Incarcerated Indirect Inguinal Hernia

Pathophysiology
● Most commonly results from incomplete obliteration of processus vaginalis; during fetal
development (but can also be acquired).
● May not become apparent until adulthood despite being present since birth.
● Lateral to the inferior epigastric blood vessels (outside Hesselbach triangle)
● Runs from the deep inguinal ring through the inguinal canal
to the superficial (external) inguinal ring (in men, along with the spermatic cord)
● Surrounded by the external spermatic fascia, cremasteric muscle fibers, and internal
spermatic fascia
● Indirect inguinal hernia may be associated with a communicating hydrocele.

A. Etiology
An inguinal hernia is caused by an organ pushing through a weakened tissue, which can
be caused or exacerbated by pressure. There are many risk factors that can lend to increased
abdominal pressure, such as chronic cough, constipation, and heavy lifting. Additionally, obesity,
advanced age, smoking, and a history of hernias can increase the risk for inguinal hernias.
Collagen diseases have also been associated with increased risk of incarcerated inguinal
hernias.

B. Signs and symptoms

Incarcerated hernia is mainly characterized by tenderness at the incarcerated site,
followed by whole abdominal pain, bloating, nausea, vomiting, and intestinal obstruction such as
absence of bowel movements.
C. Screening test
Your doctor will check for a bulge in the groin area. Because standing and coughing can
make a hernia more prominent, you'll likely be asked to stand and cough or strain. Examination
of the inguinal region in both men and women is best performed with the patient standing and
the physician seated on a stool facing the patient. Observation of the groin area in oblique light
with the patient relaxed and then actively coughing may reveal a bulge or an abnormal motion.
Scrotal masses may also be noted by inspection and palpation. Carefully observe whether any
bulge is noted. The examiner should then stand to the side of the patient with the fingers lightly
applied to the groin, the left hand on the patient's left side and the right hand on the patient's
right side. A palpable bulge or impulse located in any one of these areas may indicate a hernia.
The examiner should then return to the sitting position. In the male, the scrotum on each side is
inverted with the examining index finger entering the inguinal canal along the course of the cord
structures. The size of the external ring can be ascertained by palpating just lateral to the pubic
tubercle. Again with the patient coughing, hernia bulges can be felt either against the side of the
examining finger (direct hernia) or at the tip of the finger as it approaches the internal ring
(indirect hernia). Large, indirect hernias may extend all the way into the scrotum, giving the
gross appearance of a hydrocele. Transillumination of the scrotal contents in a darkened room
will aid in differentiating a hydrocele from an intrascrotal indirect inguinal hernia.

D. Diagnostic Test
● X-ray KUB: upright or lateral abdominal plain films often show bowel dilatation, multiple
air-fluid levels or other characteristic findings related to intestinal obstruction.

● Ultrasound examination: this often shows expansion of the intestines with reverse
peristalsis, or fixed masses without peristalsis, or expansion of a fluid-filled bowel;
intestinal fluid reflux and thickening and edema of the intestinal wall can be observed, as
well as a slightly echogenic, long strip-shaped omentum in the hernia sac. The
occurrence of hernia incarceration can be determined by observation of the blood supply
in the hernia contents with color Doppler ultrasound.

● CT scan: bowel dilation, mesangial thickening and other signs can be observed at
abdominal wall defects. A CT scan following oral iodinated contrast is more conducive to
determining whether the contents in the sac are intestinal and, if so, the intestinal type.
Enhanced scans can help identify the presence of bowel strangulation. For incarcerated
hernia with smaller abdominal wall defects, especially femoral and obturator incarcerated
hernia that are difficult to diagnosis, CT has its important clinical value. Soft tissue
signals seen between the pubic muscle and the obturator muscle, upper and lower
bundles of the external obturator muscle, or internal and external obturator muscle, on
pelvic CT, support the diagnosis of obturator hernia.

E. Laboratory Test
● Leukocytosis
-Present in a few patients of strangulated inguinal hernia.
● Lactate levels
 -Elevation of lactate is present in hypoperfusion
-Normal levels may be present in patients of strangulated inguinal hernia.
● Urinalysis
-To rule out genitourinary causes of groin pain with associated hernias.

F. Surgical Procedure
Incarcerated inguinal hernias are usually treated by emergency surgery. Individuals will
be assessed for signs of strangulation, which requires surgical repair. If there are no signs of
strangulation, a person may be placed in the Trendelenburg position, lying on their back with the
table tilted downwards so the feet are raised and the head is lowered. Reduction will then be
attempted, in which a clinician will put pressure on the hernia to guide the contents back through
the inguinal ring.

● Herniorrhaphy is the oldest type of hernia surgery and is still being used. It involves a
surgeon making a long incision directly over the hernia then using surgical tools to open
the cut enough to access it. Tissues or a displaced organ are then returned to their
original location, and the hernia sac is removed. The surgeon stitches the sides of the
muscle opening or hole through which the hernia protrudes. Once the wound has been
sterilized, it is stitched shut.
● In hernioplasty, instead of stitching the muscle opening shut, the surgeon covers it with a
flat, sterile mesh, usually made of flexible plastics, such as polypropylene, or animal
tissue. The surgeon makes small cuts around the hole in the shape of the mesh and
then stitches the patch into the healthy, intact surrounding tissues. Damaged or weak
tissues surrounding the hernia will use the mesh, as a supportive, strengthening scaffold
as they regrow. Hernioplasty is better-known as tension-free hernia repair.

G. Medical Diagnosis

Admitting Diagnosis: Incarcerated Indirect Inguinal Hernia

Final Diagnosis: Incarcerated Indirect Inguinal Hernia

H. Nursing Management
1. Managing Postoperative Pain
● Assess incision pain and nonverbal signs of pain such as crying, lethargy, and
facial grimace - Determines the need for the initiation of analgesic therapy.
● Maintain a position of comfort - Facilitates comfort and decreases pain caused by
the strain on the incision.
● Apply an ice compress on the scrotal area if the hydrocele is corrected and apply
for scrotal support if appropriate - Promotes comfort by decreasing swelling.
● Provide support to the buttocks during lifting or position changes - Avoid strain
and pull on the incision site.
● Administer analgesics appropriate for the severity of pain and age - Alleviate pain
and discomfort caused by the incision.
2. Preventing Injury and Swelling
 ● Assess skin turgor, mucous membranes, weight, fontanelles of an infant, last
void, and behavior changes - Provides information about hydration status;
including extracellular fluid losses, decreased activity levels, malaise, weight loss,
poor skin turgor, and concentrated urine.
● Assess vital signs, including apical pulse - Provides monitoring of cardiovascular
response to dehydration (weak, thready pulse, drop in blood pressure). Increased
respiratory rate may contribute to fluid loss.
● Monitor urine specific gravity, color, and amount of every voiding or as ordered -
Concentrated urine with an increased specific gravity indicates a lack of fluids to
dilute urine.
3. Initiating Education and Health Teaching
● Assess the knowledge of hernia including its causes, and surgical management;
Assess the willingness and interest to execute the treatment regimen - Promotes
efficient plan of instruction to ensure compliance.
● Provide appropriate with clear and precise information in understandable
language, utilizing teaching aids and encouraging questions - Ascertain
understanding based on age and learning ability.
● Inform to keep incision dressing until it peels off - Maintains dry and clean
incision site.
● Encourage to increase fluid intake and protein-rich diet as ordered - Promotes
return to nutritional status without causing gastrointestinal strain on the incision.