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Angeles City
College of Nursing

(A Case Report)

Submitted by:
Advincula, Krizzia Mae E.
Bala, Jessica
Ohashi, Jerico Jiromi
Pangilinan, Raidis Naomi M.
Tapnio, Crizzel
Wilson, Annabelle
BSN III-B (Group 5)

Submitted to:
Karen David Sembrano RN, MN
Clinical Instructor
I. Introduction

Hernias are abnormal protrusions of a viscus (or part of it) through a normal or abnormal
opening in a cavity (usually the abdomen). They are most commonly seen in the groin; a minority are
paraumbilical or incisional. In the groin, inguinal hernias are more common than femoral hernias.

Inguinal hernias occur in about 15% of the adult population, and inguinal hernia repair is one of
the most commonly performed surgical procedures in the world. Approximately 800,000 mesh
hernioplasties are performed each year in the United States, 100,000 in France, and 80,000 in the United

In a nationwide register-based study, using data from the Civil Registration System covering all
Danish citizens, we established a population-based cohort of all people living in Denmark on December
31st, 2010. Within this population all groin hernia repairs during the past 5 years were identified using
data from the ICD 10th edition in the Danish National Hospital Register. The study population covered n
=5,639,885 persons. During the five years study period 46,717 groin hernia repairs were performed
(88.6% males, 11.4% females). Inguinal hernias comprised 97% of groin hernia repairs (90.2% males,
9.8% females) and femoral hernias 3% of groin hernia repairs (29.8% males, 70.2% females). Patients
between 05 years and 7580 years constituted the two dominant groups for inguinal hernia repair. In
contrast, the age-specific prevalence of femoral hernia repair increased steadily throughout life peaking
at age 8090 years in both men and women.

There is morphologic and biochemical evidence that adult male inguinal hernias are associated
with an altered ratio of type I to type III collagen. These changes lead to weakening of the
fibroconnective tissue of the groin and development of inguinal hernias. Recognition of this process led
to acknowledgment of the need for prosthetic reinforcement of weakened abdominal wall tissue.

Given the evidence that the use of mesh lowers the recurrence rate, as well as the availability of
various prosthetic meshes for the reinforcement of the posterior wall of the inguinal canal, most
surgeons now prefer to perform a tension-free mesh repair. Accordingly, this article focuses primarily on
the Lichtenstein tension-free hernioplasty, which is one of the most popular techniques used for inguinal
hernia repair.

Inguinal hernia repair is one of the most commonly performed surgical procedures in the world.
Most surgeons now prefer to perform a tension-free mesh repair. The Lichtenstein tension-free
hernioplasty is currently one of the most popular techniques for repair of inguinal hernias.The existence
of an inguinal hernia has traditionally been considered sufficient reason for operative intervention.
However, the following considerations should be taken into account:
Some studies have shown that the presence of a reducible hernia is not, in itself, an indication
for surgery and that the risk of incarceration is less than 1%. Symptomatic patients should undergo
repair. Even asymptomatic patients who are medically fit should be offered surgical repair. Because of
the higher frequency of femoral hernias in women, procedures that provide coverage of the femoral
space (eg, laparoscopic repair) at the time of initial operation may be better suited for women as primary

Inguinal hernia repair has no absolute contraindications. However, the following considerations
should be taken into account:

Any medical issues should be fully addressed beforehand and the operation delayed accordingly.

Patients with elevated American Society of Anesthesiologists (ASA) scores and high operative risk
should undergo a full preoperative workup and determination of the risk-to-benefit ratio.

Recurrences after a primary posterior technique may be treated with Lichtenstein hernioplasty;
recurrences after a primary anterior technique should be treated with TEP (Totally
Extraperitoneal) technique, TAPP (Transabdominal Preperitoneal) technique, or open posterior

Asymptomatic reducible direct inguinal hernia in an elderly patient with multiple uncontrollable
comorbidities and an elevated ASA score does not require repair and may be left alone for close
observation and follow-up. No special equipment is required for inguinal hernia repair.

Inguinal hernia repair can be performed with the following types of anesthesia:


Regional (spinal epidural)

Local (infiltration field block)

For Lichtenstein hernioplasty, local anesthesia is safe and generally preferable. Antibiotic
prophylaxis is not routinely indicated in low-risk cases but may be considered when risk factors are

Inguinal hernia repairs are of the following three general types:

Herniotomy- removal of the hernial sac only.

Herniorrhaphy- herniotomy plus repair of the posterior wall of the inguinal canal.

Hernioplasty- herniotomy plus reinforcement of the posterior wall of the inguinal canal with a
synthetic mesh. This is required for large hernias and hernias in middle-aged and elderly patients
with poor abdominal wall musculature; the Lichtenstein tension-free mesh repair is an example
of hernioplasty. (This is the type of hernial repair that we used in our patient.)

The Lichtenstein tension-free mesh repair, which is an example of hernioplasty and is currently
one of the most popular open inguinal hernia repair techniques, includes the following components:

Opening of the subcutaneous fat along the line of the incision

Opening of the Scarpa fascia down to the external oblique aponeurosis and visualization of the
external inguinal ring and the lower border of the inguinal ligament

Opening of the deep fascia of the thigh and exposure of the femoral canal to check for a femoral

Division of the external oblique aponeurosis from the external ring laterally for up to 5 cm,
safeguarding the ilioinguinal nerve

Mobilization of the superior (safeguarding the iliohypogastric nerve) and inferior flaps of the
external oblique aponeurosis to expose the underlying structures

Mobilization of the spermatic cord, along with the cremaster, including the ilioinguinal nerve,
the genitofemoral nerve, and the spermatic vessels; all of these structures may then be encircled
in a Penrose drain or tape

Opening of the coverings of the spermatic cord and identification and isolation of the hernia sac

Inversion, division, resection, or ligation of the sac, as indicated

Placement and fixation of mesh to the edges of the defect or weakness in the posterior wall of
the inguinal canal to create a new artificial internal ring, with care taken to allow some laxity to
compensate for increased intra-abdominal pressure when the patient stands

Resection of any nerves that are injured or of doubtful integrity

In males, gentle pulling of the testes back down to their normal scrotal position

Closure of spermatic cord layers, the external oblique aponeurosis, subcutaneous tissue, and the

Other approaches to open inguinal hernia repair include the following:

Plug-and-patch repair - This adds a polypropylene plug shaped as a cone, which can be deployed
into the internal ring after reduction of an indirect sac
Prolene Hernia System (PHS) - This consists of an anterior oval polypropylene mesh connected
to a posterior circular component

McVay repair - In this approach, the conjoined (transversus abdominis and internal oblique)
tendon is sutured to the inguinal ligament with interrupted nonabsorbable sutures

Bassini repair - This approach involves suturing the transversalis fascia and the conjoined tendon
to the inguinal ligament behind the spermatic cord, as well as placing a vertical relaxing incision
in the anterior rectus sheath

Shouldice repair - This is a four-layer procedure in which transversalis fascia is incised from the
internal ring laterally to the pubic tubercle medially, upper and lower flaps are created and then
overlapped with two layers of sutures, and the conjoined tendon is sutured to the inguinal
ligament (again in two overlapping layers)

Darn repair - This is a pure-tissue tensionless technique that is performed by placing a

continuous suture between the conjoined tendon and the inguinal ligament without
approximating the two structures

II. Anatomy and Physiology

Hernia Anatomy The layers of the Abdominal Wall

The first concept to understand is the basic layers of the abdominal wall. These
layers are a bit different between the umbilical region and the groin, but overall the basic
layers are the same. From the outside to the inside is the skin, then a layer of fat.
Underneath the fat is the layer of muscles which provide the strength to the abdominal
wall. Under the muscles is a thin layer called peritoneum which serves as a barrier
between the muscles and the internal organs which live underneath the peritoneum.

Inguinal Hernia Anatomy

In inguinal or groin hernias a hole forms in the internal oblique and transversus
muscles. If this hole forms lateral (or away from the middle) to the inferior epigastric
blood vessels, an indirect inguinal hernia forms. If the hole forms medial (or towards the
middle) to the inferior epigastric blood vessels, a direct inguinal hernia is formed.
Regardless, in open surgery, the external oblique muscle layer is opened over the
hernia (weakened internal and transversus muscle). The hole (or holes) in the internal
oblique and the transversus muscle are found. A dual sided mesh is used to reinforce

the hernia defect and the muscle around the hole.

The image below shows the anatomy of the inguinal region looking from the inside of
the body outwards. This would be the view from inside the right groin. The right indirect
hernia is lateral or away from the middle of the patient. The left direct hernia is medial
or towards the middle compared to the inferior epigastric vessels.

Mesh Used for Inguinal Hernias

For open inguinal hernia repairs, we utilize a dual mesh (shown right). This type
of mesh allows one layer (with the blue circles) to be placed under the muscle, while the
other top layer is placed over the damaged muscle. With this type of repair, the
weakened muscles are treated from both the inside AND the outside of the hole. This
cannot be done in laparoscopic surgery since only an inner layer mesh can be used.
The image to the left again shows a view from inside the patients right groin. The
blue layer of the dual mesh has been placed under the weakened muscles. Not pictured
is that the top layer of the dual mesh is placed over the weakened muscles to reinforce
the muscles from both the inside and the outside.

Umbilical Hernia Anatomy

The CT image below shows a cross section of a patient. You can see a clear hole
in the muscle at the level of the belly button, or umbilicus. This hole is considered an
umbilical hernia.

The image below shows a normal umbilicus with no evidence of a hole, or a

hernia. Although CT scans can be helpful in determining whether there is a hernia, most
often examining the patient is all that is needed to determine whether there is a hernia

Mesh Used for Umbilical Hernias

Umbilical hernia repairs are almost always best done open. During open surgery,
a small incision is made in the crease under the belly button. The belly button is lifted off
of the underlying muscle and fat. The hole in the muscle is exposed and a mesh is
placed through the hole.

The mesh is then sutures (sewn) to the surrounding healthy muscle in several
locations. Once the mesh is securely fastened to the muscle, the belly button is
replaced down to the muscle or fat and the skin is sewn closed.

Tension Free Repair

The term tension free hernia repair is commonly used to describe hernia
surgery. Hernias are caused by a weakening of the abdominal muscles. Some surgeons
choose to sew the muscles back together, thus causing tension on the muscles around
the hernia. However, the muscles around a hernia are already weak, and over time
those muscles tend to pull apart and the hernia can recur, or come back. Therefore,
most hernia specialists today utilize a mesh to help strengthen the muscles. When using
a mesh, the muscles themselves are not sewn together (see below). Instead, a mesh is
placed over or under the hole in the muscle to prevent anything from pushing through
the abdominal wall.

III. The Patient and his Illness


A hernia refers to when an internal body part pushes through a weak area of muscle or the
surrounding tissue wall. Hernias often do not cause any symptoms, although a swelling may appear in the
abdomen or groin.

Although a hernia can develop anywhere in the body, they usually occur somewhere between the
chest and hips, with abdominal hernia being the most common form. A weakness in the abdominal wall
leads to a hole forming and abdominal organs or adipose tissue then push through the hole, creating a
bulge. Hernias can also occur in other parts of the body such as the spine, when the intervertebral discs
protrude outwards and press on nearby nerves.

Most hernias are reducible, which means the herniated contents can be manipulated back into
the abdominal cavity. Irreducible hernias, on the other hand, cannot be pushed back to their original
location. This can lead to strangulation, which refers to when pressure placed on the hernial contents may
compromise blood supply to the tissue, leading to ischemia, cell death and even gangrene. Obstruction
may also occur if part of the gut herniates and the bowel contents can no longer move through the
herniated area. This can lead to cramps, absence of defecation and vomiting.

Inguinal hernia

This is the most common form of hernia and refers to when bowel or fatty tissue protrudes into
the groin. This type of hernia mainly occurs in men. A painful dragging sensation may be felt, as well as
pain and swelling in the scrotum and testicles.

In cases of inguinal hernia, a loop of intestine protrudes through a hole in the abdominal wall into
the inguinal canal, which contains the spermatic cord. While a male fetus is in the womb, the testes are
formed in the abdomen and before birth, they descend into the scrotum via the inguinal canal. The
weakness that occurs in the abdominal wall may be present at birth or may develop later on in life.

An indirect inguinal hernia is one that occurs as a congenital lesion. It occurs as a result of the
deep inguinal ring failing to close during embryogenesis after a testicle has moved through it. Once bowel
or other abdominal tissue moves into and enlarges the empty space, a visible bulge forms and the hernia
becomes clinically evident.
Direct hernias are acquired rather than congenital and usually occur in people aged 25 or older.
This hernia occurs due to degeneration and fatty changes in the inguinal floor or posterior wall in an area
called the Hesselbach triangle. The majority of direct hernias do not have a true peritoneal lining and do
not contain intestine; they mainly contain preperitoneal fat and occasionally bladder. A long-standing
direct hernia that has become large may extend into the scrotum and may also contain abdominal content
or intestine.
a. Schematic Diagram

Modifiable factors
Non-Modifiable Factors
-Diethistory of hernia

Increase pressure in the

compartment of the abdomen is

Intra-abdominal wall of inguinal

canal into the scrotum becomes

Prevent inguinal ring from closing

Evolves to a hole or defect

Fat or part of the small intestine

slide through the inguinal canal
Swollen or enlarged scrotum

Signs and Symptoms:

A bulge in the area on A burning, gurgling, Pain or discomfort in Pain and swelling A heavy or dragging
either side of your aching sensation at the the bulge around the testicles sensation
pubic bone bulge
b. Synthesis of the disease

b.1. Definition of the disease

An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal.

Symptoms are present in about 66% of affected people. This may include pain or discomfort especially
with coughing, exercise, or bowel movements. Often it gets worse throughout the day and improves when
lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur
more often on the right than left side. The main concern is strangulation, where the blood supply to part of
the intestine is blocked. This usually produces severe pain and tenderness of the area.

Risk factors for the development of a hernia include: smoking, chronic obstructive pulmonary
disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and previous
open appendectomy, among others. Hernias are partly genetic and occur more often in certain families. It
is unclear if inguinal hernias are associated with heavy lifting. Hernias can often be diagnosed based on
signs and symptoms. Occasionally medical imaging is used to confirm the diagnosis or rule out other
possible causes.

Groin hernias that do not cause symptoms in males do not need to be repaired. Repair, however,
is generally recommended in females due to the higher rate of femoral hernias which have more
complications. If strangulation occurs immediate surgery is required. Repair may be done by open
surgery or by laparoscopic surgery. Open surgery has the benefit of possibly being done under local
anesthesia rather than general anesthesia. Laparoscopic surgery generally has less pain following the

In 2015 inguinal, femoral and abdominal hernias affected about 18.5 million people. About 27% of
males and 3% of females develop a groin hernia at some time in their life. Groin hernias occur most often
before the age of one and after the age of fifty. Globally, inguinal, femoral and abdominal hernias resulted
in 60,000 deaths in 2015 and 55,000 in 1990.

b.2. Modifiable and Non-Modifiable factors

Non-Modifiable factors


-It is congenital for indirect inguinal hernia which may occur during
embryogenesis when it fails to close the inguinal ring after your testis pass
through it.
-Direct hernias are acquired rather than congenital and usually occur in
people aged 25 or older.

It is common among males than females.

Family history of hernia

Will have a higher risk or having this disease.

Modifiable factors


Doing strenuous activity and lifting heavy objects may increase the
pressure to your abdomen which may damage your inguinal canal.


When an individual were exposed to a smoky or dusty area, they might do

excessive cough when they are not used to it. Excessive cough also will
increase the abdominal pressure that will damage your inguinal canal


Poor diet may cause weakness of abdominal muscles.

b.3. Signs and Symptoms

A bulge in the area on either side of your pubic bone

The organs that will pass through the inguinal canal specially your
intestines will cause bulging in the area where they will go.

A burning, gurgling, aching sensation at the bulge

Pain or discomfort in the bulge

The area where bulging is occurring may cause pain because of

overstretching the skin or the site and not fitting of organs in the site cause
of displacement.

Swelling around the testicles

The organs in the abdomen specially the intestines will move to your
scrotum through the inguinal canal which may cause swelling because of
excess organ.

A heavy or dragging sensation



Open Inguinal Hernia Repair (Hernioplasty)

1. Incision

The incision is placed about 1 cm above and parallel to the inguinal ligament,
beginning from the pubic tubercle and extending 5-6 cm laterally up to the midinguinal
point (see the images below). The subcutaneous fat is then opened along the length of
the incision, and careful hemostasis is achieved by ligating superficial pudendal and
superficial epigastric vessels.

The Scarpa fascia is similarly opened along the length of the incision, down to
the external oblique aponeurosis, and the external inguinal ring and the lower border of
the inguinal ligament are visualized (see the images below). Below the inguinal
ligament, on the medial aspect, the deep fascia of the thigh is opened, the femoral canal
exposed, and a check made for any concomitant femoral hernia. Although the risk is
very low, routine exploration of the femoral canal is advised in the absence of an
inguinal hernia and in women.
2. Division of external oblique aponeurosis and exposure of inguinal canal

The external oblique aponeurosis is then opened along the line of incision, starting
from the external ring and extending laterally for up to 5 cm (see the image below). The
ilioinguinal nerve, lying underneath the aponeurosis, is safeguarded during this

The superior and inferior flaps of the external oblique aponeurosis are gently
freed from the underlying contents of the inguinal canal and overturned and separated
to expose the cremaster with the cord structures, the ilioinguinal and iliohypogastric
nerves, the uppermost aponeurotic portion of the internal oblique muscle and conjoined
tendon, and the free lower border of the inguinal ligament (see the images below). Wide
separation of the two flaps provides ample space for placement and fixation of mesh
under vision while protecting the nerves.
3. Dissection of spermatic cord

The spermatic cord, along with the cremaster, is then lifted up and separated from
the pubic bone for about 2 cm beyond the pubic tubercle to create space for extending
the mesh well beyond the pubic tubercle.
When lifting the cord, the surgeon must be sure to include the ilioinguinal nerve, the
genitofemoral nerve, and the spermatic vessels along with it. All of these structures may
then be encircled in a tape for ease of handling. The anatomic plane between the
cremaster and the aponeurotic tissue attached to the pubic bone is avascular, and cord
structures encircled in the tape can be separated from the floor of the inguinal canal up
to the internal ring.
A visible landmark for safeguarding the genitofemoral nerve is the external spermatic
vein, usually referred to as the blue line. If the blue line is kept with the spermatic cord,
the surgeon can be sure that the genital branch of the genitofemoral nerve, which is
always adjacent to this vein, is well protected.

4. Identification and management of hernia sac

The cord structures and all of the nerves of the inguinal canal having been
visualized, the next step is to identify and isolate the hernia sac. The patient is asked to
cough, and the groin region is examined for the presence of an indirect hernia, a direct
hernia, a femoral hernia, a combined hernia, or a spigelian hernia.
A hernia sac can be managed by means of inversion, division, resection, or ligation.
Resection and ligation of a small hernia sac should not be performed unnecessarily,
because postoperative pain commonly results. However, the hernia sac must be well
separated from the internal ring before it is invaginated. The risk of recurrence is not
increased when a small or medium-sized indirect hernia sac is not ligated. Excision of
an indirect inguinal hernia sac is associated with a lower risk of hernia recurrence than
is division or invagination. When the hernia sac is excised or divided, the proximal sac
should never be left open; doing so may lead to recurrence. The proximal sac is
dissected free of cord structures well above the internal ring, and a high ligation of the
neck of the sac should be performed. The indirect hernia sac lies anterolateral to the
cord structures and is visualized by dividing the cremaster muscle longitudinally (see
the image below). The cremaster muscle should not be divided transversely or excised,
because doing so may result in low-lying testes and dysejaculation.
The peritoneal sac is identified and separated from the spermatic vessels and the
vas deferens up to its neck (see the images below). A small or medium-sized hernia sac
may be isolated and inverted into the preperitoneal space without suture ligation. For a
voluminous scrotal hernia sac, no attempt should be made to dissect it completely and
excise it; such an attempt can result in ischemic orchitis.
The neck of a large hernia sac is transected at the midpoint of the inguinal canal
(see the first image below), and the proximal part is suture-ligated. A high ligation of the
proximal sac is recommended, and the stump is reduced deep underneath the internal
ring (see the second image below). The distal sac is left in place; however, the anterior
wall of the distal sac is incised to prevent postoperative hydrocele formation.

A direct inguinal hernia lies posteromedial to the cord structures. The direct
hernia sac is isolated and dissected free. Its contents are reduced, and the peritoneal
sac is inverted and maintained in position with a purse-string suture.
If a femoral hernia is suspected, the femoral ring should be evaluated by incising the
medial part of the iliopubic tract. If a sac is seen entering the femoral ring, it is reduced
and dealt with by inverting or ligating the neck of the sac. A spigelian hernia is managed
in a similar manner. A sliding hernia is simply dissected free and inverted in the
preperitoneal space.

5. Placement and fixation of mesh

A 7.5 15 cm piece of polypropylene mesh is commonly used for a Lichtenstein

hernioplasty. On the medial side, the sharp corners of the mesh are trimmed to conform
to the patients anatomy. For a femoral hernia, the mesh is tailored so that it has a
triangular extension from its lower edge on its medial side. To compensate for future
shrinkage, the mesh should be wide enough to extend 3-4 cm beyond the boundary of
the inguinal triangle. To compensate for increased intra-abdominal pressure when the
patient stands up, the mesh should be placed lax in the posterior wall of the inguinal
canal in such a way that it acquires a domelike wrinkle. The first medialmost stitch fixes
the mesh 2 cm medial to the pubic tubercle, where the anterior rectus sheath inserts
into the pubic bone (see the image below). Care should be taken not to pass the needle
through the periosteum of the bone or through the pubic tubercle; this is one of the most
common causes of chronic postoperative pain.
The same suture is then used as a continuous suture to fix the lower edge of the
mesh to the free lower border of inguinal ligament up to a point just lateral to the internal
ring. No more than four or five passes are required.

For a femoral hernia, the medial portion of the iliopubic tract is excised, and the
Cooper ligament is exposed. The lower triangular extension on the medial side of the
mesh is stitched to the Cooper ligament, and the suture is continued to fix the lower
edge of the mesh to the inguinal ligament, as above. Next, a slit is made in the lateral
end of the mesh to create a narrower lower tail (the lower one third) and a wider upper
tail (the upper two thirds). The slit extends up to a point just medial to the internal
inguinal ring.
The upper tail is then passed underneath the cord in such a way as to position
the mesh posterior to the cord in the inguinal canal (see the image below), and the
spermatic cord is placed between the two tails of the mesh. The upper tail is then
crossed over the lower one, and the two tails are held in an artery forceps.

The two tails are then tucked together and fixed to the inguinal ligament just
lateral to the internal ring, thus creating a new internal ring made of mesh (see the first
image below). The tails are trimmed 5 cm beyond the internal ring and placed
underneath the external oblique aponeurosis.

Suturing the mesh beyond the internal ring is unnecessary; doing so may cause
injury to the femoral nerve. Similarly, fixation of the tails of the mesh to the internal
oblique muscle, lateral to the internal ring, may cause entrapment of the ilioinguinal
nerve. Trying to suture the two tails without crossing them or trimming the tails shorter
than 5-6 cm beyond the internal ring may result in recurrence at the deep inguinal ring.
If any of the nerves is injured or of doubtful integrity, it can be resected and its
proximal end ligated and buried within the fibers of the internal oblique muscle to keep
the stump of the nerve away from scarring. In male patients, the testes should always
be gently pulled back down to their normal scrotal position after fixation of the mesh.

6. Closure

Spermatic cord layers are closed with fine sutures, with care taken to avoid
damaging the cord contents. Hemostasis is ensured in the inguinal canal, which is then
closed by suturing the two flaps of the external oblique aponeurosis (see the images
below), with care taken not to injure the underlying ilioinguinal nerve. Suturing is started
laterally and continued medially, where an adequate opening is left at the newly created
superficial inguinal ring so as not to occlude the emerging spermatic cord.

Subcutaneous tissue is approximated with interrupted sutures to obliterate any

dead space, and the skin is approximated with sutures, clips, or adhesive strips (see the
images below). A subcuticular continuous stitch with 3-0 absorbable sutures obviates
any need for stitch or clip removal and provides better cosmetic results.
The operative site is cleaned and a sterile dressing applied. Local infiltration of a
long-acting anesthetic agent (eg, bupivacaine or ropivacaine) into the subcutaneous
tissue around the incision provides good immediate postoperative pain relief.


For open hernia repair surgery, a single long incision is made in the groin. If the
hernia is bulging out of the abdominal wall (a direct hernia), the bulge is pushed back
into place. If the hernia is going down the inguinal canal (indirect), the hernia sac is
either pushed back or tied off and removed.

The weak spot in the muscle wall-where the hernia bulges through-traditionally
has been repaired by sewing the edges of healthy muscle tissue together
(herniorrhaphy). This is appropriate for smaller hernias that have been present since
birth (indirect hernias) and for healthy tissues, where it is possible to use stitches
without adding stress on the tissue. But the surgical approach varies depending on the
area of muscle wall to be repaired and the surgeon's preference.

Mesh patches of synthetic material are now being widely used to repair hernias
(hernioplasty). This is especially true for large hernias and for hernias that reoccur.
Patches are sewn over the weakened area in the abdominal (belly) wall after the hernia
is pushed back into place. The patch decreases the tension on the weakened belly wall,
reducing the risk that a hernia will recur.
Surgical repair is recommended for inguinal hernias that are causing pain or other
symptoms and for hernias that are incarcerated or strangulated. Surgery is always
recommended for inguinal hernias in children. Infants and children usually have open
surgery to repair an inguinal hernia.

Open surgery for inguinal hernia repair is safe. The recurrence rate
(hernias that require two or more repairs) is low when open hernia
repair is done by experienced surgeons using mesh patches.
Synthetic patches are now widely used for hernia repair in both
open and laparoscopic surgery.

The chance of a hernia coming back after open surgery ranges

from 1 to 10 out of every 100 open surgeries done

Adults and children who have a hernia repair are at risk for:

Reaction to anesthesia (main risk).

Infection and bleeding at the site.
Nerve damage, numbness of skin, loss of blood supply to scrotum
or testicles resulting in testicular atrophy (all infrequent).
Damage to the cord that carries sperm from the testicles to the
penis (vas deferens), which results in an inability to father children.
Damage to the femoral artery or vein.
The following people need special preparation before surgery to reduce
the risk of complications:

Those with a history of blood clots in large blood vessels (deep vein
Those taking large doses of aspirin
Those taking anticoagulation medicines (such as warfarin or



a. Scalpel- used to cut on skin and muscle tissue to create a surgical


b. Needle holder- A needle holder, also called needle driver, is a surgical

instrument, similar to a hemostat, used by doctors and surgeons to hold a
suturing needle for closing wounds during suturing and surgical

c. Needle- is a medical device used to hold body tissues together after an

injury or surgery. Application generally involves using a needle with an
attached length of thread.
d. Thumb forceps-are commonly held between the thumb and two or three
fingers of one hand, with the top end resting on the first dorsal
interosseous muscle at the base of the thumb and index finger. Spring
tension at one end holds the grasping ends apart until pressure is applied.
This allows one to quickly and easily grasp small objects or tissue to move
and release it or to grasp and hold tissue with easily variable pressure.
Thumb forceps are used to hold tissue in place when applying sutures, to
gently move tissues out of the way during exploratory surgery and to move
dressings or draping without using the hands or fingers.

e. Tissue forceps-are used in surgical procedures for grasping tissue.

Often, the tips have "teeth" to securely hold a tissue. Typically tissue
forceps are designed to minimize damage to biological tissue.
f. Metzenbaum-are surgical scissors designed for cutting delicate tissue
and blunt dissection.

g. Army navy- is a surgical instrument with which a surgeon can either

actively separate the edges of a surgical incision or wound, or can hold
back underlying organs and tissues, so that body parts under the incision
may be accessed.
h. Mayo curve-are a type of surgical scissor, often used in the cutting of

i. Curve clamp-used by surgeons and medical professionals to cut off blood

flow or other fluids during surgery.

j. Mesh- There are many types of mesh products available, but surgeons
typically use a sterile, woven material made from a synthetic plastic-like
material, such as polypropylene. The mesh can be in the form of a patch
that goes under or over the weakness, or it can be in the form of a plug
that goes inside the hole. Mesh is very sturdy and strong, yet extremely
thin. It is also soft and flexible to allow it to easily conform to body's
movement, position, and size. Mesh is used in both tension-free and
laparoscopic tension-free hernia repairs.


Pre-operative Responsibilities:
Assist with the preparation of the room for the designated surgical procedure,
including gathering supplies for the procedure.
Scrub, Dry hands, and Glove.
Assist person scrubbed in first position with:
Setting up buck table, mayo, and basins
Arrangement of instruments.
Preparation of sutures and needles.
Preparation and counting sponges.
Arrangement and preparation of other necessary items.
Gowning and gloving surgeon and assistants.
Assist with draping.
Arrangement of sterile field.
Assure the electrosurgical dispersive pad is attached to the patient.
Intra-operative Responsibilities:
During the procedure, train self to keep eyes on field, and learn steps of
Begin developing methods of anticipating needs of surgeon and assistant.
Give the instrument needed by the surgeon.
After closing the skin:
Assist with care of instruments and counts if necessary.
Care of specimen.
Assist with wound dressing.
Post-operative Responsibilities:
After the completion of the procedure:
Assist with the gathering of all materials used in the procedure
Discard items as necessary being careful to discard sharp items in designated
Return all items to respective area
Assist with cleaning of room
Clean the materials used properly and arrange them after drying
Perform any duties which will speed up surgical procedure to follow in that room.

Pre-operative Responsibilities
Care for the patient before surgery by:
Greeting patient and assist nurse with identification.
Checking of patients chart, preparation, etc.
Checking IV Patency.
Prepare room by:
Obtaining instruments, supplies, and equipment for the designated operative
Opening unsterile supplies.
Assisting in gowning.
Observing breaks in sterile technique.
Assisting anesthesiologist as necessary.
Assisting with skin preparation and positioning.
Assisting with forming of the sterile field
Count the instruments, sharps, and sponges before the procedure and confirm
with the scrub nurse.

Intra-operative Responsibilities
During the procedure:
Remain in room and dispense materials as necessary.
Observe procedure as closely as possible.
Begin establishing method of anticipating needs of surgical team.
Care of specimen as indicated.
Care of operative records as indicated.
Before the closing, count all instruments, sharps, and sponges and confirm with
the scrub nurse.
Inform the surgeon and assistant surgeon of a report of the instruments.

Post-operative Responsibilities
Properly document all the necessary information on the patients chart.
Assist in the cleaning of the Operation room as necessary.



Inguinal hernia repair is one of the most commonly performed surgical

procedures in the world. Most surgeons now prefer to perform a tension-
free mesh repair. Hernioplasty is currently one of the most popular techniques for repair
of inguinal hernias. For open hernia repair surgery, a single long incision is made in the
groin. If the hernia is bulging out of the abdominal wall (a direct hernia), the bulge is
pushed back into place. Mesh patches of synthetic material are now being widely used
to repair hernias (hernioplasty).You should also be able to return to work after one or
two weeks, although you may need more time off if your job involves manual labour.
Gentle exercise, such as walking, can help the healing process, but you should avoid
heavy lifting and strenuous activities for about four to six weeks.

Most people who have open hernia repair surgery are able to go home the same
Recovery time is about 3 weeks.

You most likely can return to light activity after 3 weeks.

Strenuous exercise should wait until after 6 weeks of recovery.

Don't do anything that causes pain.

You'll probably be able to drive again in about 2 weeks or when you have no pain
in your groin.

You can have sexual intercourse in about 3 weeks.

Swelling over the incision is common after hernia surgery. It doesn't mean that
the surgery was unsuccessful. To reduce swelling and pain, put ice or a cold
pack on the area for 10 to 20 minutes at a time. Do this every 1 to 2 hours. Put a
thin cloth between the ice and your skin. Call your doctor if you have any of these

The incision is noticeably warm and red.

A testicle is hard and swollen.

Your wound is bleeding through your bandage.

You have a fever.

Reaction to anesthesia (main risk).

Infection and bleeding at the site.

Nerve damage, numbness of skin, loss of blood supply to scrotum or testicles

resulting in testicular atrophy (all infrequent).

Damage to the cord that carries sperm from the testicles to the penis (vas
deferens), which results in an inability to father children.

Warm or hot liquids are also recommended.

You do need to make sure you eat enough protein to repair the tissue damaged
by surgery. Adequate protein is also necessary for immune health and reducing
inflammation. To promote healing, you'll need 1 gram of protein for every 2
pounds of body weight. For example, if you weigh 150 pounds you need 75
grams of protein a day after surgery. Good sources of protein include seafood,
poultry, lean red meat, eggs, beans, tofu, eggs and low-fat dairy.

Immediately after surgery, you may feel sick to your stomach and need to follow
a clear liquid diet. This diet consists of transparent liquids and includes apple
juice, tea, broth, fruit ice and gelatin. The clear liquid diet can help you stay
hydrated after surgery but offers very little nutritional value and is low in calories.
It should only be followed for a short period of time.

Pain medications and lack of exercise may lead to constipation after your hernia
surgery. You may be able to improve bowel function by making sure you drink
plenty of fluids and eat fiber-rich foods. While fluid needs vary depending on your
activity and climate, you should aim for at least 8 cups a day. Water, 100-percent
fruit juice, unsweetened decaf tea or coffee and low-sodium broth make good
fluid choices. High-fiber food choices to help alleviate constipation include fruits,
vegetables, whole grains and beans.

During the first week rest at home, do not work and do not drive. You do not need
to remain in bed but do not walk more than is necessary to take care of your
basic needs: going.

Do not drive a car in the first week because early in your recovery you are an
impaired driver.

After four to six weeks you may resume normal activity without restriction. Your
surgeon will tell you if it is 4 or 6 for you as an individual. When resuming a
strenuous workout routine, it is advisable to start slow and easy and work your
way cautiously back up to your normal strain over the next month.
Routine follow-up care after operative repair of an inguinal hernia typically
requires only one office visit or telephone consultation if the parents have
reported no problems or complications. Scrotal swelling and bruising after
surgery are common and may last for 1-3 weeks.


After hernia repair surgery, the patient is taken to the post anesthesia care unit
(PACU). Patients are closely monitored by the nursing staff and remain there until they
are stable. The amount of time spent in the PACU depends on the patient's progress
and on the type of anesthesia they received. Patients given general anesthesia must be
awake and coherent before they leave the PACU. Ice chips are offered to the patient in
the PACU, and if those are tolerated, water is given. The intravenous line remains in
place until clear liquids can be taken and tolerated. This may occur almost immediately
following surgery, especially if a local anesthetic was used. Sometimes general
anesthesia can induce nausea, which may delay taking oral fluids. Once clear liquids
are tolerated, the diet progresses to solid foods.

Patients are transferred from the PACU to the outpatient or ambulatory unit,
where recovery is completed. Inpatients return to their room. Most patients go home
once they are up and walking around. Even though the anesthesia has worn off, most
patients remain groggy for the rest of the day. Patients must make arrangements for a
family member or friend to be with them upon discharge, if they are going home the day
of surgery.

Spinal anesthesia usually wears off within a few hours. In the first hour following
surgery, patients usually lie flat on their back to decrease the chance of an anesthetic-
induced headache, which can be painful and prolonged. A patient must regain full
sensation in the region of their body that was numbed before being discharged.

Patients experience pain at the incision site, especially conventional procedure

patients. Medication is prescribed and taken as directed. Swelling and discoloration
usually develops around the incision and eventually disappears in the healing process.
Some soreness can be expected during the first 24 to 48 hours. The tiny incisions made
during laparoscopic surgery are held together by sterile-strips that fall off in about a
week to 10 days. Patients can take a shower within two days after surgery. Regular
sutures or staples usually hold together the large incision made in the open procedure.
The wound must be kept dry until it begins to heal, so patients may have to take sponge
baths for the first few postoperative days to avoid getting the wound wet.

The laparoscopic hernia repair allows patients to return to their normal routine
much more quickly. Some people can return to work in just a few days. Recovery from
the conventional surgery takes a little longer because there is more pain and soreness
around the wound. Generally, a patient can be guided by the amount of discomfort they
feel. Any activity, such as driving, that causes pain and puts a strain on the incision
should be avoided until it can be comfortably tolerated. The same holds true for work.
People with desk jobs usually can return to work within a week or two. People whose
jobs require strenuous activity or heavy lifting may need several more weeks of healing
before they return to work.

Straining during a bowel movement also puts strain on the incision. It is therefore
important that patients eat a high-fiber diet and drink plenty of fluids to avoid
constipation. The physician may prescribe a stool softener.

Most doctors ask that their patients to return in about a week for a follow-up visit.
At this time, all stitches will be removed.

Medical Management/
Treatment Classification General Action Indication(s) or

This intravenous fluid

PNSS Isotonic volume 0.9% NaCl solution
is to maintain
(0.9 NaCl 1 L x 30 expander Sodium chloride is an
hydrostatic stability,
gtts/min) electrolysis supplement
treat hyponatremia,
agent; Sodium and and go with blood
chloride are important transfusions. Also, it is
electrolysis for the indicated for the
human body and mainly administration of
exist in extracellular intravenous

fluid, which play an medications before,

during and after
important role in
maintaining normal
volume of blood, and
extracellular fluid and
osmosis pressure.

Medical Management/ Classification General Action Indication(s) or
Treatment Purpose(s)

Generic Name: Cephalosporins, 2nd Cefoxitin is a Cefoxitin is indicated for

Cefoxitin Generation bactericidal agent that the treatment of serious
acts by inhibition of infections caused by
bacterial cell wall susceptible strains of
Brand Name: synthesis. Cefoxitin has the designated
Mefoxin activity in the presence microorganisms
of some beta-
lactamases, both
penicillinases and
cephalosporinases, of
Gram-negative and
Gram-positive bacteria.

Medical Management/ Classification General Action Indication(s) or

Treatment Purpose(s)

Generic Name: Aminoglycosides Gentamicin is a bactericidal To reduce the development

Gentamicin antibiotic that works by of drug-resistant bacteria
irreversibly binding the 30S and maintain the
subunit of the bacterial effectiveness of gentamicin
ribosome, interrupting and other antibacterial
protein synthesis. This drugs, gentamicin should
Brand Name:
mechanism of action is be used only to treat or
similar to other prevent infections that are
aminoglycosides. proven or strongly
suspected to be caused by
susceptible bacteria.
Medical Management/ Classification General Action Indication(s) or
Treatment Purpose(s)

Generic Name: Penicillins, Amino Ampicillin is in the Treating infections

Ampicillin penicillin group of beta- caused by certain types
lactam antibiotics and is of bacteria. Ampicillin is
part of the a penicillin antibiotic. It
aminopenicillin family. ... works by killing
It inhibits the third and sensitive bacteria by
Brand Name:
final stage of bacterial interfering with
cell wall synthesis in formation of the
binary fission, which bacteria's cell wall while
ultimately leads to cell it is growing.
therefore, ampicillin is
usually bacteriolytic.
Medical Management/ Classification General Action Indication(s) or
Treatment Purpose(s)

Generic Name: Narcotic Hydrocodone is a It is used for moderate to

Acetaminophen and semisynthetic narcotic anal moderately severe pain.
Hydrocodone gesic. The precise
mechanism of action of
Brand Name: hydrocodone and other
Vicodin opiates is not known,
although it is believed to
relate to the existence
of opiate receptors in the
central nervous system.
The analgesic action
of acetaminophen involves
peripheral influences, but
the specific mechanism is
as yet
undetermined. Antipyretic a
ctivity is mediated through
hypothalamic heat
regulating centers.
inhibits prostaglandin synth


Medical Management/ Classification General Action Indication(s) or

Treatment Purpose(s)

Generic Name: General Anesthesia It slows the activity of It is used to help you
Propofol the brain and nervous relax before and
system. during general
It produces its anesthesia for surgery
Brand Name: sedative/anesthetic or other medical
Diprivan, Propoven effects by the positive procedures. It is also
modulation of the used in critically ill
inhibitory function of the patients who require a
neurotransmitter GABA breathing tube
through the ligand- connected to a
gated GABA receptors. ventilator (a machine
that moves air in and
out of the lungs when a
person cannot breathe
on their own).



SUBJECTIV (Post- Herniorraphy Long Term Goal: INDEPENDEN Long Term:

E: Operative) (mechanical After 30 T: This can Client
The patient Acute pain trauma/tissue minutes of Note influence the shall
may related to injury) nursing location of amount of have
verbalize actual tissue intervention surgical pain reported
sakit ng damage the client will procedures. experienced reduction
tiyan ko secondary to Release of be able to presence of of pain
presence of Biochemical report known/ as
OBJECTIVE surgical mediators reduction of unknown evidence
: incision at pain from complications by the
The patient the RLQ of Sensitizations pain scale of may wake the pain
may the of nociceptors 9/10 it will be pain more scale
manifest: abdomen. reduced to severe than reduced
7/10. anticipated. from
Facial Release of Note when 9/10 to
grimace substance P pain occurs To medicate 7/10.
(neurotransmit (e.g. only prophylactical
Guarding ter that assist Short Term Goal: ambulation ly as Short Term:
behavior in After 15 every appropriate. Client
transmission minutes of evening) shall
Irritability of impulses nursing have
across the intervention Provide To promote identified
Controlled synapse) the client will comfort non- non-
moveme be able to measures pharmacologi pharmac
nts identify non- (assist in cal pain o-logical
A-delta fibers pharmacologi position management. methods

SUBJECTIV (Post- Occurrence of Long Term Goal: INDEPENDEN Long Term:

E: Operative) inguinal After 48 T: For Client
The patient Impaired Hernia hours nursing Assess comparative shall
may Tissue intervention surgical baseline. have
verbalize Integrity the client will wound displaye
Sobrang related to Need for be able to (location d
sakitna ng surgical intentional display size). Promo progressi
tahi ko incision at trauma progressive tes timely ve
RLQ of the (surgery) improvement Inspect interventions/ improve-
OBJECTIV abdomen. in wound wound daily revision of ment in
E: Incision at healing and for changes. plan of care. wound
The patient RLQ of the will prevent healing
may abdomen complication To and
manifest: to occur. Change prevent prevente
wound further d
Post- mash Impaired dressing complication. complica
Hernio- Tissue aseptically. - tion to
rraphy integrity Keep the occur.
Short Term Goal: wound dry
Controlled After series of and clean.
moveme nursing Cleanse the
nts Reference: intervention, area of Short Term:
Fundamental the client will wound Client
Surgical of Nursing, 7th be able to: gently with shall
incision Edition, Kozier Identify the use of have:
at RLQ appropriat required
of the e solution.

SUBJECTIVE: (Post- Occurrence Long Term INDEPENDE Long Term:

No cues Operative) of inguinal Goal: NT: To prevent Client shall have
Risk for Hernia The client Assess the spread of remained free
OBJECTIVE: infection to will remain surgical microorganis from any signs
The patient may actual tissue free from incision ms. and symptoms of
manifest: damage Need for any signs for infection.
Surgical secondary to intentional and localized
incisions presence of trauma symptoms sign of
at @RLQ surgical (surgery) of infection infection.
incision at after 24 Moisture
Post Mash RLQ Incision at hours of Change promotes
Herniorrha RLQ of the nursing surgical microbial Short Term:
phy abdomen interventio wound growth. Do Client
n. dressing this to shall have
as prevent identified
Skin is not Short Term indicated infection. methods
intact Goal: using that will be
The client aseptic useful in
will able to technique. reducing
Risk for identify the risk of
infection methods Keep To reduce acquiring
that will be wound bacterial infection.
useful in clean and colonization.
reducing dry.
the risk of To aid in
acquiring Remove blood
infection and circulation Client
after 8 replace and prevent shall have
hours of dressing if further demonstra
nursing it is respiratory ted
interventio already infection. techniques
n. soak. that will be
To determine useful in
The client Encourag its the
will be able e position effectiveness prevention
to changes and presence of
demonstrat and deep of untoward infection.
e breathing side effects.
techniques exercise.
that will be
useful in DEPENDEN
the T: To prevent Client
prevention Administe further shall have
of infection r and complicati verbalized
after 8 monitor ons. understan
hours of medicatio ding of
nursing n regimen individual
interventio and note risk factors
n. clients that will
response. prevent in
After 8 acquiring
hours of infection.
n the client
will be able
ing of
risk factors
that will
him in



SUBJECTIVE: (Pre-Operative) Invasion of Short Term INDEPENDE Short Term:
None Altered body microorgani Goal: NT Helps in Clients
temperature sm in the After 1-2 Promote reducing temperature
related to body hours of surface high shall have
inflammatory nursing cooling by temperat decreased
process Activation intervent means of ure. from 37.7C
OBJECTIVES: of ion rendering to at least
The patient may Leukocytes the patie tepid 37.5C.
manifest: nts body sponge
temperat bath.
Febrile (37.7 Activation of ure will
C) inflammator decreas To reduce
Warm to y Process e from Promote tension.
touch 37.7 C bed rest.
Weak in Activation of to at
appearance defense least To provide
Restless mechanism 37.5 C. Encourage comfort.
Cries at time the mother
of the body
to remove

Activation of wet

release of clothing
of the To maintain
pyrogen Discuss to hydration
the mother status of
Elevation of the the patient.
body importance
temperature of adequat
e fluid
intake of
the patient.


SUBJECTIVE (Post- Occurrence Short term goal: INDEPENDE Short term:

Client shall have:
: Operative) of inguinal After 3-5 hours of NT: To reduce
The patient Decreased Hernia nursing Provide tension.
may verbalize mobilization intervention comfort
di pa ako related to the client will be measures,
masyado discomforts on Need for able to: quiet
on his
makakilos operation site. intentional To move environme
trauma willingly nt, and
OBJECTIVE: (surgery) on his calm
The patient own. activities. To provide
may manifest: comfort to
Support technique
Incision at Demonst the
and assist s and
Irritability RLQ of the rate patient.
the client behaviors
Restlessn abdomen techniqu
in doing that
ess es and
Crying at such enables
times activities. safe
Skin is not s that To
intact enable Keep the prevent moving or
safe area clean infection. doing
moving and dry, activities.
or doing carefully
Start of activities dress
inflammator . wounds
y process and

Pain upon

V. Conclusion

Hernia is a term used to describe when an organ or fatty tissue squeezes through a
weak spot in a surrounding muscle or connective tissue called fascia. There are many types of
hernia. In this case report, the focus is on the inguinal type of hernia. In an inguinal hernia, the
intestine or bladder protrudes through the abdominal wall or into the inguinal canal in the groin.
The incidence of inguinal hernia has gradually declined in many industrialized countries as a
result of increased recognition and treatment of risk factors, which may include modifiable risk
factors such as smoking, obesity, and poor nutrition.

Public education is focused on prevention, recognition of manifestations, and early

treatment of inguinal hernia. As they say, prevention is better than cure. Hence, it is important
for each and every one of us to avoid these modifiable risk factors, and change sedentary
lifestyles to healthy lifestyles. Weight should be brought to a normal level, and smoking should
be stopped.

As student nurses, this case report showed us the importance of early detection of
conditions such as hernia since it may lead to more serious complications if not properly
managed or treated. Knowledge of the risk factors and preventive measures can help in
reducing the incidence of hernia. Prompt recognition, which allows for early correction of hernia,
is highly recommended to prevent further complications. Through this case report, may we be
able to help others to understand more about hernia and ways to prevent the said condition.

With this, the researchers realized that psychological and physical implications are
greatly involved in this procedure. Medically, the procedure may repair the area of concern.
However, the procedure repairs much more than that. Psychologically, the procedure may
eradicate the social stigma upon people with hernia due to their anatomy. This would definitely
improve his self-concept and hope over his condition. As aspiring nurses, the researchers
should always consider better patient outcomes so as to provide efficient and effective care
In addition to that, the researchers were able to be familiarized with the surgical
management, its benefits, and side effects to the patient during surgery.
VI. Reference/ Bibliography

Fundamentals of Nursing 7th edition, Kozier