Incarcerated abdominal herniax

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Transcript Incarcerated abdominal herniax

Incarcerated
Abdominal Hernias
Laura Maselli, BSN RN
NURS 870
Pennsylvania State University
Diagnosis
 A hernia is a protrusion of an
organ through a body wall
that normally contains it
 An abdominal hernia occurs
when something in the
abdominal cavity passes
through a weakness in the
abdominal wall
 An abdominal hernia may
become incarcerated when
the body part becomes
trapped and cannot be
reduced back into the
abdominal cavity
Abdominal wall
hernias
 Ventral





Epigastric
Umbilical
Spigelian
Parastomal
Incisional
 Groin
 Obturator
 Inguinal
 Femoral
 Congenital vs. acquired
http://images.medicinenet.com/images/illustrations/2013-illustrationabdominal-wall-hernias.jpg
Abdominal Wall Hernias
 Congenital vs. acquired
http://www.wecareindia.com/generalsurgery/incisional-hernia-surgery.html
http://ranapileshospital.com/project/hernia/
Pathogenesis
 A hernia becomes
incarcerated when it cannot
be reduced back inside
abdominal wall through
hernia ring
 Blood cannot drain from the
veins and lymphatic vessels
 Swelling occurs
 Arterial flow may be
decreased and lead to
ischemia and necrosis
 The hernia becomes
strangulated = medical
emergency
http://www.drugs.com/health-guide/hernia.html
Clinical manifestations
 Asymptomatic
 Bulge that enlarges with increasing intra-abdominal pressure
or standing
 Pain of discomfort, burning or aching at hernia site
 Pain and swelling around testicles in men
 Cannot be reduced
 Fever
 Tachycardia
 Erythema or bruising around hernia
 Nausea or vomiting, symptoms of bowel obstruction
History
 HPI: OLDCARTS
 PMH: Hernia, diabetes, cancer, smoking
 Surgical: Laparotomy or drain site
 Increased risk factors: postoperative wound infection, dehiscence,
malnutrition, obesity, smoking
 Incarceration can occur in 6-15% of cases
 Current medical history: overweight or obese, stoma, anything
causing muscle weakness, pregnancy, constipation, heavy weight
lifting, ascites, sudden weight gain, persistent cough
 Other risk factors: older age, male sex, Caucasian, abdominal wall
trauma
 Medications: Steroids
Review of Symptoms
 Fevers
 Pain, especially abdominal or groin pain
 May be colicky in nature
 Nausea, vomiting, constipation
 Any masses or swelling
 Skin color changes
Physical exam
 Thorough abdominal exam
 Inspection
 Supine and standing
 Valsalva maneuver to increase intra-abdominal pressure
 Look for a bulge that protrudes through abdominal wall defect
 Palpation
 Patient standing
 If hernia is palpated attempt to gently reduce hernia while patient
relaxes their abdominal muscles
 If hernia is irreducible look for tenderness around the area,
discoloration of skin, edema, any signs of a small bowel obstruction.
 Hernia contents may be painful when palpated
 Location, reducible, pain, edema, skin color changes
Diagnostic tests
 Ultrasound
 Abdominal CT
 MRI
 CPK
 D-dimer
 CBC, BMP, UA
*History and physical exam are the best means of
diagnosing hernias!
Differential diagnosis
Differentials
 Abdominal pain:
 Abdominal wall hematoma
 Ileus
 Constipation
 GERD
 Tumor
 Groin pain:
 Adhesions
 Appendicitis
 IBD
 Testicular disorders
 UTI
RED FLAGS
 Incarcerated hernia
 Strangulated hernia
 Small bowel obstruction
 Ectopic pregnancy
Treatment
 Immediate referral to surgeon!
 Surgical intervention: hernia patch
 Robotic-assisted laparoscopy
 Open hernia repair
http://www.premiersurgical.com/premier-surgical-services/hernia-surgery-2/
Outcomes
 Goal of surgery is to correct the hernia with
minimal complications
 Complications:
 Intestinal resection due to bowel necrosis at time of
surgical intervention
 Prevent future hernias
 Post-op wound care
 Abdominal binders
 Weight management
 Smoking cessation
Journal article critique
 Gul et al. (2012)
 Factors affecting morbidity and mortality in
patients who underwent emergency operation for
incarcerated abdominal wall hernias
 Retrospectively analyzed cases of 131 patients
who underwent emergency surgery for
incarcerated abdominal wall hernias
 70 women and 61 men, average of 63y
 Morbidity observed in 21.4%
 Wound infections, peritonitis, pneumonia, DVT,
HF, MI, UTI
 Mortality observed in 2.3%
Summary
 Incarcerated abdominal wall hernia is a
protrusion of an organ, most likely intestines,
through a weakness in the abdominal wall and it
cannot be reduced
 Risk factors: old age, male, obese, increased
intra-abdominal pressure, past abdominal
surgeries
 History and physical exam are the best means to
diagnosis a hernia
 Requires immediate referral to a surgeon
Additional Information:
 http://emedicine.medscape.com/article/189563
-overview
 http://www.uptodate.com/contents/overviewof-abdominal-wall-hernias-inadults?source=search_result&search=abdominal
+wall+hernia&selectedTitle=1%7E48
References
Ansari, P. (2014). Hernias of the abdominal wall. Merck Manual. Retrieved from
http://www.merckmanuals.com/professional/gastrointestinal-disorders/acuteabdomen-and-surgical-gastroenterology/hernias-of-the-abdominal-wall
Brooks, D. C. (2014). Overview of abdominal wall hernias in adults. Up to date. Retrieved
from http://www-uptodate-com.medjournal.hmc.psu.edu:2048/contents/overview-ofabdominal-wall-hernias-inadults?source=machineLearning&search=abdominal+hernia&selectedTitle=1%7E48&sectio
nRank=2&anchor=H21327110#H21327110
Dains J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care. 5th ed. Elsevier: St. Louis, Missouri.
Goroll, A. H. & Mulley, A. G. (2009). Primary care medicine 7th Ed. Wolters Kluwer:
Philadelphia, PA.
Gull, M., Aliosmanoglu, I., Kapan, M., Onder, A., Taskesen, F., Arikanoglu, Z., & Tacyildiz, I.
(2012). Factors affecting morbidity and mortality in patients who underwent emergency
operation for incarcerated abdominal wall hernia. International Surgery 97(4) 305-309.
Sartelli, M., Coccolini, F., Ramshorst, G. H., Campanelli, G., Mandala, V., Ansaloni, L… &
Catena, F. (2013). WSES guidelines for emergency repair of complicated abdominal wall
hernias. World Journal of Emergency Surgery 8(50) doi: 10.1186/1749-7922-8-50