A hernia occurs when all or part of a viscus protrudes from a normal location in the body. Most hernias are protrusions of part of the abdominal viscus through the abdominal wall. Although many kinds of abdominal hernias are possible, inguinal hernias are most common.
With an inguinal hernia, the large or small intestine, omentum, or bladder protrudes into the inguinal canal. Hernias can be reducible, incarcerated, or strangulated.
In males, during the 7th month of gestation, the testes normally descend into the scrotum, preceded by the peritoneal sac. If the sac closes improperly, it leaves an opening through which the intestine can slip. In either sex, a hernia can result from weak abdominal muscles or increased intra-abdominal pressure. An inguinal hernia may be indirect or direct.
An indirect inguinal hernia, the more common hernia, results from weakness in the fascial margin of the internal inguinal ring. This type of hernia enters the inguinal canal through the internal inguinal ring and emerges through the external inguinal ring. The hernia extends down the inguinal canal into the scrotum or labia.
An indirect inguinal hernia may develop at any age, is three times more common in males, and is especially prevalent in infants younger than age 1.
A direct inguinal hernia results from a weakness in the fascial floor of the inguinal canal. Portions of the bowel or omentum protrude through the floor of the inguinal canal to emerge through the external ring extending above the inguinal ligament. Instead of entering the canal through the internal ring, the hernia passes through the posterior inguinal wall, protrudes directly through the fascia transversalis of the canal (in an area known as Hesselbach’s triangle), and comes out at the external ring.
Inguinal hernia usually causes a lump over the herniated area when the patient stands or strains. The lump disappears when the patient is in a supine position. Tension on the herniated contents may cause a sharp, steady pain in the groin, which fades when the hernia is reduced.
Strangulation produces severe pain and may lead to partial or complete bowel obstruction and even intestinal necrosis. Partial bowel obstruction may cause anorexia, vomiting, pain and tenderness in the groin, an irreducible mass, and diminished bowel sounds. Complete obstruction may cause shock, high fever, absent bowel sounds, and bloody stools. In an infant, it’s common for an inguinal hernia to coexist with an undescended testis or a hydrocele.
In a patient with a large hernia, physical examination reveals an obvious swelling or lump in the inguinal area. In a patient with a small hernia, the affected area may simply appear full. Palpation of the inguinal area while the patient is performing Valsalva’s maneuver confirms the diagnosis.
To detect a hernia in a male patient, the patient is asked to stand with his ipsilateral leg slightly flexed and his weight resting on the other leg. The examiner inserts an index finger into the lower part of the scrotum and invaginates the scrotal skin so the finger advances through the external inguinal ring to the internal ring (1 ½" to 2" [4 to 5 cm] through the inguinal canal). The patient is then told to cough. If the examiner feels pressure against the fingertip, an indirect hernia exists; if pressure is felt against the side of the finger, a direct hernia exists.
A patient history of sharp or “catching” pain when lifting or straining may help confirm the diagnosis. A suspected bowel obstruction requires X-rays and a white blood cell count (which may be elevated).
gender iNFLUENCE Many symptomatic inguinal hernias go undiagnosed in women because they’re nonpalpable. Obesity, a family history, and obstipation are risk factors.
If the hernia is reducible, the pain may be temporarily relieved by pushing the hernia back into place. A truss may keep the abdominal contents from protruding into the hernial sac, although it won’t cure the hernia. This device is especially beneficial for an elderly or a debilitated patient for whom surgery is potentially hazardous.
Clinical tip Don’t try to reduce an incarcerated hernia because this may induce bowel perforation. If severe intestinal obstruction arises because of hernial strangulation, a nasogastric tube may be inserted promptly to empty the stomach and relieve pressure on the hernial sac.
Herniorrhaphy, the treatment of choice, returns the contents of the hernial sac to the abdominal cavity and closes the opening. This procedure is commonly performed laparoscopically under local anesthesia as an outpatient procedure.
Another effective surgical procedure is hernioplasty, which reinforces the weakened area with steel mesh, fascia, or wire. Complications include urine retention, wound infection, hydrocele formation, and scrotal edema.
A strangulated or necrotic hernia necessitates bowel resection. Rarely, an extensive resection may require temporary colostomy. In either case, resection lengthens postoperative recovery and requires an antibiotic, parenteral fluid, and electrolyte replacement.
❑ Apply a truss only after hernia reduction. For best results, apply it in the morning, while the patient is in bed.
❑ Watch for signs of incarceration and strangulation.
❑ Before surgery, closely monitor the patient’s vital signs. Administer I.V. fluids and an analgesic for pain as needed. Control fever with acetaminophen or tepid sponge baths as necessary. Place the patient in Trendelenburg’s position to reduce pressure on the hernia site.
❑ After surgery, evaluate the patient’s ability to void. Check the incision and dressing at least three times per day for drainage, inflammation, and swelling. Check for normal bowel sounds, and watch for fever.
❑ Observe the patient carefully for postoperative scrotal swelling. To reduce such swelling, support the scrotum with a rolled towel and apply an ice bag.
❑ Encourage fluid intake to maintain hydration and prevent constipation. Teach deep-breathing exercises, and show the patient how to splint the incision before coughing.
❑ Before discharge, warn the patient against lifting or straining. Also, tell him to watch for signs of infection at the incision site and to keep the incision clean and covered until the sutures are removed.
Review other book chapters online related to Hernia:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5 
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