HERNI

A
 Types of Hernia:

Reducible- returns back

Incarcerated- trapped
Strangulated- necrotic
 Diaphragmatic Hernia
vIt is a condition wherein abdominal
organs protrude through an opening in
the diaphragm.

vProblem
Frequently associated anomalies include
cardiac defects, chromosomal anomalies
(ie, trisomies 21, 18, and 13), renal
anomalies, genital anomalies, and
neural tube defects.

vFrequency
 vETIOLOGY:
vRelevant embryology
vCauses:
qGenetic factors: unknown
qOther causes: The role of drugs
and environmental chemicals in the
development of CDH is uncertain,
but nitrofen, quinine, thalidomide,
phenmetrazine, and polybrominated
diphenyls have been used to induce
CDH in various species.
 Clinical
Manifestations
Clinical Presentation
vPostnatal

Infant may appear normal at birth but rapidly

develops respiratory distress
deep and labored breathing
gasping and irregular with deep sternal and costal
retraction
In the physical examination, the abdomen is
scaphoid if significant visceral herniation is present.
On auscultation, breath sounds are diminished,
bowel sounds may be heard in the chest, and heart
sounds are distant or displaced.
Cool extremities and diminished peripheral pulses
vLate presentation

Patients may present outside

of the neonatal period with
intestinal obstruction, bowel
ischemia, and necrosis
following volvulus.
DIAGNOSTIC
● Lab Studies
• Postnatal
– Assess arterial blood gases.
– Hypoxemia, hypercarbia, and respiratory or
metabolic acidosis depend on the degree of
pulmonary hypoplasia, persistent pulmonary
hypertension of newborn (PPHN), right-to-left
shunting, and ventricular function.
 ● Imaging Studies
 Radiographic Examination
 it shows fluid and air filled lops of intestine in the affected side of
he chest
 80% is present on the left side
• Chest radiography
– An early chest radiograph is obtained to confirm the diagnosis of
CDH.
– Findings include loops of bowel in the chest, mediastinal shift,
paucity of bowel gas in the abdomen, and presence of the tip of a
nasogastric tube in the thoracic stomach. Repeated chest
radiographs may reveal a change in the intrathoracic gas pattern.
– Right-sided lesions are difficult to differentiate from
diaphragmatic eventration and lobar consolidation.
• Echocardiography
– Further investigations should include early echocardiography,
which may reveal cardiac defects, decreased left ventricular
mass, poor ventricular contractility, pulmonary and tricuspid valve
regurgitation, and right-to-left shunting.
– Repeated echocardiography is recommended to measure changes
TREATME
● Medical therapy
• emphasis on the management of pulmonary
hypoplasia and persistent pulmonary
hypertension.
• Immediately following delivery, the infant is
intubated (bag and mask ventilation is
avoided). A nasogastric tube is passed to
decompress the stomach and to avoid visceral
distention.
• Adequate assessment involves continuous
cardiac monitoring, arterial blood gas and
systemic pressure measurements, urinary
catheterization to monitor fluid resuscitation,
and both preductal (radial artery) and
● Surgical therapy
No ideal time for repair of CDH exists

window of opportunity is 24-48 hours after

birth to achieve normal pulmonary arterial
pressures and satisfactory oxygenation and
ventilation with minimal ventilator settings
 ● Preoperative details
ventilatory management of the
newborn

determining if the patient has

any other associated congenital
anomalies, particularly cardiac
abnormalities

An echocardiogram should

● Intraoperative details
subcostal incision is made
abdominal viscera are examined
hernia is reduced by gentle traction
careful dissection of the posterior leaf of
the diaphragm
primary repair - nonabsorbable sutures
Large diaphragmatic defect - Gore-Tex
patch, or rotational muscle flaps (Scaife,
2003) or fascial flaps (Okazaki, 2005)
If the patient is stable = malrotation
is corrected
use of chest tubes
patient with a right-sided defect and
an intrathoracicliver = kinking of the
hepatic veins and the inferior vena
cava can accompany the return of the
liver to the abdomen.
Careful manipulation of the liver into
the abdomen must be accompanied
by hemodynamic monitoring
• 2-cavity (right chest and abdomen) approach
• Thoracotomy
• ECMO = X = increased mortality rate, surgical
site hemorrhage, and intracranial hemorrhage
(Wilson, 1994)
• Intraoperative and postoperative blood loss is
decreased with the following:
– Use of electrocautery for skin incision
– No dissection of the posterior leaf if primary
repair is unlikely
– Use of prosthetic patch repair
– Limited blunt and sharp dissection
– Judicious use of electrocautery
– Application of topical thrombin to the suture line
COMPLICATIONS
• Complications observed in the
early postoperative period
include recurrent pulmonary
hypertension and deterioration in
respiratory mechanics and
gaseous exchange (Adzick,
1998).
• Less commonly observed
complications are the disruption
of the suture line, recurrence of
the diaphragmatic hernia,
leakage of peritoneal fluid and
blood into the thorax, and
development of an ipsilateral
 NURSING
CONSIDERATIONS
vPreoperative:
• Reduce stimulation –
environmental care/activities
• Prompt recognition
• Maintain suction, oxygen, and IV
fluids
• Positioning – head up
• Administer medications

vPostoperative:
• Carry out postoperative care and
observation
• Relieve pain and provide comfort
• Support family because this is a
critical illness
Independent
Management:
Allow he
head of the
infant
elevated
Turning the
Collaborative
Endotracheal
Intubation and
oxygen
administration
Nasogastric
tubing
 Inguinal hernia
vDefinition
Inguinal hernias occur when
soft tissue — usually part of
the intestine — protrudes
through a weak point or
tear in your lower
abdominal wall (inguinal
ring).
Symptoms
Signs and symptoms
in children
may be visible only when an
infant is crying, coughing or
straining during a bowel
movement
more apparent when the child
coughs, strains during a bowel
movement or stands for a long
period of time
 Other Symptoms:
you can see and feel the bulge created by
the protruding intestine – when you stand
upright, cough, or strain
Pain or discomfort in your groin, especially
when bending over, coughing or lifting
A heavy or dragging sensation in your
groin 
Occasionally, in men, pain and swelling in
the scrotum around the testicles when the
protruding intestine descends into the
scrotum
 Causes
a result of increased pressure within
the abdomen
a pre-existing weak spot in the
abdominal wall
a combination of the two
In men, the weak spot usually occurs
along the inguinal canal
In women, the inguinal canal carries a
ligament that helps hold the uterus in
place
More common in MEN
Men are more likely to
have an inherent weakness
along the inguinal canal
than women are because of
the way males develop in
the womb
 Risk factors
Family history
Certain medical conditions
Chronic cough
Certain occupations
Excess weight
Pregnancy
Chronic constipation
History of hernias
Premature birth
Tests and
diagnosis
physical
exam
cough or
strain test
 Complications
pain and swelling
a loop of intestine becomes trapped
in the weak point in the abdominal
wall = BOWEL OBSTRUCTION =
severe pain, nausea, vomiting and
the inability to have a bowel
movement or pass gas
strangulated hernia = NECROSIS OF
AFFECTED BOWEL TISSUE
Treatme
nt
two general types of
hernia operations:
Herniorrhap
hy
Hernioplast
NURSING
CONSIDERATIONS
Health teaching for
Prevention:
§ Maintain a healthy weight
§ Emphasize high-fiber foods
§ Lift heavy objects carefully
or avoid heavy lifting
altogether
§ Stop smoking
§ Don't rely on a truss for
support
 Umbilical Hernia
Definition:

An umbilical hernia, or belly button

hernia, is a condition in which a
defect or hole exists in the
abdominal wall at the level of the
umbilicus (belly button).
 Symptoms
soft swelling or bulge near the navel
(umbilicus) - less than one-half inch to about 2
inches (about 1 to 5 centimeters) in diameter
-may notice the bulge only when the
baby cries, coughs or strains
-the bulge may disappear when the
baby is calm or lies on his or her back
usually painless
 Causes
During pregnancy, the umbilical
cord passes through a small
opening in the baby's abdominal
muscles. The opening normally
closes before birth. If the muscles
don't meet together in the midline
completely, this weakness in the
abdominal wall may cause an
umbilical hernia at birth or later in
 Risk factors
Prematurity
Low birth weight infants
Black infants
The condition affects boys
and girls equally
Tests and
physical
exam
imaging
studies — such
as an
abdominal
ultrasound or
 Complications
the protruding abdominal
tissue becomes trapped
(incarcerated) and can no
longer be pushed back into
the abdominal cavity = lack
of blood flow = umbilical
pain and tissue damage
 Treatments
Most umbilical hernias close on their own
by age 1
The doctor may even be able to push the
bulge back into the abdomen during a
physical exam.
For children, surgery is typically reserved
for large or painful umbilical hernias or
those that:
§ Get bigger after age 1 or 2
§ Don't disappear by age 4
Types of surgery that
may be done

Open primary repair.

Surgery to improve
appearance of navel
 NURSING
CONSIDERATIONS
Discourage use of home
remedies (belly bands,
coins)
Support parents and
significant others
Medications for pain control
Diet – nausea after surgery
Activity – restriction
Wound care