Hernias: Types, Symptoms, Repair and Nursing Care

Table of Contents

HERNIAS

Hernias occur when an organ or tissue protrudes through an abnormal opening or weakness in the wall that normally contains it. In abdominal wall hernias, the protruding tissue is commonly fat, omentum or bowel. A hernia may cause a visible swelling, discomfort or a serious complication such as bowel obstruction or strangulation.

These lecture notes cover anatomy, classification, causes, assessment, repair and nursing care for diploma surgical nursing. Management differs by site, symptoms, age, complications and the person's fitness for surgery.

Learning objectives

Define a hernia and identify its anatomical parts.
Classify hernias by site, origin and clinical state.
Differentiate direct and indirect inguinal hernias from femoral hernias.
Explain the development of obstruction and strangulation.
Outline history taking, examination and investigations.
Describe conservative and surgical management.
Plan preoperative, postoperative and discharge nursing care with rationales.

Relevant abdominal wall and groin anatomy

The abdominal wall contains skin, subcutaneous tissue, muscle and aponeurotic layers, transversalis fascia, extraperitoneal tissue and parietal peritoneum. Its muscles support abdominal contents and participate in breathing, posture and activities that raise intra-abdominal pressure. Natural passages and previous surgical scars may create sites of weakness.

Inguinal ligament: runs from the anterior superior iliac spine to the pubic tubercle and provides an important boundary when assessing groin swelling.
Inguinal canal: an oblique passage above the medial portion of the inguinal ligament. It carries the spermatic cord in males and the round ligament in females.
Deep inguinal ring: an opening in transversalis fascia, lateral to the inferior epigastric vessels.
Superficial ring: an opening in the external oblique aponeurosis near the pubic tubercle.
Hesselbach's triangle: bounded by the lateral border of rectus abdominis, inferior epigastric vessels and inguinal ligament. Direct inguinal hernias protrude through this region.
Femoral canal: lies below the inguinal ligament and medial to the femoral vein. Its relatively narrow, firm boundaries increase concern for trapping of hernia contents.
Umbilicus and linea alba: natural midline areas where umbilical or epigastric defects can occur.

Parts of a typical hernia

Part	Description
Defect or hernial opening	The gap or weakened area through which tissue protrudes.
Sac	Usually an outpouching of peritoneum, with a neck and body.
Contents	May include omentum, small bowel, colon or another structure depending on the site.
Coverings	Tissue layers surrounding the sac, which depend on the route taken.

A narrow neck may trap tissue. Not every hernia contains a bowel loop or a typical complete peritoneal sac; the anatomy must be established clinically and, where necessary, during imaging or surgery.

Classification of hernias

By site

Type	Site and important features
Inguinal	Groin above the inguinal ligament; direct or indirect. An indirect hernia may extend into the scrotum.
Femoral	Through the femoral canal below the inguinal ligament; may be a small upper-thigh or groin swelling.
Umbilical or paraumbilical	At or close to the umbilicus; childhood and adult forms have different natural histories.
Epigastric	Through the linea alba between the umbilicus and xiphoid; often contains fat.
Incisional	Through a defect associated with a previous surgical incision, including selected port sites.
Parastomal	Adjacent to a stoma through the abdominal wall opening.
Spigelian	Along the lateral border of rectus abdominis; the swelling may be difficult to see.
Obturator	Through the obturator canal; may present with obstruction and little obvious external swelling.
Hiatus	Part of the stomach passes through the oesophageal opening in the diaphragm; commonly associated with reflux symptoms.
Internal	Bowel passes through an internal aperture, such as a mesenteric defect; may cause obstruction without an external lump.

By origin and clinical state

Congenital: associated with a developmental defect, such as a patent processus vaginalis. Symptoms may appear later.
Acquired: develops with tissue weakness or damage later in life.
Primary: first occurrence at that site; recurrent: returns after repair.
Reducible: contents return spontaneously when lying down or can be gently returned during appropriate clinical assessment.
Irreducible: contents cannot return. This may be chronic or a new acute event. The term “incarcerated” is often used for trapped contents.
Obstructed: herniated bowel blocks intestinal passage; blood supply may initially remain intact.
Strangulated: blood supply to the contents is compromised. Ischaemia can progress to necrosis, perforation and sepsis.
Inflamed: inflammation involves the contents or sac; assessment must exclude obstruction and strangulation.

Key distinction: irreducibility, obstruction and strangulation describe different problems. They may coexist. A newly painful irreducible hernia requires urgent assessment even before all textbook signs appear.

Direct versus indirect inguinal hernia

Feature	Indirect	Direct
Route	Enters the deep ring and follows the inguinal canal.	Pushes through the posterior wall in Hesselbach's triangle.
Inferior epigastric vessels	Lateral to the vessels at its origin.	Medial to the vessels at its origin.
Underlying tendency	May be associated with a persistent processus vaginalis.	Usually associated with acquired posterior-wall weakness.
Age	Can occur at any age, including childhood.	Usually occurs in adults.
Scrotal extension	May extend into the scrotum.	Less commonly extends into the scrotum.
Clinical identification	Examination may suggest the type, but clinical tests are not perfectly reliable. Imaging or operative anatomy may establish it.

Memory aid: “Indirect is lateral; direct is medial” refers to the relationship with the inferior epigastric vessels.

Causes and predisposing factors

Hernias usually develop through a combination of tissue weakness and forces that push contents through a defect. One episode of lifting does not explain every hernia.

Developmental openings or inherited connective-tissue susceptibility.
Age-related loss of tissue strength.
Previous surgery, wound infection, wound disruption or impaired healing.
Persistent cough and repeated increases in abdominal pressure.
Constipation or urinary obstruction causing repeated straining.
Obesity, pregnancy or ascites, particularly relevant to some ventral hernias.
Smoking, poor nutrition and diabetes contributing to impaired wound healing.
Repeated physically demanding work in a person with an existing weakness.
Previous hernia and family history.

Assess these factors without assuming that all have the same importance for every hernia type. Treating cough or constipation may reduce strain, but it does not close an established adult abdominal wall defect.

Pathophysiology of strangulation

Fat or bowel protrudes through a defect into the hernia.
Contents become trapped, especially where the opening is tight.
Compression first impairs venous and lymphatic drainage, causing congestion and swelling.
Increasing swelling raises pressure and worsens entrapment.
Arterial perfusion becomes impaired and tissue ischaemia develops.
Necrosis may occur; damaged bowel can perforate.
Contamination, peritonitis, sepsis and shock may follow.

A Richter hernia traps only part of the bowel wall. It can become strangulated without causing complete luminal obstruction, so continued stool passage does not exclude dangerous ischaemia.

Clinical manifestations

Uncomplicated external hernia

A groin or abdominal wall swelling, often more noticeable while standing, coughing or straining.
A swelling that becomes smaller or disappears on lying down.
Dragging, aching, heaviness or local discomfort.
Symptoms during lifting, prolonged standing or physical activity.
Sometimes no pain, with the swelling found incidentally.

Features requiring urgent surgical assessment

Sudden or increasing pain, particularly in a previously painless swelling.
A newly irreducible, tense or markedly tender lump.
Red, dusky or otherwise changed skin over the hernia.
Persistent vomiting, abdominal distension or inability to pass flatus or stool.
Fever, tachycardia, weakness, hypotension or confusion.
Peritoneal tenderness, rigidity or other evidence of systemic deterioration.

Absence of fever, skin discolouration or complete constipation does not exclude strangulation. Clinical concern and progression matter more than waiting for every sign.

Special considerations by type

Femoral hernia

Femoral hernias occur relatively more often in women and carry a greater concern for trapping and strangulation. They may be small and easily confused with other groin swellings. A suspected femoral hernia needs timely surgical referral rather than routine application of watchful waiting intended for selected men with minimally symptomatic inguinal hernia.

Umbilical hernia

In children, the defect often closes as the child grows; uncomplicated cases are commonly observed under a paediatric plan. Adult defects are less likely to close spontaneously. Pain, irreducibility or obstructive features require urgent assessment at any age. Do not strap coins over a baby's umbilicus: this does not close the defect and can damage the skin.

Incisional and parastomal hernias

Assess previous operations, wound infection, functional limitation and the size or progression of the swelling. Parastomal hernias can affect appliance fitting and cause leakage or skin problems. A stoma nurse can help with appropriate appliances and prescribed support garments. Obstruction, increasing pain or stoma colour change requires urgent review.

Hiatus hernia

A sliding hiatus hernia involves upward movement of the gastro-oesophageal junction and part of the stomach. In a paraoesophageal hernia, part of the stomach lies alongside the oesophagus; more complex forms may involve additional displacement. Heartburn, regurgitation or swallowing difficulty may occur. Management can include smaller meals, avoiding lying down soon after eating, weight management where appropriate and prescribed reflux medicines. Selected symptomatic or complicated cases need surgery. Acute severe chest or upper abdominal pain with retching or vomiting needs urgent assessment; do not assume every chest symptom is reflux.

History and physical assessment

History taking

Ask when the swelling began and whether it is enlarging.
Establish its location, relation to posture, cough and activity, and whether it previously returned when lying down.
Assess pain, onset, severity and sudden changes.
Ask about vomiting, distension, stool and flatus.
Review previous hernias, repairs and abdominal operations.
Ask about cough, constipation, urinary straining, pregnancy and ascites.
Review diabetes, cardiovascular and respiratory disease, medicines, anticoagulants and allergies.
Assess smoking, nutrition, work demands and access to referral or surgery.
Explore understanding, embarrassment, anxiety and support at home.

Examination principles

Explain the examination, obtain consent, maintain privacy and arrange a chaperone for groin examination as appropriate. Assess vital signs and general condition. A trained practitioner may inspect standing and lying positions and observe the response to coughing. Examine the location and tenderness of the swelling and assess the abdomen for obstruction or peritonitis. Examine both groins where indicated.

Nurses should not repeatedly manipulate a painful lump or attempt forceful reduction. A pulsatile groin mass requires assessment for a vascular cause. Children with a painful groin swelling or scrotal symptoms need urgent assessment because alternative diagnoses, including testicular torsion, can also be emergencies.

Differential diagnoses of a groin swelling

Enlarged lymph nodes or lymphadenitis.
Hydrocele or spermatic-cord cyst.
Lipoma or another soft-tissue mass.
Saphena varix or a vascular aneurysm.
Abscess.
Undescended testis.
Round-ligament varicosities during pregnancy.

A cough impulse, position or apparent reducibility can support assessment but should not be treated as absolute proof of a particular diagnosis.

Investigations

Investigation	Purpose
Clinical examination	Often sufficient for an obvious uncomplicated external hernia.
Ultrasound	Can assess an uncertain groin or abdominal wall swelling and selected alternative diagnoses.
CT	Useful in complex, incisional or internal hernias and when obstruction or another abdominal diagnosis is suspected.
MRI	May help selected occult or uncertain cases when appropriate.
Full blood count	Assesses anaemia and supports evaluation of infection or preoperative condition.
Electrolytes and renal function	Identify vomiting-related losses and guide perioperative fluid management.
Other ordered tests	Coagulation, glucose, lactate, blood grouping and cardiopulmonary tests depend on the clinical situation.

Normal laboratory results do not exclude early bowel ischaemia. Investigations should not delay emergency surgical action when strangulation is strongly suspected.

Management of hernias

Watchful waiting and supportive measures

Selected adult men with an asymptomatic or minimally symptomatic inguinal hernia may choose watchful waiting after clinical assessment and discussion of risks. This requires a clear follow-up and emergency plan; symptoms may later make surgery necessary. It is not a general policy for femoral hernias, symptomatic acute hernias or children with inguinal hernias.

Address cough, constipation, urinary straining and other modifiable contributors.
Support smoking cessation, nutrition, diabetes management and suitable weight optimisation before planned repair.
Adjust activities that provoke discomfort while the patient awaits assessment.
Provide a clear route for urgent help if the swelling becomes painful or irreducible.

Trusses and binders: may occasionally be prescribed for selected patients, but they do not repair the defect. They need appropriate fitting and skin assessment and must not conceal a complication or delay referral. Do not apply a truss to a painful irreducible hernia without clinical assessment.

Surgical repair

Term or approach	Meaning
Herniotomy	Management of the hernial sac, including appropriate high ligation; commonly relevant to paediatric indirect inguinal repair.
Herniorrhaphy	Repair using the patient's tissues and sutures. Terminology may also be used broadly for hernia repair.
Hernioplasty	Reinforcement of the defect, commonly with mesh.
Open repair	An incision provides direct access to the hernia. Anaesthesia depends on the operation and patient.
Laparo-endoscopic repair	Small access incisions are used to place a repair, generally under general anaesthesia.
TEP	Totally extraperitoneal groin repair, performed in a plane outside the peritoneal cavity.
TAPP	Transabdominal preperitoneal repair, entering the abdominal cavity to reach the preperitoneal plane.

Mesh repair is commonly used in adults to reinforce the area and reduce recurrence. Selected non-mesh repairs remain appropriate in particular circumstances. The surgeon considers hernia type, previous repair, tissue condition, contamination, available expertise and patient preference. Mesh is not routinely treated as an identical solution for every child or emergency presentation.

If strangulation has caused non-viable bowel, resection and an appropriate reconstruction or stoma may be necessary. A complicated emergency repair can require a much longer admission than an elective uncomplicated repair.

Emergency management

Call for urgent surgical assessment and assess ABCs.
Keep the patient nil by mouth according to the emergency plan.
Establish intravenous access, obtain ordered blood tests and implement prescribed fluid resuscitation.
Monitor vital signs, consciousness, perfusion and urine output.
Provide prescribed analgesia and antiemetics; relief should accompany assessment rather than obscure reassessment.
Prepare for nasogastric decompression when ordered for obstruction.
Administer antibiotics when prescribed for suspected ischaemic bowel, perforation or infection.
Prepare consent, theatre checklist, blood availability and transfer as required.

Reduction: a trained clinician may attempt carefully selected manual reduction when there is no suspicion of bowel ischaemia. It requires appropriate assessment, monitoring and observation afterward. Suspected strangulation needs urgent surgery; nurses or patients should not force the lump back.

Preoperative nursing care with rationales

Care area	Action	Rationale
Baseline assessment	Record vital signs, pain, swelling, bowel function, urine pattern and comorbidities.	Identifies complications and provides a comparison for recovery.
Explanation and consent	Confirm understanding of the planned repair and refer unanswered questions to the surgeon.	Supports informed participation and reduces uncertainty.
Medication review	Check anticoagulants, diabetes medicines, allergies and relevant supplements; follow authorised adjustments.	Reduces bleeding, glucose and anaesthetic risks.
Hydration and nutrition	Assess intake and losses; implement ordered correction and nutritional support.	Supports perfusion and healing.
Fasting and preparation	Follow the individual fasting instructions and skin-preparation protocol.	Reduces aspiration and infection risk without unnecessary prolonged fasting.
Breathing and mobility teaching	Explain supported coughing, breathing exercises, pain relief and safe mobilisation.	Prepares the patient to participate in recovery.
Bladder concerns	Identify urinary symptoms or prostate problems and follow the preoperative voiding plan.	Helps anticipate postoperative retention.
Safety and handover	Complete the checklist, site verification and relevant handover.	Ensures the team knows the patient's procedure and risks.

Routine bowel preparation is not necessary for every hernia repair. Antibiotic prophylaxis and thromboprophylaxis depend on the procedure, setting, individual risk and prescribed protocol.

Postoperative nursing care

Care area	Intervention	Rationale and evaluation
Airway and breathing	Monitor consciousness, respiratory rate and saturation; follow recovery protocols.	Detects anaesthetic and analgesic effects; evaluate stable breathing.
Circulation and bleeding	Monitor vital signs, perfusion, dressing and swelling.	Detects haemorrhage or expanding haematoma; evaluate stability.
Pain control	Assess at rest and movement, give prescribed medicines and reassess.	Supports mobility and comfort; persistent severe pain requires review.
Wound care	Use appropriate clean or aseptic technique and assess redness, discharge and healing.	Reduces infection risk and identifies wound problems.
Groin or scrotal swelling	Assess extent and progression; provide prescribed support and report increasing pain or marked swelling.	Some bruising occurs, but worsening findings need assessment.
Urination	Record voiding, discomfort and bladder distension; use bladder assessment according to protocol and escalate retention.	Anaesthesia and urinary disease may cause retention.
Food and fluids	Resume according to the operation and recovery plan; assess nausea and tolerance.	Supports hydration and avoids overlooking persistent vomiting.
Bowel function	Assess distension, flatus and stool; give prescribed bowel support when appropriate.	Prevents straining and helps identify ileus or obstruction.
Mobility	Assist safe early walking and prescribed thrombosis prevention.	Reduces complications of immobility.
Discharge	Confirm stable recovery, adequate pain control, safe mobility and the required voiding and support arrangements.	Promotes safe care after leaving the facility.

Nursing care plan

Problem	Goal	Interventions and evaluation
Acute pain	Patient reports acceptable relief and can move safely.	Assess pain, provide prescribed analgesia and positioning, reassess and escalate unexpected severe pain.
Anxiety	Patient understands the plan and expresses concerns.	Listen, explain the repair and recovery, involve chosen support and check understanding.
Risk of fluid deficit	Stable perfusion and adequate hydration.	Monitor intake and losses, urine and vital signs; implement prescribed replacement.
Risk of infection	Wound heals without infection.	Monitor temperature and wound, perform appropriate dressing care and teach danger signs.
Impaired mobility	Safe progressive activity.	Support walking, pain control and fall prevention; evaluate function.
Risk of urinary retention	Comfortable adequate voiding.	Assess urine pattern and bladder symptoms, encourage appropriate measures and escalate inability to void.
Knowledge needs	Patient explains safe home care and when to return.	Use teach-back for medicines, wound care, activity, complications and follow-up.

Complications

Before repair

Irreducibility and increasing discomfort.
Intestinal obstruction.
Strangulation, tissue necrosis and bowel perforation.
Peritonitis, sepsis and shock.
Functional limitation and difficulty with work or daily activities.

After repair

Haematoma, seroma or wound infection.
Urinary retention.
Persistent pain, numbness or nerve-related symptoms.
Recurrence.
Uncommon injury to bowel, bladder, vessels or reproductive structures.
Mesh-related infection or other mesh complications in selected cases.
Anaesthetic, respiratory or thromboembolic complications.

Not every postoperative swelling is recurrence. A seroma or haematoma may mimic a lump and needs appropriate assessment. Pain that persists and affects daily activities should be reviewed rather than dismissed as an inevitable result of surgery.

Discharge education and prevention of avoidable strain

Wound: follow the dressing and bathing instructions; avoid applying unprescribed substances and attend planned suture or wound review.
Medicines: explain timing, pain control and adverse effects. Opioids may cause constipation; use the prescribed bowel plan.
Activity: encourage walking and progressive normal activity as comfortable. Heavy work and strenuous lifting should follow the specific surgical advice; restrictions differ after simple groin repair and major abdominal wall reconstruction.
Cough and constipation: seek treatment for persistent cough, maintain appropriate fluids and dietary fibre when suitable, and avoid repeated straining.
Urinary symptoms: report painful inability to pass urine promptly.
General health: support smoking cessation, glucose management and nutrition.
Urgent return: severe or worsening pain, persistent vomiting, a tense painful swelling, fever, spreading wound redness, pus, heavy bleeding, breathlessness or reduced urine need prompt review.
Follow-up: provide the date, location and contact route, considering travel distance and available home support.

After anaesthesia or sedation, follow the facility's advice about an escort, supervision, driving and operating machinery. Return to work depends on the repair, symptoms and duties rather than one fixed rule for all patients.

Hernia care in children and during pregnancy

A child with an inguinal hernia needs paediatric surgical assessment because observation appropriate to an uncomplicated childhood umbilical hernia is not automatically appropriate to an inguinal hernia. Persistent crying, vomiting, a painful irreducible groin swelling or systemic illness requires urgent review. Teach caregivers to seek help rather than repeatedly squeeze the swelling.

Groin swelling during pregnancy may represent a hernia or round-ligament varicosities. Assessment can guide conservative care and timing of intervention. Painful irreducibility, obstruction or suspected strangulation remains urgent. Avoid assuming pregnancy itself establishes the diagnosis.

Revision points and questions

Remember: identify the site, determine the clinical state, look for obstruction or ischaemia, then support the appropriate referral and treatment plan.

Define hernia and describe its parts.
Compare direct, indirect and femoral hernias.
Differentiate reducible, irreducible, obstructed and strangulated hernias.
Explain why a patient can have strangulated bowel without complete constipation.
Outline emergency nursing management of a painful irreducible groin swelling.
Differentiate herniotomy, herniorrhaphy and hernioplasty.
Give ten postoperative nursing interventions with rationales.
Describe discharge education after elective hernia repair.

Clinical case: A patient with a long-standing groin bulge develops severe pain, vomiting and a lump that no longer reduces. Do not fit a truss or attempt forceful reduction. Arrange urgent surgical assessment, monitor ABCs and vital signs, implement the prescribed fasting and resuscitation plan and prepare for possible emergency operation.

References and further reading

Return to the Diploma in Nursing Direct Curriculum. Related notes: Ascites and Abdominal Cancers.