This is a case study done by me as a part of my in-service education progamme in my institution...hope this may help all nurses who wants to do a case study.

1. CASE STUDY ON INGUINAL
HERNIA
BY. JIJO T GEEVARGHESE
STAFF NURSE L5W
DUBAI HOSPITAL

2. OBJECTIVES
AT THE END OF THE PRESENTATION THE AUDIENCE WILL BE ABLE TO
• Attain knowledge regarding the definition, incidence, etiology, signs and
symptoms of hernia
• Understand the surgical correction of inguinal hernia and complications after
surgery.
• Identify patients needs , carry out interventions according to the needs and
evaluate patients response to care.

3. DEFINITION
• An inguinal hernia is a protrusion of abdominal cavity
contents through the inguinal canal.

4. INCIDENCE
About 25% of males and 2% of females develop inguinal hernias; this is the most
common hernia in males and females
Indirect inguinal hernias are the most common hernias in both men and
women; a right-sided predominance exists.

5. CLASSIFICATION
There are two types of inguinal hernia based on their relationship to inferior
epigastric vessels
DIRECT INGUINAL
HERNIA
INDIRECT INGUINAL
HERNIA

6. DIRECT INGUINAL HERNIA
Direct inguinal hernias occur medial to the inferior epigastric vessels when
abdominal contents herniate through a weak spot in the fascia of the posterior
wall of the inguinal canal, which is formed by the transversalis fascia.

7. INDIRECT INGUINAL HERNIA
Indirect inguinal hernias occur when abdominal contents protrude through
the deep inguinal ring , lateral to the inferior epigastric vessels.

8. CLINICAL CLASSIFICATIONS
 Reducible hernia: is one which can be pushed back into the abdomen by putting manual pressure to it.
 Irreducible hernia: is one which cannot be pushed back into the abdomen by applying manual pressure.
• Irreducible hernias are further classified into
 Obstructed hernia-is one in which the lumen of the herniated part of intestine is obstructed but the
blood supply to the hernial sac is intact.
 Incarcerated hernia-is one in which adhesions develop between the wall of hernial sac and the wall of
intestine.
 Strangulated hernia- is one in which the blood supply of the sac is cut off, thus, leading to ischemia. the
lumen of the intestine may be patent or not.

9. PATHOPHYSIOLOGY
CONGENITAL
OBESITY
DEFECTS IN
MUSCULAR
WALL
HERNIA
PREGNANCY
TRAUMA
INCREASED
INTRAABDOMINAL
PRESSURE

10. ETIOLOGY









Increased pressure within the abdomen
A pre-existing weak spot in the abdominal wall
Straining during bowel movements or urination
Heavy lifting
Ascites
Pregnancy
Excess weight
Chronic coughing or sneezing
Peritoneal dialysis

11. SIGNS AND SYMPTOMS
• A bulge in the area on either side of your pubic bone
• A burning, gurgling or aching sensation at the bulge
• Pain or discomfort in the groin, especially when bending over, coughing or
lifting
• A heavy or dragging sensation in groin
• Weakness or pressure in your groin
• Occasionally, in men, pain and swelling in the scrotum around the testicles
when the protruding intestine descends into the scrotum
• Signs and symptoms in children
Inguinal hernias in newborns and children result from a weakness in the
abdominal wall that's present at birth. Sometimes the hernia may be visible
only when an infant is crying, coughing or straining during a bowel
movement. In an older child, a hernia is likely to be more apparent when
the child coughs, strains during a bowel movement or stands for a long
period of time.

12. INVESTIGATION
• A health care provider can confirm that you have a hernia during a physical
exam. The growth may increase in size when you cough, bend, lift, or strain.
• X-ray abdomen/CT Scan in case of strangulated inguinal hernia

13. CONSERVATIVE MANAGEMENT
• Hernias that or not strangulated or incarcerated can be mechanically reduced.
• A truss can be placed over the hernia after it has been reduced & left in place
to prevent the hernia from recurring.(truss is a firm pad held in place by a
belt)
• The client is taught to apply the truss daily before arising & to inspect the skin
underneath for any breakdown.

14. PICTURE OF TRUSS

15. SURGICAL MANAGEMENT
Inguinal hernia surgery refers to a surgical operation for the correction of an
inguinal hernia. Surgery is not advised in most cases, watchful waiting being the
recommended option . In particular, elective surgery is no longer recommended
for the treatment of minimally symptomatic hernias, due to the significant risk
of chronic pain (Post herniorraphy pain syndrome), and the low risk of
incarceration

16. REPAIR OF INGUINAL HERNIA

17. OPEN REPAIR (LICHTENSTEIN)
• The most commonly performed inguinal hernia repair today is the
Lichtenstein repair. A flat mesh is placed on top of the defect
• It is a "tension-free" repair that does not put tension on muscles
• It involves the placement of a mesh to strengthen the inguinal region.
• Patients typically go home within a few hours of surgery, often requiring no
medication beyond Paracetamol.
• Patients are encouraged to walk as soon as possible postoperatively, and
they can usually resume most normal activities within a week or two of the
operation.
• Recurrence rate is low, <2%.

18. LAPROSCOPIC INGUINAL HERNIA REPAIR

19. LAPROSCOPIC HERNIA REPAIR
• There are mainly two methods of laparoscopic repair:
• Transabdominal preperitoneal (TAPP)
• Totally extra-peritoneal (TEP) repair.
• When performed by a surgeon experienced in hernia repair, laparoscopic
repair causes less complications than Lichtenstein, and especially half less
chronic pain.

20. SURGICAL MANAGEMENT (CONTD.)
Laparoscopic mesh surgery, as compared to open mesh surgery
ADVANTAGES
DISADVANTAGES
Quicker recovery
Less risk of chronic pain
Needs surgeon highly experienced
Less pain during first days
Fewer postoperative complication of
bleeding
Longer operating time
Increased recurrence of primary hernias if
surgeon not experienced enough

21. MESHES
PERMANENT MESH
 Commercial meshes are typically made of prolene (polypropylene) or
polyester.
 Mosquito-net mesh-Meshes made of mosquito net clothes, in co-polymer of
polyethylene and polypropylene have been used for low-income.
ABSORBABLE MESH
 Biomeshes are increasingly popular since their first use in 1999.
 They are absorbable and they can be used for repair in infected
environment, like for an incarcerated hernia. Moreover, they seem to
improve comfort.

22. MESHES USED IN HERNIA REPAIR

23. COMPLICATION
 Pressure on surrounding tissues. Most inguinal hernias enlarge over time if they're not repaired
surgically. Large hernias can put pressure on surrounding tissues — in men they may extend into
the scrotum, causing pain and swelling.
 Incarcerated hernia. This complication of an inguinal hernia occurs when a loop of intestine
becomes trapped in the weak point in the abdominal wall. This may obstruct the bowel, leading
to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas.
 Strangulation. When part of the intestine is trapped in the abdominal wall (incarcerated hernia),
blood flow to this portion of the intestine may be diminished. This condition is called
strangulation, and it may lead to the death of the affected bowel tissues. A strangulated hernia is
life-threatening and requires immediate surgery

24. COMPLICATIONS
 Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater
than 3 months after surgery of inguinal hernia.
 Hernia recurrence.. Recurrence is the most common complication of inguinal hernia repair,
causing patients to undergo a second operation. Hernia recurrence occurs less often when a
hernioplasty is performed.
 Bleeding. Bleeding inside the incision of hernia repair.It can cause severe
swelling and bluish discoloration of the skin around the incision.It is unusual and occurs in
less than 2 percent of patients
 Wound infection. The risk of wound infection is small—less than 2 percent,and is more likely
to occur in older adults and people who undergo more complex hernia repair.
 Injury to internal organs. Although extremely rare, injury to the intestine, bladder, kidneys,
nerves and blood vessels leading to the legs, internal female organs, and vas deferens.

25. COMPLICATION OF MESH REPAIR
Complications are frequent (>10%). They include, but are not limited to:
 foreign-body sensation
 chronic pain
 ejaculation disorders
 mesh migration
 mesh folding
 Infection
 adhesion formation
 erosion into intraperitoneal organs
In the long term, polypropylene meshes face degradation, due to heat effects. This increases the
risk of stiffness and chronic pain. Persistent inflammation and increased cell turnover at the
mesh-tissue interface raised the possibility of cancer transformation.

26. NURSING MANAGEMENT (GENERAL)
 Alteration in comfort pain related to disease condition
 Alteration in comfort pain related to surgical intervention
 Nursing interventions
 Fit the patient with truss/belt when hernia is reduced if ordered
 Evaluate signs and symptoms of hernia
incarceration/strangulation
 Give stool softeners as directed

27. NURSING MANAGEMENTS CONTD.
• Teach about bed rest , intermittent icepacks ,and scrotal elevation to reduce scrotal
edema or swelling.
• Encourage ambulation as permitted
• Advise patient that difficulty in urination is common after surgery , promote
elimination to eliminate as necessary or catheterise the patient.
• Teach about bed rest , intermittent ice packs and scrotal elevation to reduce scrotal
edema or swelling.
• Encourage ambulation as permitted
• Advise patient that difficulty in urination is common after surgery,promote
elimination to eliminate as necessary or catheterise the patient.
• Preventing infection
• Check dressing for drainage &incision for redness and swelling.
• Monitor for signs/symptoms of infection
• Administer antibiotics if appropriate

28. PATIENT EDUCATION
• Advise that pain and scrotal swelling may be present for 24-48 hours after
repair of an inguinal hernia.
• Apply ice intermittently
• Elevate scrotum,and use scrotal support
• Take medication prescribed to relieve discomfort
• Teach to monitor self for signs of infection.
• Report continued difficulty in voiding
• Avoid heavy lifting for 4-6 weeks.Athletics and extremesof exertion to be
avoided for 8-12 weeks post operatively

29. PATIENTS DETAILS

30. DEMOGRAPHIC DATA
• NAME: XYZ
• AGE: 70 YEARS
• SEX: Male
• NATIONALITY: PAKISTANI
• DATE OF ADMISSION: 05-08-2013
• DATE OF DISCHARGE: 10-08-2013
• DIAGNOSIS: LEFT INGUINAL HERNIA
• PROCEDURE: OPEN LEFT INGUINAL HERNIA MESH REPAIR.

31. PRESENT SURGICAL HISTORY
Mr. XYZ admitted for Elective inguinal hernia repair on 06/08/13.He had a left
groin swelling of one month duration. He is known case of Diabetes mellitus and
hypertensive for 10 years and is on regular medications.No significant past
surgical history.

32. GENERAL APPEARANCE
He is moderately built.
Maintains a erect posture and steady gait.
Hygiene and Grooming: Looks cleans and tidy. Maintains
his personal hygiene.
MOOD: Calm and Co operative.

33. FAMILY HISTORY
He is married with five children. He has a good famly
support in the home.
SOCIO ECONOMIC STATUS : He is a retired from job. He has
middle class socio economis status.

34. NUTRITIONAL HISTORY
He is a Non-vegetarian. He likes to eat red meat and fried food. He eats three
meals per day and snacks in between. He is moderately built.

35. PHYSICAL EXAMINATION
• Groin: A 3 x 4 cm Left Inguinal Swelling that is reducible and non tender on
palpitation associated with scrotal swelling.
• All other system review remained normal.

36. BASELINE DATA
•
•
•
•
•
•
•
•
•
•
VITAL SIGNS:
TEMPERATURE-36.5 C
BP-138/84 mm of Hg
Pulse:82 Beats/minute
Respiration:24 Breaths/minute
Oxygen saturation:99%(room air)
Height:156cm Weight:68kgs BMI:24
Braden Score:23
Oral Score:7
Fall score:0

37. INVESTIGATIONS
DESCRIPTION
VALUE
UNIT
RANGE
WBC COUNT
8.4
10^3uL
3.6-11.0
RBC COUNT
4.84
10^6uL
4.5-6.00
HGB
17.4
g/dL
13.0-18.0
HCT
16.3
%
40.0-52.0
PLATELET
231
10^3uL
150-400
CREATININE
1.00
mg/dL
0.7-1.2
UREA
22
mg/dL
12-40
P0TASSIUM
4.7
mmol/L
3.3-4.8
SODIUM
138
mmol/L
136-145
CHLORIDE
112
mmol/L
98-108
HIV
NEGATIVE
HbsAg
NEGATIVE
37

38. MEDICATIONS
NAME
DOSE
ROUTE
FREQUENCY
DURATION
INJ ZINACEF
750MG
IV
TDS
5DAYS
INJ FLAGYL
500MG
IV
TDS
5DAYS
INJ PARACETAMOL
1GM
IV
TDS
5DAYS
INJ TRAMADOL
100MG
IM
PRN,TDS
1DAYS

39. NURSING CARE PLAN(PRE-OP)
Assessment Diagnosis
Objective
intervention
evaluation
Patient
has
repeated
doubts
regarding
surgery
Patient is
free from
fear and
anxiety
•Assess the anxiety level
of the patient
•Explain to the patient
all procedures in simple
terms
•Introduce the patient to
similar patients who had
under gone surgery
Diversion therapy
Patient is
relieved of
fear and
anxiety
Fear and
anxiety
related to
hospitaliza
tion.
39

40. Assessment
diagnosis
objective
intervention
evaluati
on
Patient asks
doubts
regarding
pre op
preparation
Knowledge
deficit
regarding
pre and post
operative
care
Patient gains
adequate
knowledge
regarding
pre
&postoperati
ve care
•Assess the
knowledge level of
the patient
•Explain to the
patient regarding the
need for npo,pre
operative skin
preparation, site
marking.
•Explain regarding
post op pain
management, early
mobilisation,splintin
g technique.
Patient
verbaliz
ed
importa
nce of
pre op
nil by
mouth
and
importa
nce of
early
mobilisa
tion.
40

41. NURSING CARE PLAN (POST OP)
Assessment
Diagnosis
Objective
Patient
verbalizes
pain over the
operated
site.
Heart rate 100/minute
Alteration in Patient gets
comfort pain relief from
related to
pain
surgical
intervention
Interventions Evaluation
•Assess the
pain level of
the patient
•Provide
comfortable
position to
the patient
•Instruct the
patient to
splint the
surgical site
while
coughing/
moving
•Diversion
therapy
•Administer
analgesics
as ordered
Analgesics
given.
advised
splinting
techniques.
patient
resting
comfortably.
41

42. Assessment
Diagnosis
Objective
Intervention
Evaluation
Patient nil by
mouth since
previous day
midnight.
Lips dry.
High risk for
fluid volume
deficit related
to nil by
mouth status
Patient
maintains
normal fluid
volume.
•Assess the
level of
hydration of
the patient.
•Monitor vital
signs
•Monitor
urine output
•Maintain
intake output
chart
•Administer iv
fluids as
ordered.
Patient
maintains
normal fluid
volume.has
adequate
urine output.
42

43. Assessment
Diagnosis
Objective
Interventions
Evaluation
Patient has
undergone
open hernia
repair with
mesh
Patient is
having a
redivac drain
High risk for
bleeding
related to
surgical
intervention
Patient
remains free
fro bleeding
from the
surgical site
•Assess the
post
operative site
for any
bleeding or
oozing
•Monitor
drain output
•Monitor vital
signs
Post
operative
dressing site
dry and
intact
Drain within
normal limits
43

44. Assessment Diagnosis
Objective
Intervention Evaluation
Patient has
under gone
hernia
repair with
mesh
Patient
remains
free from
infection
•Assess the
post
operative
dressing for
any
discharge
•Assess the
post
operative
site for any
redness or
oozing
•Monitor
vital signs
•Administer
antibiotics
as ordered
High risk
for
infection
related to
surgical
intervention
Patient
didn’t
developed
any post
operative
infection.
44

45. COURSE OF HOSPITAL STAY
• 05-08-13-Admitted electively for left inguinal hernia repair. Site marking and
skin preparation done.NPO instructed from mid night.
• 06-08-13-undergone open left inguinal hernia with mesh repair under general
anaesthesia. He received Zinacef1.5g intraoperatively. Received with one
redivac drain in situ. Received him conscious , coherent. Post operative
dressing dry and intact. Post Op orders to start full diet when fully awake.
Continue observation.
• 07-08-13 - started on fulldiet , mobilisation, change dressing, mark drain
• 08-08-13 - drain marked at 70ml, full diet, pressure dressing.
• 09-07-13- antibiotics changed to oral zinacef 500mg BD, mark drain, pressure
dressing.

46. COURSE OF HOSPITAL STAY (CONTD.)
• 10-08-13 - to remove drain and discharge by evening. To continue full diet and
oral antibiotics.
• CONDITION AT DISCHARGE:
afebrile, vitally stable, pain free ,clean wound and free of infection.
DISCHARGE MEDICINES:
Tab Zinnat500mg BD*5DAYS
Tab Paracetamol1g TDS PRN

47. DISCHARGE INSTRUCTIONS
• Avoid heavy lifting and strenuous exercises for 6-8 weeks.
• Maintain personal hygiene.
• Continue with oral antibiotics and PRN analgesics as ordered.
• Monitor for signs of infection and to report to emergency if so.
• Encouraged to have vitamin C and protein rich food.

48. QUESTIONS
• What is inguinal hernia?
• What are the signs & symptoms of inguinal hernia?
• Which are the two types of hernia repair?
• What are the complications after hernia surgery?
• What are the discharge instructions to the patient?

49. CONCLUSION
• An inguinal hernia can occur any time from infancy to adulthood and is much
more common in males than females. Inguinal hernias may be repaired
through surgery. Surgery for inguinal hernia is usually done on an outpatient
basis. Recovery time varies depending on the size of the hernia, the technique
used, and the age and health of the patient.