Laparoscopic Instrument / Equipment62

5. Manipulation
 Atraumatic grasping
forceps.

(e.g Maryland, Johan)

Laparoscopic Instrument / 63

Equipment
Scissor for tissue

 Scissor for suture
 Laparoscopic Instrument / 64

Equipment

6. Evacuation
 Suction apparatus

7. Closure
 Needle holder for tissue
and suture.
 65

Assist in common hernia repair:

Local, regional or General
anaesthesia
LAPARASCOPIC INGUINAL HERNIA REPAIR
 Introduction
66
 Procedure used to repair either an indirect or direct reducible inguinal
hernia using mesh behind the hernial defect.

 Advantageous for repair bilateral or recurrent hernia.

 Transabdominal preperitoneal (TAPP) or intraperitoneal may be use, or

transextraperitoneal procedure (TEPP) can be performed.

 Polypropylene mesh inserted to reinforce the wall of inguinal canal &

stapled in place.
ADVANTAGES DISADVANTAGES 67

 Reduction of pain.  Need for general

 Smaller incision with anaesthesia.
less tissue  A lack of long term
manipulation & follow up data.
dissection.  The cost of
 A morerapid return instrument must
to normal activity. weighed against
 May result in fewer other economic
recurrences factor.
 Preparation of patient 68

1. Preparation of appropiate laparascopic instrument and

supplementary.

2. Position patient for laparascopic

 supine: before Pneumoperitoneum created.
 Trendeleburg : after establishment of pneumoperitoneum.

3.Position laparascopic tv monitor system is below the patient.

Intraoperatively 69

1. Open second layer of the instrument set.

2. Perform initial count with the circulating nurse.

3. Layout the required instruments on the sterile trolley.

4. Fix blade size (11 / 15) into the scalpel handle (size 3 / 7)
with heavy artery/spencer well.
 70
5.Provide antiseptic lotion (povidone) to the surgeon for skin
preparation.

6. Assisting surgeon to perform square drape.

7. Assemble and test function of the laparascopic instrument.

8.Connect the ( Co2 insufflation tubing,camera head, light source,

telescope) and secure with nonpenetrating clamp and end of cable
passed off the sterile field for connection to tv monitor system
 Assisting surgeon throughout surgery 71

1. The surgeon make incision above the

umbilicas.
2. The surgeon lift up the abdominal
wall and insert the 10/12 blunt
umbilical port (open method
technique). Usually 3 or 4 port used.
3. Insufflation of the abdomen is with
Co2.
4. And the surgeon insert the 30 degree
telescope at the umbilical port
 Cont..
72

5. The insert the second port and third

port (5mm x 2) for induction of mesh
and laparascopic instrument under
visualization.

6. Sharp dissection to take down the

peritoneum for acces to inguinal region
(e.g blunt dissecting scissor) and
continues dissect until identified the
hernia sac.
Cont..
73
7. The surgeon put the mesh and
secured with stapler (e.g ProTack) or
suture with non absorbable
3/0prolene/ nylon.

8.Start suctioning the out or release

the Co2 in the peritoneum.

9.Remove the port direct

visualization and lastly the umbilical
port.
Cont. 74
10. The skin incision are close
according to surgeon preference &
may include subcuticular technique
( 2/0 vicyrl, 2/0 novosyn, J needle)

11. The skin closure ( 3/0 nylon or

3/0 safil quick).
Nursing Care Plan:
-Scrotal Oedema, seroma, or haematoma Formation 75

Nursing Assessment
 Patient has undergo Hernia Repair

Nursing Problem/Diagnosis
 Risk of scrotal Oedema, seroma or haematoma related postoperative
procedure.

Outcome
 Patient will free from scrotal oedema, seroma and haematoma.
NURSING INTERVENTION RATIONALE
76
Assess the post operative site, dressing to determine early intervention for
and drainage for swelling, redness, patient to avoid early complication that
discharge, haematoma or bleeding can occur such as bleeding and infection.

Advice patient to avoid coughing and Pressure can cause the suture to break
avoid strenuous activities such as and tissue or bowel forced back into the
swimming, walking, biking, hiking and sac.
weight lifting.

Apply cold compress to the scrotum to Promotes comfort by decreasing the

reduce swelling and relieve pain; swelling.
elevating the scrotum on rolled towels
also can reduces swelling.
NURSING INTERVENTION RATIONALE
77
Administer analgesics as prescribed by Allays pain and discomfort caused by the
doctor as example IM pethidine 50mg if incision.
necessary to relieved pain that occurred
regarding the swelling and if pain and
swelling are not relieved informed the
doctor immediately.

Educate patient to notify any signs and Promotes understanding of patient

symptoms of bleeding and infection such regarding potential complication that can
as fever, swelling, pus around the occur postoperatively and prevents more
surgical site or tenderness and redness. severe complication of eventual
gangrene of bowel.
Conclusion 78

Knowledge and skill must stand together especially knowledges about the
anatomy of abdominal wall associated with hernia surgery.

So that, when the perioperative nurse has a proper knowledge and skill it
can make easier to them to identify any structure, organ or nerve that should
be avoided while anticipate in assisting the surgeon in the surgery process.

By that a safe surgery safe life goal can be achieved

79