I.INTRODUCTION The preservation of health is a duty. Few seem conscious that there is such a thing as physical morality.

- Herbert Spencer Health promotion and disease prevention are the major roles of a nurse. It is in our area of responsibility to take action regarding diseases that is within the scope of responsibility for us. Many people today are unaware and that of are ignorant on the possible health risks they may have. Preventing such conditions by changing those bad habits to something that will benefit your health and there must be appropriate interventions and preventive measures to disrupt the occurrence of illnesses. A herniorrhaphy is a surgical procedure used to treat medical problems stemming from a hernia condition. It is a specific surgical strategy where the hernia is repaired through a series of incisions and sutures. Herniorrhaphy is a medical term that combines the Ancient Greek words hernia and raphere the latter meaning to suture or to make a seam. A herniorrhaphy procedure may also be known as hernioplasty or hernia repair although hernioplasty denotes the use of a material foreign to the patient's body to help treat the hernia. Most often, a hernia can be found in the areas of the stomach or abdomen.It is a highly common medical problem that may be the result of genetic disposition or of strenuous activities such as heavy lifting. People that are bothered by a hernia may opt for surgery. Hernias, however, can become dangerous when the protrusion is such that the blood supply to the hernia is cut off. This can lead to tissue death. In this case, the hernia becomes a medical emergency and usually requires an emergency surgical intervention. Herniorrhaphy is a specific treatment employed relative to the type of hernia problem that the patient is experiencing. There are two possible herniorrhaphy procedures: traditional and laparoscopic. In the former, an incision is made throughthe skin covering the hernia and the protruding tissues are forced back into place. The doctor then sutures the tear. A laparoscopic herniorrhaphy

utilizes a laparoscopic device to help in the procedure. The laparoscopic device is a miniature telescope that has a tiny camera fastened to it, enabling the doctor to see the hernia on a monitor. Using longer surgical instruments, the doctor can fix the hernia from behind the abdomen wall. In the cases where herniorrhaphy is used as a surgical procedure, the success rates typically are very high. Generally, there is only a 1.6 percent chance of the hernia reoccurring. The successes in herniorrhaphy surgery have made the procedure relatively simple in the United States, which means that the patient may return home from the hospital on the same day of the operation. A herniorrhaphy procedure normally requires only the employment of a local anesthetic by the medical staff. About 75% of hernias occur in the groin (indirect inguinal, direct inguinal, femoral). Incisional and ventral hernias comprise about 10%; umbilical 3%; and others about3%. Generally, a hernial mass is composed of covering tissues (skin, subcutaneous tissues, etc), a peritoneal sac, and any contained viscera. Particularly if the neck of the sac is narrow where it emerges from the abdomen, bowel protruding into the hernia may become obstructed or strangulated. If the hernia is not repaired early, the defect may enlarge and operative repair may become more complicated. The definitive treatment of hernia is early operative repair 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 12% of male children. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushes folds of genital tissue into the inquinal 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, 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. A direct and an indirect inguinal hernia may occur at the same time; this combined hernia is called apantaloon hernia. A femoral hernia is another type of hernia that appears in the groin, occurring when abdominal organs and tissue press through the femoral ring (passageway where the major femoral artery and vein extend from the leg into the abdomen) into the upper thigh. About 3% of all hernias are femoral, and 84% all femoral hernias occur in women. These are not inquinal hernias, but they can sometimes confuse the diagnosis of inguinal hernias because they curve over the inguinal area. They are more often accompanied by intestinal obstruction than inguinal hernias.

II. ANATOMY

The

external

oblique aponeurosis inguinal canal and,

is the front wall of the

at its lateral and lower location, is the continuum of the inguinal ligament. The superficial inguinal ring is the passage through which the spermatic cord passes and is covered by a thin membrane - the external spermatic fascia. The external oblique aponeurosis is joined medially to the aponeurosis of the internal oblique and transversus muscles, forming the medial half of the anterior rectus sheath (Fig. 1.3). The lateral half of the rectus sheath is simply covered by the external oblique aponeurosis, from which it may beseparated with greater or lesser ease. Contraction of the external oblique muscle stiffens the aponeurosis and causes a narrowing of the superficial ring. The cribriform fascia is is a thin layer that occludes the ossa ovalis. It is the continuation of the femoralis fascia and isoined to the external oblique aponeurosis. It covers the femoral canal from which it is separated bylax fatty tissue. The internal oblique muscle (Fig. 1.2) Below the external oblique aponeurosis lies a lower layer. Medially, it consists of the lateral side of the rectus sheath; originating from the fusion of the aponeurosis of the internal oblique muscle and thetransversus muscle. Continuing laterally we find the internal oblique muscle which usually borders

onthe rectus sheath and sometimes covers it completely.Only the inferior part of the internal oblique muscle is a part of the inguinal region. It covers the transversus muscle and its aponeurosis. The lower fibers of the internal oblique muscle form an arch that circumscribes the funiculus along the inguinal canal. The inferior border of the internal oblique muscle normally reaches the pubic spine. In hernia patients, the insertion of the inferior edge of the internal oblique muscle often reaches the rectus sheath in a position rather high compared to the pubicspine. The result is a triangular zone surrounded by the inferior border of the internal oblique muscle,by the inguinal ligament and by the lateral border of the rectus sheath. Thus, this area, called the inguinal triangle, is not defended by the internal oblique muscle, which gives rise to atendency to yield and produce direct hernias. Theinguinal triangle must not be confused with the Hesselbach triangle which is surrounded by the inguinal ligament, inferior epigastric vessels and the lateral border of the rectus muscle. The transversus muscle (Fig. 1.3 - 1.4)

The transversus muscle follows the same path as the internal oblique muscle, is located deeper and isless present in the inguinal region than the latter. The inferior edge of the muscular part does not, inmost cases, reach the midpoint of the inguinal ligament. In 26% of all cases does not go beyond

theanterior superior iliac spine. Medially too this muscular portion ends at a certain distance from therectus muscle. The transversus muscle at inguinal canal level is scarcely represented. The aponeurosis of the transversus muscle and transversalis fascia The deep inguinal ring (Fig 1.4) The anterior aponeurosis of the transversus muscle and the transversalis fascia are practically joined together and represent the posterior plane of the inguinal region. To be exact, the aponeurosis of the transversus forms an arch, called the aponeurotic arch of the transverses which coincides substantially with the arch of the internal oblique muscle. Therefore, the posterior wall of the canal,behind the funiculus, consists of a layer, the transversalis fascia, which is reinforced laterally by theiliopubic tract and medially by the aponeurotic arch of the transversus. The aponeurotic arch of thetransversus should not be confused with the semilunar line of Spigelio (Fig 1.3) that is, the border between the muscular and the aponeurotic part of the transversus which runs from the hypochondrium to the inguinal region. Cranially and laterally, the deep ring is bordered on by the trasversalis fasciaand transversus muscle or by its aponeurosis. Medially and caudally, it borders on the planecomprising the aponeurosis of the transversus + transversalis fascia, which in this tract presents asling-shaped thickening. The two ends of this thickening are called, respectively, inferior and superiorcrura. The inferior crus is the shorter of the two, is positioned laterally, joining the iliopubic tract. The superior crus, which is longer, is directed upwards, laterally and backwards, forming a flap on the trasversalis fascia to the inner side of the deep ring.Medially, the aponeurosis of the transversus muscle joins the aponeurosis of the internal oblique muscle to form the anterior part of the rectus sheath while the trasversalis fascia passes behind the rectus muscle. Laterally, along the angle of the transversalis fascia and the inguinal ligament there is a thickening, the iliopubic tract . At a deeper level, the transversalis fascia joins the femoral vessels andthe Cooper ligament, and forms the femoral septum that occludes the crural ring. The contraction of the transversus muscle attracts the superior crus upwards and laterally and withit, the fold of the transversalis fascia which covers

the deep ring from the inside (sling effect) like aneyelid. The inferior crus is fixed. The deep ring, besides being covered posteriorly, is tightened by theibers of the aponeurosis of the transversus and pulled upwards and outwards. When the muscles contract, the deep ring passes under the internal oblique muscle, which, is simultaneously tended and lowered. This protection mechanism is called the "sphincter mechanism". The simultaneous contraction of the internal oblique and transverse muscles creates the Keith shutter mechanism, which protects the posterior wall of the inguinal canal from endoabdominal pressure Asa result of the contraction, the internal oblique muscle stiffens and becomes shorter; the archstraightens, lowers and leans on the inguinal ligament. The same happens to the aponeurotic arch of the transversus muscle. The spermatic cord The most important elements of the spermatic cord are: the deferent duct, deferential artery; the testicular artery; the pampiniform plexus. These elements are enveloped by the internal spermatic fascia, which forms a continuum with the transversalis fascia. Externally, we find the cremaster. The cremaster is the continuum of the internal oblique muscle and pulls the testicle up towards thesuperficial inguinal ring. The genital branch of the genitofemoral nerve innervates it. It is vascularized by the funicular artery, a branch of the inferior epigastric artery. In women, the content of the inguinal canal is the round ligament, accompanied by some unimportant vessels (artery of the round ligament) and by nerves (iliohypogastric, ilioinguinal, and genitofemoral). The preperitoneal tissue and the peritoneum The preperitoneal tissue is mostly fat and is located between the transversalis fascia and the peritoneum. It is easily separable from the transversalis fascia. The vessels

The inferior epigastric vessels, (artery and two veins) stem from external iliac vessels. They pass by the deep inguinal ring, below and medially with respect to it, and proceed obliquely towards the posterior surface of the rectus muscle. The vessels are located between the peritoneum and the transversalis fascia. At times they adhere to the transversalis fascia. It is advisable not to transect andtie the inferior epigastric vessels, but in cases of hemorrhage or when a prosthesis has to be positioned, this may be done with the utmost tranquillity.The funicular vessels stem from inferior epigastric vessels and reach the funiculus through the deep ring or a small hole directly under this coming very close to the transversalis fascia.The iliac and femoral vessels pass through the lacuna vasorum. They are easily recognizable in laparoscopic surgery. In traditional hernia surgery risk of lesion to these big vessels is quite remote. But excessive stenosis of a crural hernial defect during repair may cause compression of the femoralvein, which is located medially to the artery and is often more easily detected through palpation thanat sight. The nerves

The

nerves

(figure

1.5)

which are greatest - The terminal branches of the XI and XII intercostal nerves

interest are: cutaneous

- The genital branches of iliohypogastric and ilioinguinal run parallel to each other. The iliohypogastric nerve runs above the ilioinguinal one before turning inwards. At the iliac crest theypass between the transversus and the

internal oblique muscles. In the inguinal canal they are located between the internal oblique muscle and the external oblique aponeurosis together with the funiculus. During hernia surgery, the subcutaneous terminal branches, which pass through the external oblique aponeurosis, can sometimes complicate the mobilization of this layer. It is necessary to isolate them;if, on account of their position, they run the risk of being strained or becoming tangled in the suturethey should be transected to avoid postsurgical pain. - The lateral external cutaneous nerve and the femoral branch of the genitofemoral innervate the skin of the thigh laterally down to the knee as well as the skin on the upper part of the "Scarpa's triangle". These are rather marginal to the operating area during hernia surgery. - The genital branch of the genitofemoral nerve penetrates the inguinal canal through the deep ring. Together with the funicular vessels, it runs posterior to the funiculus and innervates the cremaster. It then exits through the superficial ring and innervates the skin of the scrotum or the major labium as well as the superomedial part of the thigh. These nerves are almost all sensory nerves. The only motor nerve is the genital branch of the genitofemoral nerve, which innervates the cremaster.It is important to know the nerve path well, not only to perform local anesthesia, but also because if cut or caught up in the stitches can cause hypoesthesia or postoperative pain, respectively. One may say that even when these nerves are cut the ensuing, hypoesthesia diminished over time and is confined ultimately to small skin areas. The femoral canal and the Cooper ligament (Fig. 1.6)

The femoral or crural canal is delimited: - anteriorly, by the iliopubic tract and immediately to the front by the ilioinguinal ligament - medially, by the Gimbernat ligament - posteriorly, by the pectineal fascia, which, at level of the pectineal line, grows thicker and is called the Cooper ligament - laterally, by the arcus ileopectineus which covers the psoas muscle and separates the femoral nerverom the femoral vessels. Medially to the vein, the femoral canal is closed by the transversalis fascia, which at this point is known as the septum femorale, and is crossed by a number of lymphatic vessels. Crural hernias generally occur medially to the femoral vein, due to weakness in the femoral septum; less frequently prevascular hernias are known to occur. III. The Patient and his Illness a. Pathophysiology Indirect inguinal hernias usually occur because of a persistent process vaginalis. As the hernia emerges through the deep internal ring, it carries with it fascial linings of the tissue it transverses. The hernia courses along the inguinal canal lateral to the epigastric arteries and emerges through the external ring slightly lateral to the pubic tubercle. Contents of this hernia then follow the tract of the spermatic cord down into the scrotal sac in men, or follows the round ligament in females. Direct hernias are always acquired and therefore unusual in the young. They typically affect middle-aged or elderly patients. A direct inguinal hernia occurs because of degenerationand fatty changes in the aponeurosis of the transversalis fascia in the Hesselbach triangle area. The Hesselbach triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries and medially by the lateral border of rectus abdominus. Because of the wide neck of a direct hernia, it rarely strangulates. Strangulation is more common with indirect hernia, which has a narrow neck. As

segments of the intestine prolapsed through the defect in the anterior abdominal wall, they cause sequestration of fluid within thelumen of the herniated bowel. This initially impairs the lymphatic and venous drainage, which further compounds the swelling, and over time the arterial supply becomes involved. The increased intraluminal pressure causes the wall of the affected segment to become congested, which leads to extravasations of blood into the hernia sac. The normal pinkish and shining color of the bowel wall is lost and replaced with a dull congested bowel segment, followed by loss of tone within the bowel wall. This favors bacterial proliferation and subsequent infection of the blood-stained fluid in the hernia sac. Gangrene ensues and, if left untreated, perforation occurs. Peritonitis occurs initially within the sac and then spreads to the peritoneal cavity.

b. Pathophysiology BOOK-BASED PREDISPOSING FACTORS (Non-modifiable factors) Aging Race Sex Family History ` PRECIPITATINGFACTORS (Modifiable Factors) - Increase in weight

b. Synthesis of the disease Definition of the disease An external hernia is an abnormal protrusion of intra-abdominal tissue through a fascial defect in the abdominal wall. A reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recumbent. Though the lumen of a segment of bowel within the hernia sac may become obstructed, there may initially be no interference with blood supply. Compromise to the blood supply of the contents of the sac (eg, omentum or intestine) results in a strangulated hernia, in which gangrene of the contents of the sac has occurred. The incidence of strangulation is higher in femoral than in inguinal hernias, but strangulation may occur in other hernias as well.

Prevention

Control your weight and exercise: There's a clear link between obesity weighing more than is appropriate for your age and height. The association is stronger if you gain the weight later in life, particularly after menopause. Make healthy choices in the foods you eat and the kinds of drinks you have each day. Stay active. Eat foods high in fiber. Increase the amount of fiber to eat to between 20 and 30 grams daily. Among its many health benefits, fiber may help reduce the amount of circulating estrogen in the body. Foods high in fiber include fresh fruits and vegetables and whole grains.

 Limit the amount of alcohol you drink: Drinking alcohol is strongly linked to breast cancer. To help protect against Hernia, limit the amount of alcohol you drink to less than one drink a day or avoid alcohol completely. IV. CLINICAL INTERVENTION

a. Description of Prescribed Surgical Treatment Performed Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical Hernia repair is a surgical procedure for correcting procedure for correcting hernia. A hernia is a bulging of internal organs or tissues, which, protrude through an opening in the muscle wall.opening in the muscle wall. Hernias can occur in abdomen and groin. The surgery may be a standard open procedure through an incision large enough to access the hernia or a laparoscopic procedure performed through tiny incisions, using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair. When the surgery involves reinforcing the weakened area with steel mesh, the repair is called hernioplasty. APPROACHES All modern hernia surgery consists in three phases: - reaching the sac and the hernia defect - treating the sac - repair The sac and the hernia defect may be reached through three different surgical approaches: inguinal, preperitoneal and transperitoneal. The inguinal approach The inguinal approach is the most direct. The hernia defect may be reached anteriorly in two ways: 1) through an oblique incision in the skin, parallel to the groin, and medially at about a distance of two fingers from it, or 2) by a transverse incision at deep inguinal ring level.

The external oblique aponeurosis is incised following the grain of the fibers and the superficial ring is opened. The spermatic cord is isolated starting from the pubic spine and drawn back laterally. In indirect hernias, the sac is isolated from the elements of the spermatic cord, once the internal spermatic fascia has been opened. In direct hernia, the sac is reached easily after cutting the transversalis fascia on the back wall of the inguinal canal.

The preperitoneal approach The hernia defect may be reached from behind through the preperitoneal space. Today these approaches have been re-evaluated thanks to the advent of laparoscopy. The most common skin incisions currently used are the following: - midline umbilico pubic; - transverse suprapubic according to the Pfannenstiel method; - suprainguinal transversal, two fingers above the symphysis pubis. The first two types of incisions allow simultaneous treatment of bilateral hernias. Dissection of the deep layers Through a midline incision, passing through the two rectus muscles the preperitoneal tissue is reached. In the Pfannenstiel incision, the sheath of the rectus muscles is incised transversally and detached from the underlying level. The peritoneum is then separated from its wall until the affected inguinal area is reached. The epigastric vessels remain attached to the wall. The suprainguinal incision must be executed slightly above the deep ring. The incision is made transversally along the rectus sheath starting from the midline and across the internal oblique and the transversus muscles. This way the transversalis fascia may be reached.

The lateral edge of the rectus muscle is retracted towards the midline. Then the transversalis fascia may be incised longitudinally down the lateral edge of the rectus muscle or, as Nyhus proposes, transversally, to reduce herniation of the wound. Under no circumstances should the peritoneum be cut. This incision leads to the inferior epigastric vessels which, normally, must be interrupted and tied. Then, continuing to separate the peritoneum from the wall, the hernial sac is reached. The laparoscopic approach Even if an intraperitoneal laparoscopic approach exists, a preperitoneal one is generally preferred. The preperitoneum may be reached directly, without opening the peritoneum, as well as transperitoneally. In the latter case, the hernia defect may be reached through the inner side of the abdomen cavity by an incision on the parietal peritoneum which will later be sutured.The laparoscopic approach requires specific experience and a good "inside" knowledge of anatomy. The transabdominal preperitoneal approach After having performed a pneumoperitoneum, a laparoscope with a 30-degree view is introduced through the umbilicus. Two trocars are inserted at the lateral edge of the rectus muscle, one on the left, the other on the right, at umbilical level. The total extraperitoneal approach A vertical incision, 1-2 cm long, under the umbilicus and 1 cm lateral to the linea alba, on the side opposite to the hernia, is made. The anterior rectus sheath is incised, the muscle is retracted and a special balloon probe, which slides along the posterior sheath of the rectus muscle until it reaches the pubic bone, is inserted. The optics are inserted, the balloon is inflated to separate the preperitoneum. After 3-4 minutes, the optics are removed. The balloon is deflated and the probe is removed. Through the same hole, a sealed trocar is introduced and carbon dioxide blown in. Two trocars are inserted at the midline, one above the pubis, the other half way between the umbilicus and pubis

The inguinal approach Is undoubtedly the most frequently chosen. Advantages: - the possibility of performing under local anesthesia - direct and easy access on all anatomic levels - very low risk of lesion of large vessels. Disadvantages: - difficult dissection in hernia recurrence with added risk of lesion to testicular vessels - frequent traumatism of the inguinal canal nerves with consequent hypoesthesia and neuralgia The preperitoneal approach In many cases this requires a general anesthesia, except in the case of suprainguinal incisions. Advantages: - in hernia recurrences, the difficult dissection of the scar tissues is avoided. The risk of testicular vessel lesion is reduced. - elimination of inguinal canal nerve traumas - the possibility of treating hernia during operation for other pathologies - bilateral hernias may be treated simultaneously if a midline incision is performed Disadvantages: - limited possibility of performance in local anesthetic - increased width and depth of the operating field compared to the inguinal approach - impossibility of reaching surface layers of the inguinal region

- practically imperative use of prosthesis due to the poor results with use of direct suture and avoid risk of hernia on the wound.

The laparoscopic approach Perhaps, because it is very recent, it is still too soon to express a proper evaluation of this new approach and when it is indicated. Problems of training, the development of new methods and instruments are being developed. On the one hand, enthusiasm for novelty and the strong influence of the biomedical industry are keenly felt, but on the other, distrust towards new and more sophisticated techniques exists, also because these techniques are difficult to acquire. Those who advocate this method assert that the risk of trauma is low, that postoperative pain is mild and that immediate resumption of physical activity is possible, and that no risk of ischemic orchitis exists. The criticism this technique arouses is similar to that for extraperitoneal techniques. Concluding, the inguinal approach is still the most frequently chosen. Only in particular cases are different approaches preferred. Cases in which preperitoneal or laparoscopic approaches are indicated: - complicated hernia recurrence and multiple recurrence - bilateral hernias to be treated simultaneously - treatment of hernia during operations for other ailments. b. Indication of Prescribed Surgical Treatment Inguinal hernia repair is usually effective, depending on the size of the hernia, how much time has gone by between its first appearance and the corrective surgery, and the underlying condition of the patient. Most first-time hernia repair procedures will be one-day surgeries, in which the patient will go home the same day or in 24 hours. Only the most challenging cases will require an overnight stay. Recovery times will vary, depending on the type of surgery

performed. Patients undergoing open surgery will experience little discomfort and will resume normal activities within one to two weeks. Laparoscopy patients will be able to enjoy normal activities within one or two days, returning to a normal work routine and lifestyle within four to seven days, with the exception of heavy lifting and contact sports.
c. Required Instruments, Devices, Supplies, Equipments and Facilities

Adson pick ups- smooth: used to grasp delicate tissue; with teeth: used to grasp the skin.

Allis- used to grasp tissue. Available in short and long sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue.

Army-Navy retractor- used to retract shallow or superficial incisions

Babcock clamp- used to grasp delicate tissue (intestine, fallopian tube, ovary)

 Mayo Curve- used to cut heavy tissue (fascia, muscle)

Metzenbaum- used to cut delicate tissue

Needle holders- used to hold needles when suturing. They may also be placed in the sewing category

Richardson retractor- used to retract deep abdominal or chest incisions.

 Towel drapes

clipsin

used to hold towels and place

Clamp- used to clamp small blood vessels

Kelly- used to clamp larger vessels and tissue : Kelly, hemostat, mosquito (left to right)

 Scalpel- a small, light, straight knife with a very sharp blade, used by surgeons and in anatomical dissections

Scalpel blades- scalpel blades are gradually curved for greater precision when cutting through tissue.

Chromic- used in stitching the 1st and 2nd layer of the abdomen

 Vicryl- used to stitch the fascia

Plain- used to stitch the subcutaneous

Cotton- The fine thread or other material used surgically to close a wound or join tissues especially the skin layer

 Abdominal Pack- used to absorb blood

Thumb Forcep- are used to hold tissue in place when applying sutures, to gently move tissues out of the way during exploratory surgery and to move dressings or draping without using the hands or fingers.

Tissue Forcep- a toothed forcep used to grasp or hold tough tissue such as skin.

OS- To absorb blood and cover the incision site

 Cutting Needles- used in stitching the skin

Round Needles- used in stitching in layers underneath the skin

Betadine Solution- used for cleaning minor wounds and used in hospitals to prepare a patient's skin prior to surgery.

 Sterile Gown- a kind of clothing designed for medical staff performing surgery

Surgical Gloves- used when performing invasive medical or surgical procedure

 Surgical Mask- intended to be worn by health professionals during surgery and at other times to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose.

Surgical Cap- used to cover hair completely

Suction Machine- it is an equipment that produces an air pressure that can withdraw blood, and other secretion from the end of the nozzle or the suction tube

 Suction Tube- it is attached to the suction machine and it channels secretions from the patients operative site to suction bottle

Cautery Machine instrument use to burn or fuse small areas of body tissue to destroy dead cells, prevent the spread of infection, or seal tiny blood vessels to minimize blood loss during surgery.

O.R. Table- it is where the patient is laid during the procedure

 Operating Room - is a room within a hospital within which surgical operations are carried out.

Perioperative tasks and responsibilities of the nurse SCRUB NURSE Pre-operative Responsibilities 1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure. 2. Scrub, dry hands, gown, and glove. 3. Assist person scrubbed in first position with: a. Setting up back table, mayo, and basins b. Arrangement of instruments c. Preparation of suture and needles d. Preparation and counting sponges e. Arrangement and preparation of other necessary items f. Gowning and gloving surgeon and assistantsg. Assist with draping h. Arrangement of sterile field.

Intra-operative Responsibilities 1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure. 2. Begin developing methods of anticipating needs of surgeon and assistant. 3. After closing the skin: a. Assist with care of instruments and counts if necessary b. Care of specimen c. Assist with dressing of wound

Post-operative Responsibilities 1. After the completion of the Procedure: a. Assist with the gathering of all materials used during the procedure b. Discard items as necessary being careful to discard sharp items in designated places c. Return all items to respective aread. Assist with cleaning of roome. Clean the materials used properly and arrange them after drying 2. Perform any duties which will speed up the surgical procedure to follow in that room.

CIRCULATING NURSE

Pre-operative Responsibilities 1. Care for the patient before surgery by: a. Greeting patient and assist nurse with identification

b. Checking patient's chart, preparation, etc. 2. Prepare the room by: a. Obtaining instruments, supplies, and equipment for the designated operative procedure b. Opening unsterile supplies c. Assisting in gowning d. Observing breaks in sterile technique e. Assisting anesthesiologist as necessary f. Assisting with skin preparation and positioning g. Assisting with forming of the sterile field 3. Count the instruments, sharps and sponges before the procedureand confirm with scrub nurse. Intra-operative Responsibilities 1. During the Procedure: a. Remain in room and dispense materials as necessary b. Observe procedure as closely as possible c. Begin establishing method of anticipating needs of surgical team d. Care of specimen as indicated e. Care of operative records as indicated f. Assist with application of dressing g. Monitor the instruments, sharps and sponges used and take note of additional instruments. 2. Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and confirm with scrub nurse.

3. Inform the surgeon and assistant surgeon of a report of the instruments. Post-operative Responsibilities 1. Properly document all the necessary information on the patients chart. 2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation:

A careful history and physical examination are performed toexclude the possibility of other gastrointestinal diseases thatmay mimic biliary colic, such as peptic ulcer disease or reflux esophagitis. When the diagnosis of acute cholecystitis is suspected thepatient should receive nothing by mouth; however, nasogastric suction usually can be reserved for patients who are vomiting or have ileus and abdominal distention. Intravenous fluids are given to correct volume depletion and any electrolyte imbalances are measured and corrected. Monitor and regulate IVFs The nurse instructs the patient about the need to avoid smokingto enhance pulmonary recovery postoperatively and avoidrespiratory complications. It is also important to instruct thepatient to avoid the use of aspirin and other agents that can alter coagulation and other biochemical process On of the most important responsibility of the nurse is to let the patient sign an informed consent regarding the surgery. The patient is given anaesthesia prior to surgery and the patient is under NPO.

During the operation Monitoring the vital signs of the patient is one of theresponsibilities of the nurse during the surgery.

Assisting the anesthesia care provider during induction of general anesthesia Ensuring adequate oxygenation and hydration

After the operation

After recovery, the nurse places the patient in the low fowlers position. IV fluids may be given and nasogastric suction may be given to relieve abdominal distention. Water and other fluids aregiven in about 24hours, and soft diet is started when bowel sounds returned. Placing warm blankets on the patient to enhance comfort and preserve the patient's body temperature Assessing the patient's vital signs, oxygen saturation level, levelof consciousness, circulation, pain, IV site, fluid rate, andhydration status, as well as the status of the surgical site and dressing and all related monitoring equipment The nurse helps in relieving the pain by instructing the patient regarding proper positioning. The nurse helps in improving the respiratory status by instructing the patient regarding deep breathing exercises. The nurse also provides skin care like cleaning the incision part and providing clean dressing following a strict aseptic technique The nurse instructs the patient about the medications that are prescribed by the physician Discussing recommended follow-up management with the physician and the surgeon

e. Medical Management of Physiologic Outcomes

MEDICAL MANAGEMENT

GENERAL DESCRIPTION

INDICATION/PURPOSE

o D5LRS is a hypertonic solution in which the concentration D5LRS solution that is of of greater the of

It

lowers

osmotic causing to

pressure intracellular

water to shift from extracellular which may cause cellular dehydration, causing shrink cells and to the

concentration body fluids.

o It has an osmolality greater mOsm/L. than 295

extracellular space to expand. o Provides ions of plasma. Replacement acute losses of of principle normal

extra cellular fluid volume. It is given to patient to and plasma prevent dehydration maintain volume.

NURSING RESPONSIBILITIES: Before: When inserting an IV line to the patient, always prepare all the materials to be used. Wash hands thoroughly before performing the procedure. Identify the correct patient by checking the name on the chart or by asking directly the patient. Explain the procedure to the patient. During: Regulate and monitor infusion rate. After: Monitor patients therapeutic response to treatment. Check the IV infusion site for signs of infiltration: bulging, heat, pain, and redness.

MEDICAL MANEGEMENT

GENERAL DESCRIPTION

INDICATIONS

Foley Catheter

o To provide continuous Indicated or intermittent bladder operatively drainage repeated of and or permit operatively and to

prepostprevent

installation bladder distention and or urinary retention as a

medication post-op

irrigating fluids. Pre-op result of anesthesia. urinary drainage to prevent bladder distention and urinary retention as a result of anesthesia.

NURSING RESPONSIBILITIES: Before: Check for the doctors order. Explain the procedure to the patient/SO with its purpose and importance. Wash hands and observe other appropriate infection control procedures. Provide due privacy to the patient. Never force a catheter against resistance. During: Ensure patency of indwelling catheter. Keep a strict I and O record. Measure urine output, empty it and record the amount at least once every shift or after one to two times as necessary. Include perineal care at least twice a day. After: Empty the bag and record the amount of contents. Observe for urinary meatal irritation.

V.

CONCLUSION

Herniorraphy is the repair of a herniation (protrusion) of the abdominal contents, caused by a musculofascila defect in the abdominal wall or groin area. A hernia can occur within an old scar that is usually located in the abdominal (ventral) region, and is referred to as an incision hernia. Hernias are either reducible or irreducible that is incarcerated. The contents of an incarcerated hernia may become strangulated, compromising the viability of trapped tissues and thus necessitating their resection in addition to the herniography. Important nursing responsibilities perioperatively are: the pensrose drain should be moistened with saline before use; synthetic mesh is often used to repair recurrent hernias or large ventral hernias; and a specimen will be collected only during an indirect herniorrhaphy.

Angeles University Foundation College of Nursing Angeles City

Case Report: Herniorrhaphy

Submitted by: Bacani, Marie Jo Cabigting, Gabriel Patrick Dayrit, Reann Marie Hokson, Kalinina

BSN III;Group 9

Submitted to: Sammy David, RN, MN