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 abdominal-wall-hernias.jpg

Abdominal Wall Hernias  Congenital vs. acquired surgery/incisional-hernia-surgery.html

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

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

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:  -overview -overview  of-abdominal-wall-hernias-in- adults?source=search_result&search=abdominal +wall+hernia&selectedTitle=1%7E48 of-abdominal-wall-hernias-in- adults?source=search_result&search=abdominal +wall+hernia&selectedTitle=1%7E48

References Ansari, P. (2014). Hernias of the abdominal wall. Merck Manual. Retrieved from abdomen-and-surgical-gastroenterology/hernias-of-the-abdominal-wall abdomen-and-surgical-gastroenterology/hernias-of-the-abdominal-wall Brooks, D. C. (2014). Overview of abdominal wall hernias in adults. Up to date. Retrieved from abdominal-wall-hernias-in- adults?source=machineLearning&search=abdominal+hernia&selectedTitle=1%7E48&sectio nRank=2&anchor=H #H http://www-uptodate-com.medjournal.hmc.psu.edu:2048/contents/overview-of- abdominal-wall-hernias-in- adults?source=machineLearning&search=abdominal+hernia&selectedTitle=1%7E48&sectio nRank=2&anchor=H #H Dains J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care. 5 th ed. Elsevier: St. Louis, Missouri. Goroll, A. H. & Mulley, A. G. (2009). Primary care medicine 7 th 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) 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: /