Introduction:-
A hernia is a protrusion of a portion of an organ or organs through an abnormal opening.
Incidence
• About 5 out of 100 children have inguinal hernias (more boys than girls).
• Some may not have symptoms until adulthood.
Causes, and risk factors
• Usually, there is no obvious cause of a hernia, although they are sometimes associated with heavy lifting.
• Hernias can be seen in infants and children. This can happen when the lining around the abdominal organs does not close properly before birth.
• If you have any of the following, you are more likely to develop a hernia:
- Family history of hernias
- Cystic fibrosis
- Undescended testicles
- Extra weight
- Chronic cough
- Chronic constipation from straining to have bowel movements
- Enlarged prostate from straining to urinate
Types
• Diaphragmatic
• Hiatal
§ sliding
• Epigastric hernia
• Abdominal
§ Umblical
§ Omphalocele
§ gastroschisis
• Intraabdominal
• Inguinal hernia
§ Direct
§ Indirect
A diaphragmatic hernia
§ Is a birth defect, which is an abnormality that occurs before birth as a fetus is forming in the mother's uterus.
§ An opening is present in the diaphragm (the muscle that separates the chest cavity from the abdominal cavity).
§ With this type of birth defect, some of the organs that are normally found in the abdomen move up into the chest cavity through this abnormal opening.
types of diaphragmatic hernia:
Bochdalek hernia
A Bochdalek hernia involves an opening on the left side of the diaphragm. The stomach and intestines usually move up into the chest cavity.
Morgagni hernia
A Morgagni hernia involves an opening on the right side of the diaphragm. The liver and intestines usually move up into the chest cavity.
Incidence
® Bochdalek hernia:
§ makes up about 90 percent of all cases.
§ occurs in one out of every 2,200 to 5,000 live births.
® Morgagni hernia makes up two percent of all cases
® Parents who have had one child with an isolated diaphragmatic hernia have 2 percent or two in 100.
® Morgagni hernia is more common in girls than boys, whereas Bochdalek hernia is slightly more common in boys than girls.
® Babies with the Bochdalek type of diaphragmatic hernia are more likely to have another birth defect.Almost 20 percent have a congenital heart defect.
® Between 5 to 16 percent have a chromosomal abnormality.
Causes of diaphragmatic hernia
® As a fetus is growing in its mother's uterus before birth, different organ systems are developing and maturing.
® The diaphragm forms between the 7th and 10th week of pregnancy.
® The esophagus (the tube that leads from the throat to the stomach), the stomach, and the intestines are also developing at this time.
® In a Bochdalek hernia, the diaphragm may not develop properly, or the intestine may become trapped in the chest cavity as the diaphragm is forming.
® In a Morgagni hernia, the tendon that should develop in the middle of the diaphragm does not develop properly.
® In both cases, normal development of the diaphragm and the digestive tract does not occur.
® Diaphragmatic hernia is a multifactorial condition, which means that "many factors," both genetic and environmental, are involved.
Symptoms of a diaphragmatic hernia
The symptoms of a Bochdalek diaphragmatic hernia are often observable soon after the baby is born they are .
§ difficulty breathing
§ fast breathing
§ fast heart rate
§ cyanosis (blue color of the skin)
§ abnormal chest development, with one side being larger than the other
§ abdomen that appears caved in (concave)
§ A baby born with a Morgagni hernia may or may not show any symptoms.
Diagnosis
§ physical examination.
§ A chest x-ray to look at the abnormalities of the lungs, diaphragm, and intestine.
§ A blood test known as an arterial blood gas is often performed to evaluate the baby's breathing ability.
§ blood test for chromosomes (to determine if there is a genetic problem)
§ ultrasound of the heart (echocardiogram)
Treatment for a diaphragmatic hernia:
Specific treatment will be determined by your baby's physician based on the following:
¾ when the problem is diagnosed (during pregnancy or after birth)
¾ your baby's overall health and medical history
¾ the severity of the problem
¾ your baby's tolerance for specific medications, procedures, or therapies
¾ your opinion or preference
Definitive Treatment may include:
Neonatal intensive care
¾ Babies with diaphragmatic hernia are often unable to breathe effectively on their own because their lungs are underdeveloped.
¾ Most babies will need mechanical ventilator to help their breathing.
¾ Correct acidosis
¾ GI decompression
ECMO
¾ Some infants may need to be placed on a temporary heart/lung bypass machine called ECMO if they have severe problems.
¾ ECMO may be used temporarily while a baby's condition stabilizes and improves.
Surgery
¾ When the baby's condition has improved, the diaphragmatic hernia will be repaired with an operation.
¾ The stomach, intestine, and other abdominal organs are moved from the chest cavity back to the abdominal cavity. The hole in the diaphragm is repaired.
¾ Many babies will need to remain in the NICU for a while after surgery. Although the abdominal organs are now in the right place, the lungs still remain underdeveloped. The baby will usually need to have breathing support for a period of time after the operation. Once the baby no longer needs help from a breathing machine (ventilator), he/she may still need oxygen and medications to help with breathing for weeks, months, or years.
Nursing care : preop
¾ Reduce stimulation- envt/ care stimulation
¾ Promt recognition , resuscitation and stabilisation
¾ Maintain suction , o2 & IVF
¾ Positioning – head up
¾ medications
Nursing care : postop
¾ Carryout routine post op care and observation
¾ Relieve pain and discomfort
¾ Support family because it is a critical illness
Complications
¾ Many babies will have chronic lung disease and may require oxygen or medications to help their breathing for weeks, months, or years.
¾ Many babies will have gastroesophageal reflux
¾ Some babies will have difficulty growing. This is known as failure to thrive
¾ Delayed milestone
¾ Prone for hearing loss
Hiatal hernia
Sliding: protrusion of an abdominal structure usually stomach through esophagial hiatus
Symptoms
¾ Dysphagia
¾ FTT
¾ Vomiting‘
¾ Neck contortions
¾ Frequent unexplined respiratory problem
¾ Bleeding
¾ Usually associated with GER
¾ May cause gastric volvulus and obstruction
Dignosis
¾ Fluroscopy
Management
¾ Management of GERD symptoms
¾ Positioning
¾ Pharmacological measures
¾ Dietary management
¾ Surgical management hen complications are related to GERD despite medical management
Nursing care
¾ Be alert to significant signs and carryout routine post op. care
Epigastric
Epigastric hernia
Introduction
A midline protrusion may be due to the failure of the rectus abdominis muscles to join inutero.This occurs in the midline on the linea alba in the midline between the umblicus and lower end of sternum.
Feature
¾ Severe pain
¾ When running a finger down the midline of the abdomen while the child is standing , if hernia persist a small protrusion may be felt between the fingers of the linea alba
Tratment
Surgical correction
Abdominal
Umbilical Hernia
Weakness in the abdominal wall around umbilicus ; incomplete closure of abdominal wall , allowing the abdominal contents to protrude through opening
Incidence
High in premature and african American infants
Symptoms
¾ Noted by inspection and palpation of the abdomen
¾ Usually closes spontaneously by 1-2 yrs of age
Therapeutic management
§ No treatment for small cases
§ Operative repair if persist to age 4-6 yrs or if defects is>1.5-2cm by age 2
Nursing care
§ Discourage use of home remadies ( eg belly bands, coins etc )reassure parents
Omphalocele
Omphalocele
Protrusion of intraabdominal viscera into the base of the umbilical cord, sac is covered with peritoneum without skin
Gastroschisis
Gastroschisis
Protrusion of the intra abdominal containts through the defect in the abdominal wall lateral to umbilical ring , there is never a peritoneal sac
Intraabdominal hernia
Intraabdominal
Is caused by a loop of bowel slipping out of its normal position and becoming caught in a defective area of the mysentery or becoming compressed between the bands of the peritoneum
Intestinal obstruction can occur
Inguinal hernia
Incidence:
§ 3% in full term infants.
§ Hernias are more common in premature males.
Indirect inguinal hernia
§ the protruding loop of bowel passes obliquely through the abdominal wall,while in
a direct inguinal hernia
§ the herniating bowel pushes directly forward through the abdominal wall, taking a shorter course to the outside.
Diagnosis
§ Palpable mass along the inguinal canal.
§ Placing a finger tip on the scrotum and extending the finger into the inguinal canal will demonstrate a patent tunnel and one may feel bowel within the canal.
Treatment:
§ Inguinal hernias do not spontaneously resolve so surgery is required. If bowel becomes entrapped within the inguinal canal an incarcerated hernia can occur. This is a surgical emergency because the entrapped bowel can become ischemic.
LAPAROSCOPIC HERNIA REPAIR
§ During laparoscopic surgery, we make a small ½ inch cut in the skin at the belly button.
§ Then a cannula (thin tube) is introduced in between the muscle fibres without cutting any of the muscle.
§ Through the cannula, the laparoscope is inserted into the patient's body.
§ It is equipped with a tiny camera and light source that allows it to send images through a fibre-optic cord to a television monitor.
§ The television monitor shows a high resolution magnified image. Watching the monitor, the surgeon can perform the procedure.
§ Herniorrhaphy
§ Herniotomy
Nursing care preoperative care
§ Infant should be fed until few hours before the surgery
§ Preanesthetic medicines as ordered
Post operative care
§ Shift from the surgical facility when the effects of GA over and the child able to tolerate oral feeds
§ Keep the incision clean and dry
§ Sponge bath
§ Change soiled linen
Conclusion :
Hernia which is the protrusion of organ or organs through the abnormal opening ,varies in its severity based on its location and the organs involved and the age of the child.
BIBLIOGRAPHY:
1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001
2. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace & company; 1998
3. Dr.Chaudari KC. Indian Journa of Paediatrics. Nov22 2007
4. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002
Judith A.S Straight A’s in Paediatric Nursing. 2nd edition.Wolters Kluwer : Newyork;2008
