I. Introduction General description of disease condition requiring surgical procedure.

About 75% of all hernias are classified as inguinal hernias, which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. Because humans stand upright, there is a greater downward force on the lower abdomen, increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinal hernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia). According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men. Hernias are divided into two categories: congenital (from birth), also called indirect hernias, and acquired, also called direct hernias. Among the 75% of hernias classified as inguinal hernias, 50% are indirect or congenital hernias, occurring when the inguinal canal entrance fails to close normally before birth. The indirect inguinal hernia pushes down from the abdomen and through the inguinal canal. This condition is found in 2% of all adult males and in 1 2% of male children. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushes folds of genital tissue into the inguinal canal opening. In fact, women will more likely have an indirect inguinal hernia than direct. Direct or acquired inguinal hernias occur when part of the large intestine protrudes through a weakened area of muscles in the groin. The weakening results from a variety of factors encountered in the wear and tear of life. Inguinal hernias may occur on one side of the groin or both sides at the same or different times, but occur most often on the right side. About 60% of hernias found in children, for example, will be on the right side, about 30% on the

left, and 10% on both sides. The muscular weak spots develop because of pressure on the abdominal muscles in the groin area occurring during normal activities such as lifting, coughing, and straining during urination or bowel movements, pregnancy, or excessive weight gain. Internal organs such as the intestines may then push through this weak spot, causing a bulge of tissue. A congenital indirect inguinal hernia may be diagnosed in infancy, childhood, or later in adulthood, influenced by the same causes as direct hernia. There is evidence that a tendency for inguinal hernia may be inherited.

Relevant and current statistical evidences or critical findings 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. The incidence is also high among clients 50 to 60 years of age and then gradually decreases in older age groups. These hernias can become extremely large and often descend into the scrotum. Indirect inguinal hernias typically cause a bulge in the groin (at the top of or within the scrotum) and usually with increased abdominal pressure. The bulge may or may not be painful. By palpating the inguinal canal and asking the patient to cough while standing, one can usually elicit the hernia. In fact, one can often times palpate an inguinal hernia without invaginating the scrotum (as is typically taught in medical school). Rather, by placing one's fingers over the inguinal canal and asking the patient to cough, one can often feel the bulge against the lower abdominal wall. As indirect and direct hernias are unreliably differentiated by physical exam alone, the need to invaginate the scrotum to feel into the inguinal canal is often more uncomfortable to the patient, than revealing to the physician. Rarely, palpation is not even necessary, as the hernia is large enough to be visualized.

Indirect inguinal

hernias are the most common type of hernia

encountered. Virtually any patient under the age of 25 presenting with hernia will have an indirect hernia. They are more prevalent in men (the male to female ratio being about 9:1). This is because, during their descent, the testicles and blood vessels pass through the inguinal canal, making the opening from the abdomen less likely to close completely.

Recent trends, refinements, and/ or innovations in treatment The first hernia repair, or herniorrhaphy, took place in 1887. For nearly 100 years, surgeons simply used sutures to bring the separated tissues together. But this puts the tissues under tension and they pull apart in up to 7% of patients. The hernia may then come back. Surgeons use only two types of surgeries to repair groin hernias. Tension-free repair In the early 1980s, Dr. Irving Lichtenstein developed a way to repair hernias without putting tissues under tension. Surgeons close the defect with a sheet of mesh. It can be done as outpatient surgery under local or spinal anesthesia. Because patients experience less pain and there is a lower risk of the hernia returning, tension-free repair has quickly became the favored operation.

Laparoscopic surgery This newer rival burst onto the scene in the early 1990s. Whereas open repairs require a four- to six-inch incision in the groin, the laparoscopic repair requires only three half-inch incisions in the abdomen. First, the surgeon inflates the

abdomen with carbon dioxide. Next, he inserts a thin fiber-optic tube (laparoscope) through the incisions. While watching through a video camera, he then inserts instruments that he uses to pull the intestinal contents back into place and to staple a mesh patch over the defect. Inflating the abdomen is painful, so laparoscopic surgery requires general anesthesia. It also requires specialized equipment and extra training, so it is more expensive than open surgery. General or Local Anesthesia? It's the simplest of the three questions. If you have a laparoscopy, you'll need general anesthesia. Open surgery can be done with local, spinal or general anesthesia. However, randomized clinical trials report that local anesthesia produces less post-operative pain and fewer problems with urination. Still, if you and your doctors have a reason to choose general or spinal anesthesia, they are also reasonable options.

Implications of the above information for nurses as a productive member of society The nurse can explain what to expect before, during, and after the surgery. Parents, especially those of a newborn, are anxious because their child requires general anesthesia for the procedure. If possible, use preoperative teaching tools such as pamphlets and videotapes to reinforce the information. Allow as much time as is needed to answer questions and explain procedures. The nurse also instructs patients and parents on the care of the incision. Often, the incision is simply covered with collodion (a viscous liquid that, when applied, dries to form a thin transparent film) and should be kept clean and dry. Encourage the patient to defer bathing and showering and instead to use

sponge baths until he or she is seen by the surgeon at a follow-up visit. Explain how to monitor the incision for signs of infection. Infants or young children who are wearing diapers should have frequent diaper changes, or the diapers should be turned down from the incision so as not to contaminate the incision with urine. Teach the patient or parents about the possibility of some scrotal swelling or hematoma; both should subside over time.

Hernia surgery pain is centered on the abdomen. The muscles that have been sewn together are active and healing, and when they pull on the stitches, it causes pain. In addition, the incisions are healing, so doing anything but resting that area of the body can cause a sharp shooting pain. Certain pain is normal after a hernia surgery, but other forms of discomfort may be a sign of infection or complication. According to the Society of American Gastrointestinal and Endoscopic Surgeons, patients should see their doctors if they have a persistent fever of more than 101 degrees F, bleeding or swelling in the groin. Other symptoms that require immediate medical attention include nonstop nausea or vomiting, stubborn pain, inability to urinate, chills, coughing, shortness of breath, pus, and growing redness near the incision, and the inability to eat or drink. If the patient does not have surgery, teach the signs of a strangulated or incarcerated hernia: severe pain, nausea, vomiting, diarrhea, high fever, and bloody stools. Explain that if these symptoms occur, the patient must notify the primary healthcare provider immediately. If the patient uses a truss, she or he should use it only after a hernia has been reduced. Assist the patient with the truss, preferably in the morning before the patient arises. Encourage the patient

to bathe daily and to apply a thin film of powder or cornstarch to prevent skin irritation. II. Anatomy and Physiology

A useful learning tool in gaining a working knowledge of the inguinal region is visualizing it as it is surgically approached in the open technique.

The inguinal

region is

part of

the

anterolateral abdominal wall, which is made up of 9 layers. These layers, from superficial to deep, are the skin, the Camper and Scarpa fascia, the external oblique aponeurosis, the internal oblique and transversus muscles, the transversalis fascia, the preperitoneal fat, and the peritoneum.
o

The first layers encountered upon dissection through the subcutaneous tissues are the Camper and Scarpa fascia. Contained in this space are the superficial branches of the femoral vessels, namely, the superficial circumflex and the epigastric and external pudendal arteries, which can be safely ligated and divided when encountered. The inguinal canal can be visualized as a tunnel traveling from lateral to medial in an oblique fashion. It has a roof facing anteriorly, a floor facing posteriorly, a superior (cranial) wall and an inferior (caudal) wall, as shown below. The canal contents (cord structures in men or the round ligament in women) are the traffic that traverses the tunnel.Anatomy of the inguinal canal.

The external oblique aponeurosis serves as the roof of the inguinal canal and opens just lateral to and above the pubic tubercle. This is the superficial inguinal ring, which allows the cord structures egress.[5] The floor of the canal is composed of the transversus abdominus muscle and the transversalis fascia. The entrance to the inguinal canal is through these layers, and this entrance comprises the internal or deep ring. The inferior wall is the inguinal (Poupart) ligament. The inguinal ligament is formed by the lower edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to its attachments at the pubic tubercle and fans out to form the Lacunar ligament (Gimbernat ligament). The inguinal ligament folds over itself to form the shelving edge. This folded-over sling of external oblique aponeurosis is the true lower wall of the inguinal canal. The superior wall consists of a union of the internal oblique and transversus muscles aponeurosis, which arches from its attachment at the lateral segment of the inguinal ligament over the internal inguinal ring, ending medially at the rectus sheath and coming together inferomedially to insert on the pubic tubercle, thus forming the conjoined tendon. The cord structures include the vas deferens, testicular artery, artery of the ductus deferens, cremasteric artery, pampiniform plexus, and genital branch of the genitofemoral nerve, parasympathetic and sympathetic nerves, and lymph vessels.

Nerves of the groin Since the widespread acceptance of meshed-based repairs and the significant reduction of inguinal hernia recurrence, the most vexing complication of herniorrhaphy is chronic groin pain. Causalgia syndromes of each of the 3 nerves of the groin are well described. Controversy exists as to whether to section the nerves or to preserve them. Current recommendations are nerve identification (nerves are depicted in image below) and preservation.

Ilioinguinal nerve: The ilioinguinal nerve runs medially through the inguinal canal along with the cord structures traveling from the internal ring to the external ring. It innervates the upper and medial parts of the thigh, the anterior scrotum, and the base of the penis. Iliohypogastric nerve: The iliohypogastric nerve runs below the external oblique aponeurosis but cranial to the spermatic cord, then perforates the external oblique cranial to the superficial ring. It innervates the skin above the pubis. Genital branch of the genitofemoral nerve: This branch travels with the cremasteric vessels through the inguinal canal. It innervates the cremaster muscle and provides sensory innervation to the scrotum. Some variations remain in the anatomical distribution of these nerves, eg, the occasional absence of an ilioinguinal nerve.

External Inguinal Ring The external inguinal ring or the superficial ring is an anatomical structure in the anterior wall of the human abdomen. It is a triangular opening that forms the exit of the inguinal canal, which houses the ilioinguinal nerve, the genital branch of the genitofemoral nerve, and the spermatic cord (in men) or the round ligament (in women). At the other end of the canal, the deep inguinal ringforms the entrance.

It is found within the aponeurosis of the external oblique, immediately above the crest of the pubis, 1 centimeter above and medial to the pubic tubercle. It has medial and lateral crura. It is at the layer of the aponeurosis of the obliquus externus abdominis.

Internal Inguinal Ring The internal inguinal ring or the deep inguinal ring is the entrance to the inguinal canal. Its surface markings are 1 to 1.5cm superior to the midinguinal point. Its borders are:

superolateral: internal oblique and transversus abdominis muscles

medial: inferior epigastric vessels and interfoveolar ligament inferior: inguinal ligament

It lies lateral to the inferior epigastric vessels as they pass upwards from the external iliac artery and vein. It is the point at which the spermatic cord or round ligament push through the transversalis fascia.

Inguinal Canal Is the oblique passage through the lower abdominal wall. In males it is the passage through which the testes descend into the scrotum and it contains the spermatic cord, in women the round ligament. The inguinal canal is larger and more prominent in men. Each person has two, on the left and right sides of the abdomen.

Scrotum The scrotum is a part of a male's body located behind the penis. The scrotum is the sac (pouch) that contains the testes, blood vessels, and part of the spermatic cord. It containing is also a dual-chambered muscle, divided by

protuberance

of skin and

the testicles and

a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the scrotum becomes covered with pubic hairs at puberty.

Small Intestine Where much of of food the digestion and takes place. It

absorption through controlled

receives bile juice and pancreatic juice heptopancreatic by Spincter tract" of and duct, oddi. "large

In invertebrates such as worms, the terms "gastrointestinal intestine" are often used to describe the entire intestine. This article is primarily about the human gut, though the information about its processes is directly applicable to most placental mammals. The primary function of the small intestine is the digestion, absorption of nutrients and minerals found in food. It is also a tubular structure within the abdominal cavity that carries the food in continuation with the stomach up to the colon from where the large intestine carries it to the rectum and out of the body via the anus. It is divided into the duodenum (the first section of the small intestine in most higher vertebrates.), jejunum (middle section of the small intestine and usually defined as the Duodenojejunal flexure), and ileum (final section of the small intestine).

Perineum Is a region of the body including the perineal body and surrounding structures. There is some variability in how the boundaries are defined, but the term generally includes the genitals and anus.

III. The Patient and his Illness A. Schematic diagram

Book-Based Pathophysiology
Predisposing Factors:
Smoking Life-threatening condition ( i.e. cystic fibrosis) Poor knowledge about proper nutrition Prolonged hospitalization or residence in a nursing home Obesity
Etiology:
It is considered

Precipitating Factors:
Emphasize high-fiber foods Maintain a healthy weight Avoid heavy lifting altogether Stop smoking

mainly to be a congenital lesion. It is denoted indirect because the bowel and peritoneum do not herniate directly through a weakness in the abdominal wall.

An organ, intestine, or tissue from your abdomen falls into the inguinal canal

Incarcerated organs become intertwined

Decrease or complete deprivation of blood flow to the protrusion

Intestines become incarcerated Abdomen become painful and tender Accompanied by nausea, vomiting, fever, inflammation, bowel obstruction and the appearance of blood in stool

Swollen skin in your groin that is red, gray, or blue Lump or swelling in your scrotum
Indirect Inguinal Hernia

Indirect inguinal hernias in infants and children are congenital and result from an arrest of embryologic development, failure of obliteration of the processus vaginalis, rather than an acquired muscular weakness. The pertinent

developmental anatomy of congenital indirect inguinal hernia relates to development of the gonads and descent of the testis through the internal ring and into the scrotum late in gestation. The gonads develop near the kidney as a result of migration of primitive germ cells from the yolk sac to the genital ridge, which is completed by 6 wk of gestation. Differentiation into testis or ovary occurs by 7 or 8 wk of gestation under hormonal influences. The testes descend from the urogenital ridge in the retroperitoneum to the area of the internal ring by about 28 wk of gestation. The final descent of the testes into the scrotum occurs late in gestation between weeks 28 and 36. The testis is preceded in descent to the scrotum by the gubernaculum and the processus vaginalis. The processus vaginalis is present in the developing fetus at 12 wk of gestation as a peritoneal outpouching that extends through the internal inguinal ring and accompanies the testis as it exits the abdomen and descends into the scrotum. The gubernaculum testis forms from the mesonephros (developing kidney), attaches to the lower pole of the testis, and directs the testis through the internal ring and inguinal canal and into the scrotum. The testis passes through the inguinal canal in a few days but takes about 4 wk to migrate from the external ring to the scrotum. The cordlike structures of the gubernaculum occasionally pass to ectopic locations (perineum or femoral region), resulting in ectopic testes. In the last few weeks of gestation or shortly after birth, the layers of the processus vaginalis normally fuse together and obliterate the patency from the peritoneal cavity through the inguinal canal to the testis. The processus vaginalis also obliterates just above the testes, and the portion of the processus vaginalis that envelops the testis becomes the tunica vaginalis. In girls, the processus vaginalis obliterates earlier, at about 7 mo of gestation. Failure of the processus vaginalis to close permits fluid or abdominal viscera to

escape the peritoneal cavity and accounts for a variety of inguinal-scrotal abnormalities seen in infancy and childhood. The ovaries descend into the pelvis from the urogenital ridge but do not exit from the abdominal cavity. The cranial portion of the gubernaculum in girls differentiates into the ovarian ligament, and the inferior aspect of the gubernaculum becomes the round ligament, which passes through the internal ring and attaches to the labia majora. The processus vaginalis in girls extends into the labia majora through the inguinal canal and is also known as the canal of Nuck. Androgenic hormones, adequate end-organ receptors, and mechanical factors such as increased intra-abdominal pressure influence complete descent of the testis through the inguinal canal. The testes and spermatic cord structures (spermatic vessels and vas deferens) are located in the retroperitoneum but are affected by increases in intra-abdominal pressure as a consequence of their intimate attachment to the processus vaginalis. The genitofemoral nerve also has an important role: It innervates the cremaster muscle, which develops within the gubernaculum, and experimental division or injury to both nerves in the fetus prevents testicular descent. Failure of regression of smooth muscle (present to provide the force for testicular descent) might have a role in the development of indirect inguinal hernias. Several studies have investigated genes involved in the control of testicular descent for their role in closure of the patent processus vaginalis, for example, hepatocyte growth factor and calcitonin gene-related peptide. Unlike in adult hernias, there does not appear to be any change in collagen synthesis associated with inguinal hernias in children

B. Synthesis of the disease

B.1 Definition of the disease An indirect inguinal hernia follows the tract through the inguinal canal. This results from a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.

B.2 Predisposing / Precipitating factors o Family History: There is an increased risk of hernia with a close family history o Certain Medical Conditions: Cystic fibrosis, or conditions associated with a chronic cough increase the risk of developing a hernia o Smoking: Like cystic fibrosis, a chronic cough increases risk o Excess Weight & Pregnancy: Increases risk by weakening and placing stress on lower abdominal muscles o Inherited gene: Having one hernia puts you at risk of having another

B.3 Signs and symptopms with rationale Hernia symptoms in children o In infants, a hernia may bulge when the child cries or moves around. o Strangulated hernias, in which part of the intestine becomes trapped in the hernia, are more common in infants and children than in adults. They can cause nausea and vomiting. An infant with a strangulated

hernia may cry and refuse to eat. Astrangulated hernia is a medical emergency that requires immediate surgery. In adults o A bulge in the groin or scrotum. The bulge may appear gradually over a period of several weeks or months, or it may form suddenly after the patient has coughed, bent, strained or laughed because of the protrusion of the intestine on the sac. Many hernias flatten when the patient lie down. o Groin discomfort or pain. The discomfort may be worse when the patient has bend or lift. Although he/she may have pain or discomfort in the scrotum, many hernias do not cause any pain. o You may have sudden pain, nausea, and vomiting if part of the intestine becomes trapped (strangulated) in the hernia.

Other symptoms of a hernia include: o Heaviness, swelling, and a tugging or burning sensation in the area of the hernia, scrotum, or inner thigh. Males may have a swollen scrotum, and females may have a bulge in the large fold of skin (labia) surrounding the vagina. o Discomfort and aching that are relieved only when the patient lie down. This is often the case as the hernia grows larger.

IV. Clinical Interventions 1.1 Description of prescribed surgical treatment performed A hernia is usually because of weakness in an individuals abdominal wall, which allows the inner tissue or organs to protrude as a bulge on the skin. Most often, hernias are found in the abdomen or in the groin area. A herniorrhaphy procedure repairs a hernia by making an incision on the skin, pushing the protrusion back into its place and suturing the edges of healthy muscle tissues together. This works when the hernias are small or when the tissues are healthy and the stitches would not add to the strain on the tissue. The herniorrhaphy

technique used may use a traditional incision or a laprascopic surgery.

In hernia cases involving trapped tissues which run the risk of having their blood supply cut off, leading to tissue death, surgery is usually urgently required. In males, before they are born, the testicles descend into the scrotum through the inguinal canal in the abdomen. Usually the inguinal canal closes before birth or by the age of two. In some cases, it may remain open well into adult life. In such cases, tissue from inside the abdomen may bulge through it, leading to indirect inguinal hernia. An inguinal herniorrhaphy procedure in children is usually an open surgery requiring about four weeks for recovery. Herniorrhaphy protocol in some cases may involve the use of synthetic material as patches. These patches are sewn over the weakened area of the abdominal wall after the hernia is pushed backed into its place, so that there is
This patient has an indirect inguinal hernia (A). To repair it, the surgeon makes an incision over the area and separates the muscle and tissues to expose the hernia sac (B). The sac is cut open (C), and the contents are replaced into the abdomen (D). The neck of the hernia sac is tied off (E), and the muscles and tissues are sutured (F). (Illustration by GGS Inc.)

no recurrence. These patches are used both in open and laparascopic surgeries to ensure that the stress on the weakened wall is minimal. This procedure is also called hernioplasty. Open surgery for small children with hernias on one side or both sides of the groin is in most cases found to be quite a safe procedure. An inguinal hernia needs to be treated and will not disappear on its own. Incarcerated hernias in children need to be repaired because there is a risk of strangulation of blood supply to the tissue or intestine. Tension-free Hernioplasty (Open Surgery)

Using this technique, the hole in the muscle of the abdominal wall is not closed by pulling the edges together, but rather the defect is bridged by the mesh which covers the hole. Because of the combination of safety and excellent success rate in preventing recurrence of the hernia, the tension-free hernioplasty technique is now recommended.

An 8-centimeter incision is made for an open surgery. Laparoscopic repair would begin with two 5-millimeter and one 10-millimeter holes for the ports.

Permanent polypropylene mesh, which is a well-tolerated biologically safe and very strong tissue substitute, is sutured to strong tissues in the groin to close the gap in the inguinal canal. The hernia mesh is inserted in the preperitoneal space (above the abdominal cavity, but below the muscle layer) to afford the strongest mechanical advantage. Placing the mesh in this location allows it to incorporate into the patients tissues more rapidly. It is important that the surgeon avoid pulling the edges of the hole together and causing tension, as tension causes swelling and pain, and may cause the sutures to tear out leading to a recurrent hernia.

Any foreign body inserted into human tissue may become infected and need to be removed. To improve the chances of acceptance, the mesh is soaked in an antibiotic solution prior to implantation, and prophylactic (preventive) antibiotics are administered intravenously to reduce the risk of infection. Any infections that may occur generally happen within the first two weeks after surgery. After the hernia is repaired, the remaining layers are closed with absorbable sutures, dressings are applied and the patient is transferred to the recovery room. Surgery takes 1 to 1-1/2 hours with a recovery room time of approximately 3 hours. Following surgery, patients are not restricted or

A completed tension-free hernia repair

bedridden, though they must avoid very heavy lifting for 30 days. They are given a prescription for pain medication, and encouraged to gradually return to full
activities as tolerated. The surgical dressings are waterproof, and bathing is allowed.

Shouldice/Canadian Repair (Open Surgery) Developed during World War II by Dr. E. E. Shouldice, a Canadian surgeon, this technique is widely used as a non-mesh option for hernia repair. Two

permanent, continuous back-and-forth sutures are used close the hole in the abdomen wall. By sliding four layers of tissue together, this technique is considered a more secure closure of the hole in the abdominal wall than the single-layer Bassini repair. In addition, the Shouldice technique uses the deepest layers of muscle while the Bassini repair uses more superficial layers. This technique has a high success rate and low rate of recurrence. However, tension in the closure of the incision can lead to swelling and patient discomfort lasting several weeks.

Laparoscopic Repair Laparoscopic surgery is performed using general anesthesia. The surgeon makes several small incisions in the lower abdomen and inserts a laparoscope a thin tube with a tiny video camera attached to one end. The camera sends a magnified image from inside the body to a monitor, giving the surgeon a closeup view of the hernia and surrounding tissue. While viewing the monitor, the surgeon uses instruments to carefully repair the hernia using synthetic mesh. Laparoscopic repair is less invasive than an open approach. It uses three ports, or trocars, inserted into the area of the surgery through which a TV camera and

instruments are placed to allow surgeons to visualize the anatomy, define the hernia defect, and implant the mesh. People who undergo laparoscopic surgery generally experience a

somewhat shorter recovery time. However, the doctor may determine laparoscopic surgery is not the best option if the hernia is very large or the person has ha d pelvic surgery.

Laparoscopic surgery

A Microscopic view of mesh

Outline/Illustration of the process: (Open surgery) o Confirm and mark the correct surgical site preoperatively in the holding area. o Position the patient supine, comfortably securing the upper extremities. o For large defects, slight Trendelenburg positioning may help exposure by reducing the visceral contents into the abdomen. o Shave the surgical site with electric clippers. o Prepare and drape the surgical site in standard surgical fashion, exposing only the intended operative groin site

After final verification of the correct side of surgery and the infiltration of local anesthesia (described in Anesthesia), make an oblique skin incision (or along the Langer lines) approximately 2 finger breadths (2 cm) superior to and parallel to the thigh crease, and extend it 5 cm toward the anterior superior iliac spine, starting from just lateral to the pubic tubercle. In thin patients, the external ring can actually be palpated just lateral and slightly above the pubic tubercle and

should be the medial starting point of incision, as shown below. Marking of the incision site Continue the dissection deeper through the subcutaneous tissue until the aponeurosis of the external oblique is identified. During dissection, take note of the superficial vessels that can be ligated and divided when encountered. Identify the external oblique aponeurosis. The following 3 landmarks must also be identified before incising the external oblique:

Firstly, the Scarpa fascia can mimic the external oblique, as it is well developed and thickened in some patients. Avoiding this mistake, especially in patients who are overweight, can be accomplished if the fibers of the external oblique aponeurosis are always visualized, since the Scarpa fascia does not have these fibers.

Secondly, the inguinal canal should be entered at its apex. To correctly identify the apex of the canal, identify the lower wall of the canal, which is where the external oblique aponeurosis disappears into the fat of the thigh. Approximately one finger breadth above this point is a good entry site into the canal.

Thirdly, the external ring must be identified. This is important because the external ring is ultimately the end point of the division to be made in the external oblique aponeurosis and defines the orientation of this cut.

Once the external oblique aponeurosis is identified, thoroughly expose it and make a gentle stab incision in its mid-portion along the orientation of its fibers. Extend this incision superiorly, and medially downward, through the superficial ring, thus exposing the inguinal canal and the cord structures, as shown below.

Division of the external oblique aponeurosis

Circumferentially mobilize the cord structures off the floor of the canal by working on the pubic tubercle as a fulcrum as shown below. With blunt dissection of the index finger in a sweeping and medially encircling fashion, the cord is sufficiently freed, so that the cord structures can be surrounded by a Penrose drain for convenient retraction. This allows exposure of the inguinal floor

and protects the cord structures.

Next, examine the anteromedial aspect of the cord for an indirect component of the hernia. Separating the cremasteric muscle along its fibers often facilitates this. The cremasteric muscle fibers must be dissected carefully with slow electrocautery coagulation, as the cut muscle fibers tend to bleed.
Cord structures and hernia sac encircled by a Penrose drain

If an indirect hernia is present, dissect the sac off the cord structures, down toward its base at the internal inguinal ring, until it is comfortably invaginated into the preperitoneal space as shown below. This is preferably achieved without division of the sac. However,

If necessary, as with certain large hernias, the sac can be entered carefully and examined for visceral contents, and then divided with a high ligation (ie, proximal).
Hernia sac separated from the cord

Closure of the defect and buttressing of the inguinal canal floor can now be structures performed. This can be done using a prosthesis, as in the Lichtenstein repair, or primarily with native tissue, as in the McVay and Bassini repairs. Possible closure methods are detailed below.

Lichtenstein repair: In the Lichtenstein repair, a mesh is positioned and trimmed as necessary so that its medial rounded edge comfortably overlaps the pubic tubercle by approximately 2 cm. The rounded lower edge of the mesh is fixed to the lacunar ligament with 3-0 Prolene suture and continued inferolaterally in running fashion along the inguinal ligament and beyond the internal ring. A slit is cut in the superior portion of the mesh in the shape of an inverted T, so that its 2 tails can be draped over and then loosely reapproximated around the exiting cord, thus fashioning an artificial internal ring. The superomedial aspect of the mesh is secured with interrupted sutures to the rectus sheath and to the conjoint tendon at its upper portion.

Plug and patch: This adds a polypropylene plug shaped as a cone, which can be deployed into the internal ring following indirect sac reduction. The plug then acts as a toggle bolt to reinforce this defect.

Prolene hernia system (PHS): This system consists of an anterior oval polypropylene mesh connected to a circular posterior component.

The posterior component is deployed in a bluntly created preperitoneal space, as shown in the image above

The anterior portion is then laid out with a cut made to recreate the internal ring, as depicted as shown in the image above

The following repairs are not simply of historical interest. Surgeons must know and understand these repairs so that they can be used when needed. Specifically, cases that involve a contaminated field such as necrotic or perforated bowel secondary to hernial strangulation are not amenable to prosthetic repair. In
below to the shelving edge of the inguinal and is tucked behind the such cases, either a primary tissue repair orligament biologic implant repair is necessary. external oblique, as shown above The anterior portion is then sutured above to the conjoined tendon and

McVay repair: The conjoined tendon is sutured with interrupted nonabsorbable sutures to the inguinal ligament. Bassini repair: The conjoined tendon is sutured to the Cooper ligament with a transition stitch onto the inguinal ligament over the femoral vessels. In addition, a relaxing incision is made to the anterior rectus sheath. Recent reports using an acellular dermal implant (eg, AlloDerm) in cases of a contaminated surgical field have appeared in the literature, but long-term results are not yet available.

Reapproximate the external oblique aponeurosis with a running 3-0 polyglactin suture as shown below; be mindful of the underlying ilioinguinal nerve. Closure of the external oblique aponeurosis

Follow this with reapproximation of the Scarpa fascia with interrupted 3-0 polyglactin suture and then a running subcuticular closure of the skin with 3-0 poliglecaprone suture, shown below.

Skin closure

Clean the operative site and apply sterile dressing.

1.2 Indication of prescribed surgical treatment Indication: The existence of an inguinal hernia has been reason enough for operative intervention. However, recent studies have shown that the presence of a reducible hernia is not, in itself, an indication for surgery and that the risk of incarceration is less than 1% Symptomatic patients (with pain or discomfort) should undergo repair; however, up to one third of patients with inguinal hernias are asymptomatic. The question of observation versus surgical intervention in this asymptomatic or minimally symptomatic population was recently addressed in 2 randomized clinical trials. The trials found similar results, namely that after long-term follow-up, no significant difference in hernia-related symptomology was noted, and that watchful waiting did not increase the complication rate. In one study, the substantial patient crossover from the observation group to the surgery arm led the authors to conclude that observation may delay but not prevent surgery. This reasoning holds particularly true in the younger patient population. Thus, even an asymptomatic patient, if medically fit, should be offered surgical repair. After a long-term follow-up, one study determined that most patients with a painless inguinal hernia will develop symptoms over time, and therefore, surgery is recommended for medically fit patients. Koch et al found that recurrence rates were higher in women and that recurrence in women was 10 times more likely to be of the femoral variety than in men. This has led some to the conclusion that repairs that provide coverage of the femoral space (eg, laparoscopic repair) at the time of initial operation are better suited for women as a primary repair.

Contraindication: Inguinal hernia repair has no absolute contraindications. Just as in any other elective surgical procedure, the patient must be medically optimized. Any medical issues, whether acute (eg, upper respiratory tract or skin infection) or exacerbations of underlying medical conditions (eg, poorly controlled diabetes mellitus), should be fully addressed and the surgery delayed accordingly.

Risk Vs. Benefit Hernia surgery is considered to be a relatively safe procedure, although complication rates range from 126%, most in the 712% range. This means that about 10% of the 700,000 inguinal hernia repairs each year will have complications. Certain specialized clinics report markedly fewer complications, often related to whether open or laparoscopic technique is used. One of the greatest risks of inquinal hernia repair is that the hernia will recur. Unfortunately, 1015% of hernias may develop again at the same site in adults, representing about 100,000 recurrences annually. The risk of recurrence in children is only about 1%. Recurrent hernias can present a serious problem because incarceration and strangulation are more likely and because additional surgical repair is more difficult than the first surgery. When the first hernia repair breaks down, the surgeon must work around scar tissue as well as the recurrent hernia. Incisional hernias, which are hernias that occur at the site of a prior surgery, present the same circumstance of combined scar tissue and hernia and even greater risk of recurrence. Each time a repair is performed, the surgery is less likely to be successful. Recurrence and infection rates for mesh repairs have been shown in some studies to be lower than with conventional surgeries.

Complications that can occur during surgery include injury to the spermatic cord structure; injuries to veins or arteries, causing hemorrhage; severing or entrapping nerves, which can cause paralysis; injuries to the bladder or bowel; reactions to anesthesia; and systemic complications such as cardiac arrythmias, cardiac arrest, or death. Postoperative complications include infection of the surgical incision (less in laparoscopy); the formation of blood clots at the site that can travel to other parts of the body; pulmonary (lung) problems; and urinary retention or urinary tract infection. Surgical repair is recommended for inguinal hernias that are causing pain or other symptoms and for hernias that are incarcerated or strangulated. Surgery is always recommended for inguinal hernias in children. Infants and children usually have open surgery to repair an inguinal hernia. Open surgery for inguinal hernia repair is safe. The recurrence rate (hernias that require two or more repairs) is low when open hernia repair is done by experienced surgeons using mesh patches. Synthetic patches are now widely used for hernia repair in both open and laparoscopic surgery. The chance of a hernia coming back after open surgery ranges from 1 to 10 out of every 100 open surgeries done.

1.3 Required instruments, devices, supplies, equipment, and facilities Packs/Drapes

Laparotomy pack or minor pack Four folded towels

Instrumentation

Basic tray or minor tray Self-retraining retractor

Supplies/ Equipment

Basin set Suction Needle counter Penrose drain Dissector sponges Sutures Solutions saline, water Synthetic mesh Skin closure strips

Standard operating room anesthesia equipment, outfitted for possible conversion to general anesthesia and endotracheal intubation, is required. A standard open surgical tray, including self-retaining retractors, a Penrose drain, and different size meshes, should be available on standby. Mesh: The mesh must be a permanent material large enough to produce a wide overlap beyond the defects edges. A polypropylene or polyester

mesh (5 X 10 cm to 7 X 15 cm) is generally used. Recently, manufacturers have shifted toward lighter, more porous constructions that maintain the strength of the repair but putatively reduce the inflammatory response. Different mesh configurations may be chosen, primarily based on surgeon preference and training. None have been shown to be better at preventing recurrence. The question of absorbable versus permanent sutures to secure the mesh is based on surgeon preference; to date, no evidence supports one over the other. A theoretical advantage of absorbable suture is that, if nerve impingement is inadvertently caused, the suture material disappears with time. The authors prefer to use absorbable (2-0 polyglactin) suture for mesh fixation. Laparoscopic inguinal hernia repair (LH) requires similar scar size to traditional open repair. To perform LH with minimal access, finer instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 3-mm trocars to perform LH by the transabdominal preperitoneal approach. Polyester mesh was placed over the hernia orifice and the peritoneum was closed with 3-0 silk sutures. Sixteen patients underwent smaller access LH and 24 had standard LH. Although smaller access LH took longer (105.7 versus 83.9 min), significantly fewer patients required analgesia after smaller access LH than after standard LH (12.5 versus 70.8%), and the postoperative hospital stay was shorter (4.6 versus 5.6 days). In addition, a better cosmetic outcome was obtained with smaller access LH. In conclusion, access was minimized by using fine-caliber instruments and polyester mesh, making LH less invasive and improving the cosmetic outcome.

Blacksmith surgical Set Blacksmith Surgical has a set of instruments Hernia/Hydrocoelectomy Set that is primarily used by surgeons to perform herniorrhaphy and hydrocoelectomy. The comprehensive Hernia/Hydrocoelectomy Set by Blacksmith Surgical is composed of forty-four (44) instruments. Included are the scissors: Mayo scissors for cutting heavy fascia and sutures; Metzenbaum scissors for cutting delicate tissues; and dressing scissors. A wide variety of forceps are present too: tissue forceps for controlling tissues during surgery, especially during suturing; artery forceps for grasping and compressing an artery; Allis forceps for grasping tissues; and different dissecting forceps. There are three types of retractors for separating the edges of a surgical incision or wound, or holding back underlying organs and tissues, so that body parts under the incision may be accessed; these items. The performance of the medical practitioners in any area of the hospital is highly affected by the quality of the equipment they use during their operations. Blacksmith Surgical knows this information; that is why the company ventures into providing only the best items and instruments for diagnostic, medical and surgical purposes. As we all know, operative procedures such as herniorrhaphy and hydrocoelectomy warrant efficient execution. That is the reason why Blacksmith Surgicals Hernia/Hydrocoelectomy Set provides the best quality instruments for the goal of helping the doctors perform the surgical procedure better. Customer satisfaction is achieved through quality, efficiency, fastest are Farabeuf, Langenbeck, and Senn-Miller. Blacksmith Surgical incorporate a surgical blade handle, needle holders and other miscellaneous

delivery on competitive prices. Instruments are nicely arranged in quality packaging.

S.No. Set

Description of item

Qty

Hernia/Hydrocoelectomy Contents: Set Forceps, Sponge Holding, 180mm Towel Clip, Backhaus, 90mm Handle For Surgical Blade No3 Scissors, Mayo, Straight, 140mm Scissors, Mayo, Curved, 140mm Scissors, Metzenbaum, Curved, 180mm Scissors, Dressing, Straight 145mm Forceps dissecting slender pattern 1 5cm Forceps, Dissecting, Straight, Plain, 145mm Forceps, Dissecting, Straight, Plain, 145mm Forceps, Dissecting, Straight, 1/2 Teeth, 145mm Forceps, Dissecting, Straight, 1/2 Teeth, 180mm Forceps, Tissue, Allis, 4x5 Teeth, 155mm Forceps, Artery, Straight, 125mm Forceps, Artery, Curved, 140mm Forceps, Artery, Straight, 135mm Forceps, Artery, Straight, Kocher, 1/2teeth, 160mm Forceps, Artery, Straight, Kocher, 1/2teeth, 185mm Forceps, Mikulicz peritoneum 205mm Forceps, Mikulicz peritoneum 205mm Needle Holder, Mayo, 150mm Needle Holder, Mayo, 200mm Director, 1 5cm 2 4 1 1 1 1 1 1 1 1 1 1 1 1 4 6 1 1 1 1 1 1 1

32

Probe, Myrtle leaf, 1 5cm diameter 5cm Retractor, fine pattern 1 sharp prong Retractor, Senn-Miller baby, sharp Retrators, Set of Farabeuf Retractor, Langenbeck, 28 x 10mm

2 2 1 2 2

1.4 Perioperative tasks and responsibilities of the Nurse Responsibilities of a Circulating & Scrub Nurse Circulating and scrub nurses are two of the most important healthcare workers in an operating room. Together, they are responsible for anticipating and meeting the needs of the surgeon and patient. During a surgery, each performs her own duties, but they work together to make the procedure as successful as possible.

Responsibilities of the Circulating Nurse Role The circulating nurse plays a number of roles before, during and after surgery. A circulating nurse ensures the sterility of the operating room before and during surgery. These nurses supervise the technicians that clean and sterilize the operating room (OR) and any tools, equipment and supplies needed to perform a surgical procedure. Circulating nurses also coordinate schedules with physicians, anesthesiologists and other nurses to make sure that all participants understand the procedure being performed and arrive on time. A circulating nurse acts on behalf of the patient during a procedure; she may make decisions for the patient by proxy and ensures that the patient receives proper care before, during and after a procedure.

Pre-surgery Circulating nurses assess operating room conditions and ensure that all necessary surgical tools are available. They inspect the room to ensure its sterile to prevent patient infections. They also assist doctors in scrubbing up and donning sterile gowns and gloves. Conditions Circulating nurses work primarily in hospitals, as part of trauma units and in other facilities that perform surgery. During surgery, these nurses may stand for long periods of time, some of which involves handling supplies and positioning a patient to receive anesthesia. These nurses work directly with patients in surgical and non-surgical settings. They also oversee staff that includes other nurses and technicians. This position requires that a nurse combine communication, team work, problem-solving and leadership skills with nursing knowledge. Circulating nurses take courses, seminars and certifications to continually update their knowledge base with the latest surgical practices and procedures. Patient Preparation Since circulating nurses work as patient advocates, they must understand specific patient's needs before surgery. They'll do a check on patient vital signs prior to surgery and make sure patients aren't wearing anything, such as jewelry, that can interfere with the surgical process. They also speak with patients and answer any questions they have about the surgery. During Surgery Circulating nurses help put patients to sleep for surgery. When the surgery starts, they remain in a non-sterile function, meaning they may venture outside the operating room if there's a need to get supplies. They also open packaging as necessary so doctors can grab the sterile supplies inside without infecting their gloves or gowns.

Patient Advocate During most surgeries, patients are anesthetized, so they can't make decisions for themselves. The circulating nurse must serve the role of patient advocate to ensure the operating room remains sterile and all procedures are being followed.

Post-Surgery After surgery, circulating nurses must account for all surgical instruments used during the procedure and make sure nothing was left inside the patient. Circulating nurses also do follow-up health checks on patients in the PostAnesthesia Care Unit to ensure their vitals are good.

Emergency Preparation During surgery, there's always a risk of complications with which the circulating nurse must be able to assist. Patients' vital signs can crash during surgery, so emergency procedures take place to save their lives. Circulating nurses, who operate between surgical teams and the rest of the hospital, must coordinate getting supplies and other doctors and staff to patients during emergencies.

Responsibilities of the Scrub Nurse

The scrub nurse has an important role during surgery. As a part of a team of trained professionals, a scrub nurse will be sure that sterile techniques are used throughout the surgery and advocate patient safety. They may be a surgical technologist or registered nurse and are trained to assist the surgeon and help provide an optimal outcome to the procedures. The scrub nurse interacts with the patient prior to the surgery. She explains the procedure to the patient and family members, in addition to obtaining consent forms. She also washes, shaves and disinfects incision sites and later transports the patient to the operating room. There, the surgical technician helps to move the patient onto the surgical table and covers the patient in sterile surgical drapes. The scrub technician oversees the patient's vital signs and uses the patient's chart to verify all the steps that will be undertaken. The duties and responsibilities of a scrub nurse do not end when the procedure begins. A technician sometimes delivers specimens to testing labs, while a scrub nurse who also is an RN assists with suturing at the conclusion of the operation. Preparation and Organization Organization is important to all things in medicine and the operating room is not any different. The scrub nurse goes into the operating room to set the room up and set up the sterile field before the procedure begins. The room is set up differently according to the specific surgery. Correct instruments and materials are placed in the room by the scrub nurse so that leaving the operating room during the procedure and potentially breaking the sterile field is avoided. They also check that needed equipment is in good working condition for a smooth process.

Before Surgery The scrub nurses duties begin far before the start of the operation. He ensures the operating room is clean and ready to be set up, then prepares the instruments and equipment needed for the surgery. He counts all sponges, instruments, needles and other tools and preserves the sterile environment by scrubbing in, which requires washing his hands with special soaps and putting on sterile garments, including a gown, gloves and face mask. When the surgeon arrives, the nurse helps her with her gown and gloves before preparing the patient for surgery. During Surgery Another duty of the scrub nurse is to identify all instruments to be used in the operating room. She is responsible for passing the appropriate instruments to the surgeons during surgeries and other procedures. The nurse's knowledge and understanding of each instrument's function will help ensure that the procedure will run smoothly and finish on time. It is also part of the scrub nurse's duties to make sure that surgeons can comfortably and efficiently perform their procedures. They must be keen observers and must immediately notice if the surgeon's needs. After Surgery After the operation, the scrub nurse again counts all instruments, sponges and other tools and informs the surgeon of the count. He removes tools and equipment from the operating area, helps apply dressing to the surgical site and transports the patient to the recovery area. He also completes any necessary documentation regarding the surgery or the patient's transfer to recovery.

1.5 Expected outcomes of surgical treatment performed These guidelines are intended for Claims and Clinical Staff as general guides for the direction, timing, expected outcomes for post-surgical rehabilitation patients/clients. These guidelines have been developed through an evidencebase process. The guideline may also vary on the institute or surgeon preference.

*Without post-operation complication*

1.6 Medical management of physiologic outcomes Wound Healing and Systemic Implications of Inguinal Hernia Whether the hernia repair involves tissues alone, or a prosthetic graft, the normal healing process involves a cascade of activities. Platelets are released and surround the traumatized tissue. Macrophages and neutrophils move in to clean

the area of debris and bacteria, and to elaborate soluble substances vital to the healing process. A fibrin matrix is deposited that becomes polymerized and oriented into an ideal cross-linking configuration forming reliable collagen. Work by Peacock and Maddenon defective cross-linking and the imbalance of collagen metabolism, as well as the observations by Read regarding the correlation of groin hernia disease with arterial aneurysm and nicotine consumption in smokers suggest that some metabolic factors, including collagenolysis and elastase, contribute to the clinical eventuality of a inguinal hernia. Hernia repair site The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon. Patients should also report a fever, and men should report any pain or swelling of the testicles. The surgeon may remove the outer sutures in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair. To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery. The postoperative activities of patients undergoing repeat procedures may be even more restricted.

The surgery drugs commonly used before, during and after procedures vary widely from patient to patient. The drugs you will receive are based upon the type of surgery you are having, the anesthesia you will be receiving and other variables, including any medical conditions you may have.

Surgery drugs are sometimes prescribed before and after the procedure, to prevent problems after surgery. For example, you may be prescribed an antibiotic before your surgery to prevent infection after your procedure. Surgery Drugs: Antibiotics Antibiotics are a category of drugs used to combat bacteria that cause infection. Antibiotics can be given orally, in pill form, or intravenously, or through an IV. While in the hospital, antibiotics are most commonly given through an IV, but the vast majority of home antibiotics are prescribed as pills. The selection of the antibiotic depends on the type of surgery and the risk of infection by certain types of bacteria. Examples include:

Amoxicillin Ampicillin Ancef (Cefazolin) Keflex (Cephalexin) Levaquin (Levofloxacin) Linezolid Maxipime (Cefepime) Piperacillin Rifampin Rocephin (Ceftriaxone) Vancomycin

Analgesics-Pain Relievers Analgesics, or pain medications, are used to control pain before and after surgery. They are available in a wide variety of forms, and can be given as an

IV, in pill form, as a lozenge, a suppository, as a liquid taken by mouth and even as an ointment where the medication is absorbed through the skin. The strength of individual pain medications varies widely, just as the dosage prescribed by a physician can be different from one patient to another. For this reason, the medication prescribed will depend greatly on the condition for which it is prescribed. Most post-operative analgesics contain opioids, either purely or in combination with acetaminophen or NSAIDs. The following are examples of commonly prescribed choices:

Codeine Darvocet Demerol(Meperidine) Dilaudid (Hydromorphone) Fentanyl Lortab (Hydrocodone) Morphine Percocet (Oxycodone) Ultram (Tramadol) Vicodin (Hydrocodone)

IV Fluids Intravenous fluids, or IV fluids, are given to patients for two primary reasons, to replace fluids they have lost through illness or injury, or to provide fluids when they are unable to drink as they normally would. The solution that is used is selected based on the patients needs and can change periodically during a hospital stay.

Half-Normal Saline (.45 NaCL) Normal Saline (.9 NaCl) Lactated Ringers 5% Dextrose (D5)

Electrolytes Electrolytes are compounds in the blood that can conduct an electrical charge and help the body complete essential functions, including helping the heartbeat. Too many electrolytes, or too few electrolytes, can cause disruptions in the hearts function or other serious problems. To prevent complications from electrolyte imbalances, supplements can be given, orally or through an IV.

Calcium Chloride Magnesium Chloride Potassium Chloride Phosphorous (Potassium Phosphate)

Anticoagulants Anticoagulants are a category of medications that slow the clotting of the blood. This is important after surgery as one of the risks of surgery is blood clots, especially deep vein thrombosis, which often occur in the legs. To prevent blood clots from forming and causing complications such as a stroke or pulmonary embolus, anticoagulants are given through an IV, an injection, or in a pill form.

Argatroban Coumadin (Warfarin)

Heparin Lovenox (Enoxaparin)

Diuretics Diuretics are medications that increase the rate of urination. They can be used to stimulate kidney function and are also used to help control high blood pressure.

Lasix (Furosemide) Hydrochlorothiazide (HCTZ)

Anesthesia Drugs/Paralytics There are several types of medication that are used to provide anesthesia for patients having surgery. To keep patients calm immediately before the procedure, a barbiturate may be used. During surgery, a combination of paralytics-drugs that paralyze the muscles of the body, and drugs that cause unconsciousness are used together.

Isoflurane Nitrous Oxide pancuronium Propofol Succinylcholine Vecuronium

Barbiturates/Benzodiazepines Barbiturates and benzodiazepines, commonly known as downers or sedatives, are two related classes of prescription medications that are used to depress the

central nervous system. They are sometimes used with anesthesia to calm a patient prior to surgery. Because of side effects, barbiturates have basically been replaced by benzos to treat anxiety and can be used to relieve symptoms of insomnia and prevent seizure activity.

Ativan (Lorazepam) Librium (Chlordiazepoxide) Pentobarbital Valium (Diazepam) Versed (Midazolam) Phenobarbital Seconal (Secobarbital)

Antacids Antacids are common part of recovery from surgery. Even if you arent feeling well enough to eat or drink, your stomach continues to produce stomach acids. To prevent nausea, vomiting, or other complications from acid being produced but not used, antacids are given.

Pepcid (Famotidine) Tagamet (Cimetidine): Used as both a mouth swish and to treat ulcers

Mouth Care Mouth care is very important after surgery, especially for patients who are on a ventilator. Studies have shown that good mouth care, including rinsing the mouth with a solution that helps kill bacteria, can help prevent ventilator acquired pneumonia, which is when pneumonia develops in a patient who has been intubated and placed on a ventilator.

Mouth care is also important after dental surgeries, helping prevent infection in the gums and the areas where surgery was performed.

Chlorhexidine Lidocaine HCl (oral solution)

1.7 Nursing management of physiologic, physical, and psychosocial outcomes

III. Conclusion What has been learned from the clinical experience and correlation of facts and practices featured in your report?

We have learned that indirect inguinal hernia during assessment there will be an obvious swelling in the inguinal area. And that there are many method in relieving the patients condition by means of nursing interventions such as proper positioning. Positioning plays a vital role pre-operative and postoperative. Also in determining the diagnosis, Indirect hernias, the more common form, can develop at any age but are especially prevalent in infants younger than age 1. This form is three times more common in males. Because it is more common in young infant males its very hard to tell if they have the condition. Inguinal hernia is a common congenital malformation that may occur in males during the seventh month of gestation. Normally, at this time, the testicle descends into the scrotum, preceded by the peritoneal sac. If the sac closes improperly, it leaves an opening through which the intestine can slip, causing a hernia.

IV. References / Bibliography

Books: Joyce M. Black, Jane Hokanson Hawks Medical-Surgical Nursing Clinical Management for Positive Outcomes 8th Edition page 710 Lippincott Williams and Wilkins Professional guide to diseases 9th edition page 278

Maddern, Guy J. Hernia Repair: Open vs. Laparoscopic approaches. London: Churchill Livingstone, 1997.

Others: "Focus on Men's Health: Hernia." MedicineNet Home Jan. 2003. http://www.medicinenet.com .

"Inguinal Hernia." Healthwise, Inc. February 2001. http://www.laurushealth.com/library http://www.surgeryencyclopedia.com/Fi-La/Inguinal-HerniaRepair.html#ixzz2YKSEVnvR http://www.nursingdirectorys.com/2011/01/nursing-care-plan-for-inguinalhernia.html http://www.unboundmedicine.com/nursingcentral/ub/view/Diseases-andDisorders/73635/all/inguinal_hernia http://fitsweb.uchc.edu/student/selectives/Luzietti/hernia_inguinal_indirect.htm http://www.intelihealth.com/IH/ihtIH/EM/35320/75768/1369341.html?d=dmtHMS Content http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/#diagnosis http://www.mayoclinic.com/health/inguinalhernia/DS00364/DSECTION=symptoms