1. Incarcerated Abdominal Hernias Laura Maselli, BSN RN NURS 870 Pennsylvania State University

2. 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

3. Abdominal wall hernias  Ventral  Epigastric  Umbilical  Spigelian  Parastomal  Incisional  Groin  Obturator  Inguinal  Femoral  Congenital vs. acquired http://images.medicinenet.com/images/illustrations/2013-illustration- abdominal-wall-hernias.jpg

4. Abdominal Wall Hernias  Congenital vs. acquired http://www.wecareindia.com/general- surgery/incisional-hernia-surgery.html http://ranapileshospital.com/project/hernia/

5. 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

6. 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

7. 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

8. 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

9. 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

10. Diagnostic tests  Ultrasound  Abdominal CT  MRI  CPK  D-dimer  CBC, BMP, UA *History and physical exam are the best means of diagnosing hernias!

11. 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

12. 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/

13. 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

14. 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%

15. 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

16. Additional Information:  http://emedicine.medscape.com/article/189563 -overview http://emedicine.medscape.com/article/189563 -overview  http://www.uptodate.com/contents/overview- of-abdominal-wall-hernias-in- adults?source=search_result&search=abdominal +wall+hernia&selectedTitle=1%7E48 http://www.uptodate.com/contents/overview- of-abdominal-wall-hernias-in- adults?source=search_result&search=abdominal +wall+hernia&selectedTitle=1%7E48

17. References Ansari, P. (2014). Hernias of the abdominal wall. Merck Manual. Retrieved from http://www.merckmanuals.com/professional/gastrointestinal-disorders/acute- abdomen-and-surgical-gastroenterology/hernias-of-the-abdominal-wall http://www.merckmanuals.com/professional/gastrointestinal-disorders/acute- 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 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=H21327110#H21327110http://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=H21327110#H21327110 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) 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