A hernia occurs when part of an internal organ protrudes through an abnormal opening in the containing wall of its cavity. Hernias typically occur in the abdominal cavity. Although many kinds of abdominal hernias are possible, inguinal hernias (also called ruptures) are most common. (See Common sites of hernia, page 726.) In an inguinal hernia, the large or small intestine, omentum, or bladder protrudes into the inguinal canal. Hernias can be reduced (if the hernia can be manipulated back into place with relative ease), incarcerated (if the hernia can’t be reduced because adhesions have formed, obstructing the intestinal flow), or strangulated (part of the herniated intestine becomes twisted or edematous, seriously interfering with normal blood flow and peristalsis, and possibly leading to intestinal obstruction and necrosis).
An inguinal hernia may be indirect or direct. An indirect inguinal hernia, the more common form, results from weakness in the fascial margin of the internal inguinal ring. In an indirect hernia, abdominal viscera leave the abdomen through the inguinal ring and follow the spermatic cord (in males) or round ligament (in females); they emerge at the external ring and extend down the inguinal canal, commonly into the scrotum or labia. An indirect inguinal hernia may develop at any age, is more common in males, and is especially prevalent in infants younger than age 1. According to the American Academy of Pediatrics, about 5 out of 100 children have inguinal hernias.
A direct inguinal hernia results from a weakness in the fascial floor of the inguinal canal. Instead of entering the canal through the internal ring, the hernia passes through the posterior inguinal wall, protrudes directly through the transverse fascia of the canal (in an area known as Hesselbach’s triangle), and comes out at the external ring.
In males, during the seventh month of gestation, the testicle normally descends 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 (caused by congenital malformation, trauma, or aging) or increased intra-abdominal pressure (due to heavy lifting, pregnancy, obesity, or straining).
About 10% of people develop some type of hernia during their lifetime, and more than 500,000 hernia operations are performed in the United States each year. Hernias are seven times more common in males than in females.
Inguinal hernia usually causes a lump to appear over the herniated area when the patient stands or strains. The lump disappears when the patient is supine. 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, an inguinal hernia commonly coexists with an undescended testicle or a hydrocele.
In a patient with a large hernia, physical examination reveals an obvious swelling or lump in the inguinal area. In the 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 (about 1 ½" to 2" [4 cm 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. Suspected bowel obstruction requires X-rays and a white blood cell count (may be elevated).
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; however, this won’t cure the hernia. This device is especially beneficial for an elderly or debilitated patient for whom surgery might be hazardous.
For infants, adults, and otherwise healthy elderly patients, herniorrhaphy is the treatment of choice. Herniorrhaphy replaces the contents of the hernial sac into the abdominal cavity and closes the opening. In many cases, this procedure is performed under local anesthesia in a short-term unit or as a single-day admission. Another effective surgical procedure for repairing hernia is hernioplasty, which reinforces the weakened area with steel mesh, fascia, or wire.
A strangulated or necrotic hernia necessitates bowel resection. Rarely, an extensive resection may require temporary colostomy. In either case, bowel resection lengthens postoperative recovery and requires antibiotics, parenteral fluids, and electrolyte replacement.
Care includes managing symptoms to increase patient comfort and prevent worsening.
❑ Apply a truss only after a hernia has been reduced. For best results, apply it in the morning, before the patient gets out of bed.
❑ To prevent skin irritation, tell the patient to bathe daily and apply cornstarch or baby powder. Warn against applying the truss over clothing because this reduces the effectiveness of the truss and may make it slip.
❑ If incarceration and strangulation occur, don’t try to reduce the hernia because this may perforate the bowel. If severe intestinal obstruction develops because of hernial strangulation, inform the physician immediately. A nasogastric tube may be inserted promptly to empty the stomach and relieve pressure on the hernial sac.
❑ Before surgery for an incarcerated hernia, closely monitor the patient’s vital signs. Administer I.V. fluids and analgesics, as ordered. Place the patient in Trendelenburg’s position to reduce pressure on the hernia site.
❑ Give special reassurance and emotional support to a child and parents when hernia repair is scheduled. Encourage him to ask questions, and answer them as simply as possible. Offer appropriate diversions to distract him from the impending surgery.
❑ After outpatient surgery, make sure that the patient voids before he leaves the hospital. Teach him to check his incision and dressing for drainage, inflammation, or swelling and to watch for fever. If any of these occur, he should notify the physician.
❑ To reduce scrotal swelling, have the patient support the scrotum with a rolled towel and apply an ice bag.
❑ Instruct the patient to drink plenty of fluids to maintain hydration and prevent constipation.
❑ Before discharge, warn the patient against lifting heavy objects or straining during bowel movements. In addition, tell him to watch for signs and symptoms of infection (oozing, tenderness, warmth, and redness) at the incision site and to keep the incision clean and covered until the sutures are removed.
❑ Advise the patient not to resume normal activity or return to work without the surgeon’s permission.
Review other book chapters online related to Inguinal hernia:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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