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§io
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