Download Complicated inguinal hernias and their emergency surgical

PROFORMA FOR THE REGISTRATION OF SUBJECT
FOR DISSERTATION
“A STUDY TO ASSESS THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON
KNOWLEDGE REGARDING INGUINAL HERNIA
AMONG INDUSTRIAL WORKERS IN SELECTED
INDUSTRIES OF TUMKUR WITH A VIEW TO
DEVELOP AN EDUCATIONAL PAMPHLET”
SUBMITTED BY;
JOSE CHERIAN
MEDICAL SURGICAL NURSING
RAMANAMAHARSHI COLLEGE OF NURSING
TUMKUR
2011-13
0
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA
PROFORMA FOR THE REGISTRATION OF
SUBJECT FOR DISSERTATION
1
NAME OF
CANDIDATE AND
ADDRESS
Mr. JOSE CHERIAN
1 YEAR M Sc NURSING
RAMANAMAHARSHI COLLEGE
OF NURSING, TUMKUR
2
3
4
NAME OF THE
RAMANAMAHARSHI COLLEGE
INSTITUTION
OF NURSING
COURSE STUDY AND
I YEAR M.SC. NURSING
SUBJECT
MEDICAL SURGICAL NURSING
DATE OF ADMISSION
TO COURSE
5
TITLE OF THE TOPIC A STUDY TO ASSESS THE
EFFECTIVENESS OF
STRUCTURED TEACHING
PROGRAMME ON KNOWLEDGE
REGARDING INGUINAL HERNIA
AMONG INDUSTRIAL WORKERS
IN SELECTED INDUSTRIES OF
TUMKUR WITH A VIEW TO
DEVELOP AN EDUCATIONAL
PAMPHLET
1
6. BRIEF RESUME OF THE INTENDED WORK
Introduction
“To acquire knowledge one must study but to acquire wisdom one must
observe”
An inguinal hernia is a condition in which intra-abdominal fat or part of the small
intestine, also called the small bowel, bulges through a weak area in the lower
abdominal muscles. An inguinal hernia occurs in the groin—the area between the
abdomen and thigh. This type of hernia is called inguinal because fat or part of the
intestine slides through a weak area at the inguinal ring, the opening to the inguinal
canal. An inguinal hernia appears as a bulge on one or both sides of the groin. An
inguinal hernia can occur any time from infancy to adulthood and is much more
common in males than females. Inguinal hernias tend to become larger with time.
The majority of hernias occur in males. Nearly 25% of men and only 2% of women in
the United States will develop inguinal hernias. Inguinal hernias occur nearly three
times more often in African American adults than in Caucasians. Among children, the
risk of groin hernia is greater in premature infants or those of low birth weight.
Indirect inguinal hernias will occur in 10–20 children in every 1,000 live births.
The inguinal ligament is a tight band located between the thigh and the stomach and
there are several weak spots along it.
Obesity, pregnancy, heavy lifting, chronic coughing, constipation and straining to
pass stools can cause the intestine to push against the abdominal wall, and a part of
intestine may slip through a weak spot, creating a lump. This lump is called a hernia.
A hernia consists of a sac - the peritoneum - which may contain a piece of intestine
(an intestinal loop). It is often able to move inside your body, meaning that it
disappears when you lie down, and reappears when you stand up or are straining to
pass a stool. The hernia itself is harmless.
However, a hernia can be dangerous if it gets trapped in the weak spot in the
abdominal wall and becomes tender. This is known as a strangulated hernia. If the
intestinal loop is damaged, its contents can leak out. Gangrene and peritonitis, which
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can be life-threatening, may occur as a result. Strangulation is an emergency requiring
urgent surgery.
The two types of inguinal hernia have different causes.
Indirect inguinal hernia. Indirect inguinal hernias are congenital hernias and are
much more common in males than females because of the way males develop in the
womb. In a male fetus, the spermatic cord and both testicles—starting from an intraabdominal location—normally descend through the inguinal canal into the scrotum,
the sac that holds the testicles. Sometimes the entrance of the inguinal canal at the
inguinal ring does not close as it should just after birth, leaving a weakness in the
abdominal wall. Fat or part of the small intestine slides through the weakness into the
inguinal canal, causing a hernia. In females, an indirect inguinal hernia is caused by
the female organs or the small intestine sliding into the groin through a weakness in
the abdominal wall.
Indirect hernias are the most common type of inguinal hernia. Premature infants are
especially at risk for indirect inguinal hernias because there is less time for the
inguinal canal to close.
Direct inguinal hernia. Direct inguinal hernias are caused by connective tissue
degeneration of the abdominal muscles, which causes weakening of the muscles
during the adult years. Direct inguinal hernias occur only in males. The hernia
involves fat or the small intestine sliding through the weak muscles into the groin. A
direct hernia develops gradually because of continuous stress on the muscles. One or
more of the following factors can cause pressure on the abdominal muscles and may
worsen the hernia:

sudden twists, pulls, or muscle strains

lifting heavy objects

straining on the toilet because of constipation

weight gain

chronic coughing
Indirect and direct inguinal hernias usually slide back and forth spontaneously
through the inguinal canal and can often be moved back into the abdomen with gentle
massage
3
Symptoms of inguinal hernia include:

a small bulge in one or both sides of the groin that may increase in size and
disappear when lying down; in males, it can present as a swollen or enlarged
scrotum

discomfort or sharp pain—especially when straining, lifting, or exercising—
that improves when resting

a feeling of weakness or pressure in the groin

a burning, gurgling, or aching feeling at the bulge
To diagnose inguinal hernia, the doctor takes a thorough medical history and conducts
a physical examination. The person may be asked to stand and cough so the doctor
can feel the hernia as it moves into the groin or scrotum. The doctor checks to see if
the hernia can be gently massaged back into its proper position in the abdomen.
In adults, inguinal hernias that enlarge, cause symptoms, or become incarcerated are
treated surgically. In infants and children, inguinal hernias are always operated on to
prevent incarceration from occurring. Surgery is usually done on an outpatient basis.
Recovery time varies depending on the size of the hernia, the technique used, and the
age and health of the patient. The two main types of surgery for hernias are as
follows:

“Open” hernia repair. In open hernia repair, also called herniorrhaphy, usually
the area of muscle weakness is reinforced with a synthetic mesh or screen to
provide additional support—an operation called hernioplasty.

Laparoscopy. Laparoscopic surgery is performed using general anesthesia.
The surgeon makes several small incisions in the lower abdomen and inserts a
laparoscope—a thin tube with a tiny video camera attached to one end. The
camera sends a magnified image from inside the body to a monitor, giving the
surgeon a close-up view of the hernia and surrounding tissue. While viewing the
monitor, the surgeon uses instruments to carefully repair the hernia using
synthetic mesh1.
4
Diagnosis/Preparation
Reviewing the patient's symptoms and medical history are the first steps in diagnosing
a hernia. The surgeon will ask when the patient first noticed a lump or bulge in the
groin area, whether or not it has grown larger, and how much pain the patient is
experiencing. The doctor will palpate the area, looking for any abnormal bulging or
mass, and may ask the patient to cough or strain in order to see and feel the hernia
more easily. This may be all that is needed to diagnose an inguinal hernia. To confirm
the presence of the hernia, an ultrasound examination may be performed. The
ultrasound scan will allow the doctor to visualize the hernia and to make sure that the
bulge is not another type of abdominal mass such as a tumor or enlarged lymph gland.
It is not usually possible to determine whether the hernia is direct or indirect until
surgery is performed.
Preparation
Patients will have standard preoperative blood and urine tests, an electrocardiogram,
and a chest x ray to make sure that the heart, lungs, and major organ systems are
functioning well. A week or so before surgery, medications may be discontinued,
especially aspirin or anticoagulant (blood-thinning) drugs. Starting the night before
surgery, patients must not eat or drink anything. Once in the hospital, a tube may be
placed into a vein in the arm (intravenous line) to deliver fluid and medication during
surgery. A sedative may be given to relax the patient.
Aftercare
The hernia repair site must be kept clean and any sign of swelling or redness reported
to the surgeon. Patients should also report a fever, and men should report any pain or
swelling of the testicles. The surgeon may remove the outer sutures in a follow-up
visit about a week after surgery. Activities may be limited to non-strenuous
movement for up to two weeks, depending on the type of surgery performed and
whether or not the surgery is the first hernia repair. To allow proper healing of muscle
tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after
surgery. The postoperative activities of patients undergoing repeat procedures may be
even more restricted.
Prevention of indirect hernias, which are congenital, is not possible. However,
preventing direct hernias and reducing the risk of recurrence of direct and indirect
hernias can be accomplished by:
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
maintaining body weight suitable for age and height

strengthening abdominal muscles through regular exercise

reducing abdominal pressure by avoiding constipation and the build-up of
excess body fluids, achieved by adopting a high-fiber, low-salt diet
lifting heavy objects in a safe, low-stress way, using arm and leg muscles2

If a hernia is not surgically repaired, an incarcerated or strangulated hernia can result,
sometimes involving life-threatening bowel obstruction or ischemia.
6.1 NEED FOR THE STUDY
A hernia is a lump that results from a part of the intestine (bowel) slipping through a
weakness in the abdominal wall. The most common hernias are inguinal hernias
(groin hernias).
There are three types of inguinal hernia:

indirect inguinal hernia which is common in children - they may be present at
birth - and young people. They are mostly seen in males but can also occur in
females.

direct inguinal hernias mostly afflict adults especially middle-aged and elderly
men.

femoral hernia is rarer than the other types and mainly affects women.
The opinion of a specialist doctor is usually necessary to determine which type of
hernia is present3.
Importance

An inguinal hernia is a condition in which intra-abdominal fat or part of the
small intestine, also called the small bowel, bulges through a weak area in the
lower abdominal muscles. An inguinal hernia occurs in the groin—the area
between the abdomen and thigh.

An inguinal hernia can occur any time from infancy to adulthood and is much
more common in males than females.
6

Direct and indirect hernias are the two types of inguinal hernia, and they have
different causes.

Symptoms of an inguinal hernia usually appear gradually and include a bulge
in the groin, discomfort or sharp pain, a feeling of weakness or pressure in the
groin, and a burning, gurgling, or aching feeling at the bulge.

An incarcerated inguinal hernia is a hernia that becomes stuck in the groin or
scrotum and cannot be massaged back into the abdomen.

A strangulated hernia, in which the blood supply to the incarcerated small
intestine is jeopardized, is a serious condition and requires immediate medical
attention. Symptoms include extreme tenderness and redness in the area of the
bulge, sudden pain that worsens quickly, fever, rapid heart rate, nausea, and
vomiting.

An inguinal hernia is diagnosed through a physical examination.

Inguinal hernias may be repaired through surgery. Surgery is performed
through one incision or with a laparoscope and several small incisions.

Surgery for inguinal hernia is usually done on an outpatient basis. Recovery
time varies depending on the size of the hernia, the technique used, and the
age and health of the patient.

Complications from inguinal hernia surgery are rare and can include general
anesthesia complications, hernia recurrence, bleeding, wound infection,
painful scar, and injury to internal organs4.
Description
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. 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
7
as inguinal hernias, 50% are indirect or congenital hernias, occurring when the
inguinal canal entrance fails to close normally before birth. This condition is found in
2% of all adult males and in 1–2% of male children. Indirect inguinal hernias can
occur in women, too, when abdominal pressure pushes folds of genital tissue into the
inguinal 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.
About 60% of hernias found in children, 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 a pantaloon hernia.
Because inguinal hernias do not heal on their own and can become larger or twisted,
which may close off the intestines, the prevailing medical opinion is that hernias must
be treated surgically when they cause pain or limit activity. Protruding intestines can
sometimes be pushed back temporarily into the abdominal cavity, or an external
support (truss) may be worn to hold the area in place until surgery can be performed.
Sometimes, other medical conditions complicate the presence of a hernia by adding
constant abdominal pressure. These conditions, including chronic coughing,
constipation, fluid retention, or urinary obstruction, must be treated simultaneously to
reduce abdominal pressure and the recurrence of hernias after repair5.
Hernia operations are among the most common procedures performed today.
Most hernias result from a tear in the lining, or fascia, beneath the abdominal muscles,
allowing the intestines to protrude. In many cases, this process begins at birth and is
an inherited condition.
While far more common in men, they are quite frequent in women as well. These
hernias affect people of all age groups, from infants to seniors.
Four different types of hernias account for almost 100 % of the hernias repaired by
surgeons:
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Type
Location
Frequency
Defect
Inguinal
Groin
93%
Fascia
Incisional
Entire Abdomen
5%
Fascia
Ventral/umbilical
Upper Abdomen
1%
Fascia
More common in males than females.
Indirect hernias - most common overall
Femoral hernias - more common in females.
Most common side for inguinal and femoral hernias is the right side; explanation:
delay atrophy of processus vaginalis
A paediatric inguinal hernia can appear / occur at any age, but the peak incidence is
during infancy and early childhood with 80 to 90% occurring in boys.
About 3% to 5% of healthy, full-term babies may be born with an inguinal hernia and
one third of hernias of infancy and childhood appear in the first 6 months of life. In
premature infants the incidence of inguinal hernia is substantially increased, up to
30%. In just over 10% of cases, other members of the family have also had a hernia
at birth or in infancy.
The occurrence of an inguinal hernia in boys is related to the development and
descent of the testes. The testes develop within the abdomen and at around the
seventh month of pregnancy they descend into the scrotum. On their way through the
abdominal wall, they pass through the inguinal canal. After they reach the scrotum,
the opening behind should close. Failure to close adequately results in a hernia with
an opening remaining in the abdominal wall at this point6.
Statistics on Hernia
Groin hernias occur in approximately 2% of the adult population and 4% of infants.
Their relative frequencies are as follows:

Inguinal 80%

Incisional 10%

Femoral 5%
9

Umbilical 4%

Epigastric <1%

Other: <1%
Inguinal are approximately 10 times more common in males, while femoral and
paraumbilical are more common in women.
Prognosis of Hernia depends on whether the patient develops complications. Hernias
are treatable surgically; although they may recur. The recurrence of a inguinal hernias
after surgical repair may occur but should be less than 2%7.
Based on the statistics available regarding inguinal hernia, there is a need to educate
community regarding early detection of hernias and its prompt treatment.
6.2 REVIEW OF LITERATURE
The review of literature is defined as broad, comprehensive in-depth,
systematic and critical review of scholarly publications, unpublished scholarly
print materials, audio visual materials and personal communications.
Kang SK, Burnett CA et al conducted a study on “Hernia: is it a workrelated condition?” which says that development of hernias among active workers is a
major occupational problem, however, the work-relatedness of hernias has not been
well investigated. It is a difficult question for occupational and primary care
physicians who must often address whether a worker with an inguinal hernia should
be restricted from work requiring lifting of heavy objects. To evaluate the possible
work-relatedness of inguinal hernias, a cross-sectional study was performed. The goal
of the study was to determine hernia incidence according to occupation with the
Annual Survey of Occupational Injuries and Illnesses from the Bureau of Labor
Statistics in 1994. Hernia incidence rates (per 10,000 workers) for industry and
occupation categories were calculated with the estimates of the number of hernias in
males and the employed male workers from the Current Population Survey. Rate
ratios (RR) of hernia incidence rates were calculated. In 1994, an estimated 30, 791
work-related hernias in males were reported by US private establishments. The
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occupation groups with the highest RR were laborers and handlers (RR, 2.47; 95%
confidence interval (CI), 2.14-2.80), machine operators (RR, 2.13; 95% CI, 1.812.44), and mechanics and repairers (RR, 1.72; 95% CI, 1.43-2.00).
Rate ratios for hernias vary considerably within industries and occupations, with the
highest ratios found in industries and occupations involving manual labor. This
provides support for the hypothesis that the hernias are work-related, especially in
work involving strenuous, heavy manual labor8.
Liem MS, van der Graaf Y et al conducted a study on “Risk factors for
inguinal hernia in women: a case-control study. The Coala Trial Group” which says
that potential risk factors for inguinal hernia in women were investigated and the
relative importance of these factors was quantified. In women, symptomatic but
nonpalpable hernias often remain undiagnosed. However, knowledge on this subject
only concerns hernia and operation characteristics, which have been obtained by
review of case series. Virtually nothing is known about risk factors for inguinal
hernia. The authors performed a hospital-based case-control study of 89 female
patients with an incident inguinal hernia and 176 age-matched female controls.
Activity since birth with two validated questionnaires was measured and smoking
habits, medical and operation history, Quetelet index (kg/m2), and history of
pregnancies and deliveries were recorded. Response for cases was 81% and for
controls 73%. Total physical activity was not associated with inguinal hernia
(univariate odds ratio (OR) = 0.8, 95% confidence interval (CI) 0.6-1.1), but high
present sports activities was associated with less inguinal hernia (multivariate OR =
0.2, 95% CI 0.1-0.7). Obesity (Quetelet index > 30) was also protective for inguinal
hernia (OR = 0.2, 95% CI 0.04-1.0). Independent risk factors were positive family
history (OR = 4.3, 95% CI 1.9-9.7) and obstipation (OR = 2.5, 95% CI 1.0-6.7). In
particular, smoking, appendectomy, other abdominal operations, and multiple
deliveries were not associated with inguinal hernia in females. The protective effect of
present sports activity may be explained by optimizing the resistance of the abdominal
musculature protecting the relatively small inguinal weak spot in the female. The
individual predisposition for inguinal hernia may be quantified by these risk factors,
and, with this in mind, the authors advise that further evaluation might be needed for
the patient with unexplained inguinal pain9.
11
Lau H, Fang C et al conducted a study on “Risk factors for inguinal hernia in
adult males: a case-control study” which says that inguinal hernia is one of the most
common surgical pathologies. Research studies on clinical factors predisposing a
person for the development of inguinal hernia, however, remain scarce. The objective
of the present study was to evaluate the risk factors for the development of inguinal
hernia in adult males, using a case-control design in a hospital-based population.
Between January 2002 and January 2004, a total of 1,418 male patients were recruited
at the general surgical or hernia clinic of a University-affiliated teaching hospital.
Patients were divided into case and control groups according to the presence of a
primary inguinal hernia. Each patient was interviewed by a research assistant using a
standardized questionnaire. Clinical data were studied by multivariate, logistic
regression analyses to identify independent predictors of inguinal hernia in adult
males. Clinical factors associated with the presence of inguinal hernia included a
higher work activity index (P = 0.03), a higher total activity index (P = 0.01), a
positive family history of inguinal hernia (P < 0.01, odds ratio = 8.73), and chronic
obstructive airway disease (P = 0.04, odds ratio = 2.04). After adjustments for the type
of hernia, chronic obstructive airway disease was a risk factor only for direct hernia,
whereas total activity index and family history of hernia remained significantly
related to both direct and indirect hernias. On logistic regression analyses, positive
family history of hernia was the only independent predictor for inguinal hernia.
Family history of hernia was the most important determinant factor for developing
inguinal hernia in adult males. A male subject who has a positive family history of
hernia is 8 times more likely to develop a primary inguinal hernia10.
Ruhl CE, Everhart JE conducted a study on “Risk factors for inguinal hernia
among adults in the US population” which says that inguinal hernia among US adults
(5,316 men and 8,136 women) participating in the First National Health and Nutrition
Examination Survey (1971-1975) who were followed through 1992-1993 for a
hospital (International Classification of Diseases, Ninth Revision, Clinical
Modification, code 550) or physician diagnosis of inguinal hernia. Ninety-six percent
of the baseline cohort was recontacted, with a median follow-up of 18.2 years (range,
0.02-22.1 years). Because the cumulative incidence of inguinal hernia was higher
among men (13.9%) than among women (2.1%), more detailed analyses were
12
conducted in men. Among men in multivariate analysis, a higher incidence (p < 0.05)
of inguinal hernia was associated with an age of 40-59 years (hazard ratio (HR) = 2.2,
95% confidence interval (CI): 1.7, 2.8), an age of 60-74 years (HR = 2.8, 95% CI: 2.2,
3.6), and hiatal hernia (HR = 1.8, 95% CI: 1.2, 2.7), while Black race (HR = 0.58,
95% CI: 0.42, 0.79), being overweight (HR = 0.79, 95% CI: 0.66, 0.95), and obesity
(HR = 0.51, 95% CI: 0.36, 0.71) were associated with a lower incidence. Among
women, older age, rural residence, greater height, chronic cough, and umbilical hernia
were associated with inguinal hernia. In the United States, inguinal hernias are
common among men, especially with aging. The lower risk among heavier men was
unexpected and bears further study11.
Wu XY, Huang MZ et al conducted a study on “A case-control study on the
risk factors for inguinal hernia in children” which says that inguinal hernia is a
common birth defect in children, but there is limited information about the risk factors
for this disorder. The study aimed to explore the risk factors for the development of
this disorder in children. A frequency matching case-control study based on hospital
group data was performed. One hundred and thirty-two 0-6 years old children with
inguinal hernia and 132 aged-matched controls were enrolled. Children's general
characteristics and their mothers' general characteristics before and during pregnancy
were obtained by a questionnaire survey. Risk factors for inguinal hernia were
investigated by logistic regression analysis. Multivariate logistic regression analysis
showed that the development of inguinal hernia was related to children's cry and
unease records (OR=3.70195%CI1.724-7.945), maternal consumption for pickles
(OR=2.53495%CI: 1.279-5.021) and maternal anemia (OR=3.76195%CI1.497-9.450)
one year before pregnancy and during the first 3 months of pregnancy, and the family
history of inguinal hernia (OR=13.50595%CI5.825-31.307).
Children's cry and unease records, maternal anemia and pickle consumption one year
before pregnancy and during the first 3 months of pregnancy, and family history of
inguinal hernia are risk factors for the development of inguinal hernia in children12.
Carbonell JF, Sanchez JL et al conducted a study on “Risk factors
associated with inguinal hernias: a case control study” with an objective to assess
reported risk factors for the development of inguinal hernias, to develop a method of
quantifying physical effort, and to correlate them. Case control study at District
13
hospital, Valencia, Spain. 290 selected patients who had undergone inguinal hernia
repair, and 290 age and sex matched controls. Each patient was interviewed and data
collected on a specially designed questionnaire, and an "effort score" calculated.
Incidence of specified risk factors.
The only significant risk factor was physical effort (lifting heavy objects repeatedly
over long periods of time), relative risk 2.92, 95% confidence interval 2.11 to 4.04. In
addition, there were significant differences between index cases and controls in
standard of education (p < 0.001), consumption of alcohol (p = 0.02), chronic cough
(p < 0.001), net monthly income (p = 0.04), and amount of physical effort expended
(p < 0.001). Patients with indirect hernias expended significantly more physical effort
and were both heavier and taller, and patients with femoral hernias waited
significantly longer than the others before having their hernias repaired.
Inguinal hernias are associated with the expenditure of a considerable amount of
physical effort, and are commoner among younger, poorly educated manual
workers13.
Mbah N conducted a study on “Morbidity and mortality associated with
inguinal hernia in Northwestern Nigeria” which says that treatment of uncomplicated
inguinal hernia is relatively simple and the outcome is often favourable. Complicated
hernias are fraught with increased mortality with and without operative management.
To determine the scope of adverse events which attend the management of inguinal
hernia in extreme northwestern region of Nigeria. Subjects From the hospital records
department, the case folders of all patients with the clinical diagnosis of hernia seen
between January 2000 and December 2002 were retieved. Of the cases identified, 227
patients diagnosed of inguinal hernia, either alone or in combination with other forms
of hernia formed the basis of this report. Relevant data extracted and analyzed
included the patient's demographics, clinical details, treatment offered and outcome.
Two hundred and fifty three inguinal hernias in 227 individuals were seen.. This
represented 76.9% of patients diagnosed of external abdominal hernias., 16 times
more commonly in males than females. Fifty two (20.6%) hernias presented as acute
abdominal emergencies while 225 hernias in 199 patients were repaired. Local
anesthesia was used in 32 (16.1%) of the patients with 33 (14.7%) inguinal hernias.
14
Four (1.8%) individuals were managed on day case basis. Twelve (5.3%) deaths
occurred in this series, three of which were pre-operative. At a mean follow up of 7
months (range 1-23 months), 1 (0.4%) hernia recurrence was noted.
Complicated inguinal hernias and their emergency surgical treatment are associated
with increased mortality in our environment. Prophylactic elective herniorrhaphy is
recommended as a safeguard for inguinal hernia as soon as identified irrespective of
patient's age14.
Holzheimer RG conducted a study on “Inguinal Hernia: classification,
diagnosis and treatment—classic and traumatic hernia” which says that inguinal
hernia repair is performed in more than 600,000 cases every year in the United States.
However, the true prevalence may be even higher. Many groin hernias are not
diagnosed, e.g., Sportmans' hernia, or are asymptomatic. The etiology of classic
inguinal hernia, Sportsman's hernia or traumatic hernia may be different. The hernia
repair is performed in agreement with a classification of the hernia, e.g., Nyhus
classification. According to recent randomized controlled trials and meta-analyses
open-mesh repair demonstrates several advantages in comparison to laparoscopic
procedures. Laparoscopic procedures require more time and cost more, show a
potential for serious complications and may be followed by an increased rate of
recurrence. There may be a faster reconvalescence after laparoscopic procedures.
However, there may be also a selection bias. Laparoscopic procedures are associated
with specific complications, e.g., pneumomediastinum, pneumothorax, gas
extravasation, trocar injuries, intraabdominal adhesions, bowel obstruction, which are
rarely or never seen in open-mesh repair. In the United States we could observe an
uncoupling of hernia repair from classification. In more than 90% of cases the
treatment was open-mesh. In many hernia studies the hernias were classified as direct
or indirect, primary or recurrent. The existing classifications are based on anatomical
findings in relation to the development of the hernia: posterior floor integrity,
enlarged interior ring and size of the hernia. However, the size of the hernia may not
always be associated with the severity of the hernia and it may be difficult to estimate.
The outcome of hernia repair may be influenced by other factors. There may be
differences in the presentation of the hernia to the surgeon based on the damage done
to the surrounding tissue in the inguinal canal, e.g., external ring, aponeurosis of the
15
external oblique, inguinal ligament, which is most often accompanied by severe
adhesions. Further factors influencing outcome of hernia repair may be patient-related
factors, e.g., constipation, ASA classification, diabetes, smoking. A classification
should be simple to use and easy to remember: (A) indirect hernia, (B) direct hernia,
(C) scrotal or giant hernia, (D) femoral hernia. A and B can be classified as (0)
uncomplicated, (1) posterior floor defect, (2) posterior floor defect plus defect in the
anterior part of the inguinal canal. All four types (A-D) may be either primary or
recurrent. In this classification combined femoral, indirect and/or direct hernias can be
categorized by using the types A, B, C, or D as in a modular construction system. The
category "other" is reserved for rare types of hernia, e.g., obturator hernia, Spieghelian
hernia. Aggravating factors are included: Diabetes, obesity, age above 65,
constipation, ASA III or more and cigarette smoking. This classification may be
helpful to evaluate outcome of hernia repair with regard to patient related factors and
the increased demands for the surgeon and the staff. In some health care systems the
general belief is that all hernias are equal and be managed equally. However, groin
hernias may be complex and need individual treatment15.
Flich J, Alfonso JL et al conducted a study on “Inguinal hernia and certain
risk factors” which says that there are several studies on inguinal hernias that give
some clues about the association between this type of hernia and certain risk factors.
This association was suspected long ago but had not been demonstrated. The present
study tries to correlate the origin of inguinal hernias and the physical effort of the
subjects in accordance with their work activity. The results of this study show that
physical effort, as a risk factor, is closely related to the appearance of inguinal
hernias. A person whose work involves lifting or other strenuous exertion has a higher
risk than those whose jobs are less strenuous (p less than 0.05). This conclusion was
reached after taking into account not only the weight lifted but also the number of
years in this activity16.
Sanjay P, Woodward A conducted a study on “Single strenuous event: does
it predispose to inguinal herniation?” which says that there is a general belief that
inguinal hernias are often caused by a single strenuous event, however there are no
data to support this association. This study aims to assess the frequency with which
inguinal hernia is attributed to a single muscular strain and to identify predisposing
16
factors. All patients who underwent inguinal hernia repair under the care of one
surgeon over a nine-year period were studied. Five hundred and twenty patients were
sent a structured postal questionnaire. There was a 62% response rate (320). The
median age of the study group was 61.5 (range 19-88) years. Out of a total 320
hernias, 51% (163) of the hernias were gradual in onset and in 42.5% (137) of hernias
there was a history suggesting an association between a particular strenuous event and
the sudden onset of hernia. In the sudden-onset group 101 (74%) patients had indirect
hernias while in the gradual-onset group, 93 patients (57%) had indirect hernias (P <
0.05). Thirty-four patients (25%) had direct hernias in the sudden-onset group and 63
(39%) in the gradual-onset group (P < 0.05). The various predisposing factors were
lifting (67.8%, 93), coughing (14.5%, 20), exercise (10.2%, 14), and gardening (7.3%,
10). Heavy work was associated with sudden inguinal herniation.
This study supports the hypothesis that the appearance of inguinal herniation may be
attributed to a single strenuous event. Indirect hernias are more likely to present
following such an event17.
Ohene-Yeboah M, Abantanga FA conducted a study on “Inguinal hernia
disease in Africa: a common but neglected surgical condition” which says that hernia
surgery is one of the most frequent procedures done by surgeons - paediatric and
general surgeons -in the African continent. To review the surgical literature, on the
epidemiology, clinical features, treatment and outcome of inguinal hernia surgery in
Africa. The search terms used were groin hernias in Africa, hernia surgery in Africa,
inguinal hernias in Africa, hernias in adults and hernias in children in Africa using
Medline, Cochrane Central Register of Controlled Trials and EMBASE.
All journal articles on inguinal hernias performed in Africa and published in the world
journals from 1990-2010 were retrieved. All articles containing information on
inguinal hernias in children and adults were carefully studied for epidemiology,
clinical presentation, method of hernia repair, complications (including morbidity and
mortality rates) and the future of hernia surgery in Africa. There was an absolute
dearth of knowledge of the burden of inguinal hernias in the various communities in
Africa, especially, in sub-Saharan Africa. There were non-existent population-based
studies in the sub-Saharan context that could inform us about the epidemiology of
inguinal hernias and hence estimate the necessity for surgery in Africa. The studies
17
were all clinical in nature and did not reflect the true burden of the disease among
Africans. In many of these hospital-based studies, the method of inguinal hernia repair
used most was the Bassini repair. Not much was found in the literature about the use
of the Lichtenstein tension-free mesh repair of inguinal hernias, the reason being that
the mesh was too expensive for the patients to afford. Scarcely, was laparoscopic
hernia repair mentioned.
Based on the clinical studies reviewed, there is a large disease burden of inguinal
hernias in Africa. There is, understandably, also a limited surgical capacity to reduce
this burden. The authors advocate the formation of an African Hernia Society to
partner with corporate and international organizations to make hernias a public health
problem and to attempt to determine, using population-based studies, the actual
burden of the disease in Africa and then to take modern hernia surgery to most parts
of the continent to help reduce the hernia burden, especially its complications18.
Ouellette LR, Dexter WW conducted a study on “Inguinal hernias: value of
preparticipation examination, activity restriction decisions, and timing of surgery”
which says that though groin pain is common, the differential diagnosis is broad, and
narrowing down the diagnosis of an inguinal hernia can be challenging. Once a hernia
is diagnosed, play becomes limited based on severity of symptoms and physician and
patient comfort, and the athlete should be closely monitored for worsening symptoms.
Several surgical approaches are available for the repair of inguinal hernias, but
without knowing the true natural history of this disorder, it is difficult to know when it
is appropriate to have a hernia repaired19.
18
6.3 STATEMENT OF THE PROBLEM
“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING
PROGRAMME
ON
KNOWLEDGE
REGARDING
INGUINAL HERNIA AMONG INDUSTRIAL WORKERS IN SELECTED
INDUSTRIES OF TUMKUR WITH A VIEW TO DEVELOP AN
EDUCATIONAL PAMPHLET”
6.4 OBJECTIVES OF THE STUDY
1. To assess the knowledge regarding the inguinal hernia among industrial
workers.
2. To evaluate the effectiveness of structured teaching programme among
industrial workers regarding inguinal hernia.
3. To find out the association of knowledge of industrial workers regarding the
inguinal hernia with selected demographic variables.
4. To develop and distribute educational pamphlet.
6.5 OPERATIONAL DEFINITIONS
Knowledge: In this study knowledge refers to the information possessed by industrial
workers regarding inguinal hernia as assessed by structured knowledge questionnaire.
Structured teaching programme: It refers to organized group teaching method to
impart knowledge for industrial workers regarding the inguinal hernia.
Industrial workers: In this study industrial workers refers to those who are working
as labourers in different industries of Tumkur.
Inguinal hernia: In this study inguinal hernia refers to a condition in which intraabdominal fat or part of the small intestine, also called the small bowel, bulges
through a weak area in the lower abdominal muscles.
Educational pamphlet: In this study, educational pamphlet refers to systematically
prepared health package which includes information regarding inguinal hernia which
can be easily understood by industrial workers irrespective of their knowledge.
19
6.6 HYPOTHESIS
1. H1- There is a significant difference between knowledge of industrial workers
regarding the inguinal hernia.
2. H2- There is a significant association between the knowledge of industrial
workers regarding inguinal hernia with selected demographic variables.
6.7 ASSUMPTIONS
1. Industrial workers may have minimal knowledge about the inguinal hernia.
2. Administration of structured teaching programme may have impact on the
knowledge of industrial workers regarding the inguinal hernia.
3.
Educational pamphlet enhances the knowledge regarding inguinal hernia
among industrial workers.
6.8 VARIABLES UNDER STUDY
Dependent Variables: Knowledge of inguinal hernia among industrial
workers.
Demographic Variables: Age, sex, education, duration of work,
socioeconomic status, source of information.
6.9 DELIMITATIONS
The study is limited to the industrial workers who,
 Will be present during the period of data collection.
 Are willing to participate in the study.
 The sample size is limited to 40 industrial workers.
6.10 PILOT STUDY
The pilot study will be conducted with 4 industrial workers and who will be
excluded in the main study. The purpose of pilot study is to find out the feasibility of
conducting study and design on plan of statistical analysis. The findings of the pilot
study samples will not be included in main study.
20
7.0 MATERIALS AND METHODS
A written permission will be obtained from the concerned authority prior to
the onset of the study, the purpose of the study and method of data collection will be
explained to the participants and informed consent will be taken, confidentiality will
be assured to all subjects to get their co-operation. Data will be collected from 40
industrial workers in selected industries as per the inclusion criteria for the study. At
the end subjects will be thanked for their co-operation during the study.
7.1 SOURCES OF DATA
Data will be collected from industrial workers in selected industries of
Tumkur.
 RESEARCH DESIGN
The design is selected for the present study is Single group pre test, post test
design.
 RESEARCH APPROACH
The experimental survey approach will be considered appropriate for this
study.
 RESEARCH SETTING
The study will be conducted in selected industries of Tumkur.
 POPULATION
Population in the study consists of industrial workers in selected industries of
Tumkur.
 SAMPLE SIZE
Total sample of the study will consist of 40 industrial workers in selected
industries of Tumkur.
SAMPLE TECHNIQUE
Non-probability convenient sampling will be used for the study.
 SAMPLING CRITERIA
 INCLUSION CRITERIA
1. Industrial workers those who are working in selected industries.
2. Industrial workers those who are available at the time of data collection.
21
 EXCLUSION CRITERIA
1. Industrial workers who are not willing to participate in the study.
2. Industrial workers who are not available at the time of data collection.
7.2
METHODS OF COLLECTION OF DATA
 TOOL FOR DATA COLLECTION
Tools for data collection are divided into following categories:
Part I: Items on demographic variables will be listed under structured questionnaire.
Part II: Items on knowledge of industrial workers regarding the inguinal hernia will
be assessed by structured knowledge questionnaire.
Part III: Structured teaching programme on inguinal hernia among Industrial
workers.
 METHOD OF DATA ANALYSIS & INTERPRETATION
The data will be organized, tabulated and analyzed by using descriptive and
inferential statistics. The data will be planned to present in the form of tables and
figures.

Descriptive statistics:
To describe demographic variable by percentage, mean, mode, median and
standard deviation.

Inferential statistics:
1. Chi-square test will be used to test the association between the knowledge of
Industrial workers and the demographic variables.
2. Independent “t” test to be used to find out the difference between Pre-test and
Posttest scores.
 TIME AND DURATION OF THE STUDY:
The time and duration of the study will be limited to 6 weeks as per the
guidelines of the university.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR
OTHER HUMAN OR ANIMAL?
Yes, structured teaching program will be conducted on industrial workers.
22
7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM
YOUR INSTITUTION?
Yes, the pilot study and the main study will be conducted after the approval
from the research committee of Ramanamaharshi College of Nursing, Tumkur.
Permission will be obtained from the concerned head of the institutions. The
purpose and details of the study will be explained to the study subjects and an
informed consent will be obtained from them. Assurance will be given to the study
subjects on the confidentiality and anonymity of the data collected from them.
23
8.0 LIST OF REFERENCES
1. Inguinal hernia, http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/
2. Inguinal hernia, http://www.tour2india4health.com/inguinal-hernia-surgeryindia.htm
3. Inguinal hernia, www.righthealth.com
4. Inguinal hernia, http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/
5. Inguinal hernia, http://www.tour2india4health.com/inguinal-hernia-surgeryindia.htm
6. Hernia, http://www.aphernia.com/herniastatistics.htm
7. Statistics of hernia,
http://www.virtualmedicalcentre.com/diseases.asp?did=217&title=Hernia
8. Kang SK, Burnett CA et al, Hernia: is it a work-related condition?, American
journal of industrial medicine, 1999 Dec;36(6):638-44.
9. Liem MS, van der Graaf Y et al, Risk factors for inguinal hernia in women: a
case-control study. The Coala Trial Group, American journal of epidemiology.
10. Lau H, Fang C et al, Risk factors for inguinal hernia in adult males: a casecontrol study, Surgery. 2007 Feb;141(2):262-6. Epub 2006 Jul 31.
11. Ruhl CE, Everhart JE, Risk factors for inguinal hernia among adults in the US
population American journal of epidemiology ,2007 May 15;165(10):1154-61.
Epub 2007 Mar 20.
12. Wu XY, Huang MZ et al, A case-control study on the risk factors for inguinal
hernia in children, Zhongguo Dang Dai Er Ke Za Zhi. 2008 Aug;10(4):489-92.
13. Carbonell JF, Sanchez JL et al, Risk factors associated with inguinal hernias: a
case control study, European journal of surgery, 1993 Sep;159(9):481-6.
14. Mbah N, Morbidity and mortality associated with inguinal hernia in
Northwestern Nigeria, West African journal of medicine, 2007 OctDec;26(4):288-92.
15. Holzheimer RG, Inguinal Hernia: classification, diagnosis and treatment—
classic and traumatic hernia, European journal of medical research, 2005 Mar
29;10(3):121-34.
16. Flich J, Alfonso JL et al, Inguinal hernia and certain risk factors, European
journal of epidemiology, 1992 Mar;8(2):277-82.
24
17. Sanjay P, Woodward A, Single strenuous event: does it predispose to inguinal
herniation?, Hernia. 2007 Dec;11(6):493-6. Epub 2007 Jun 23.
18. Ohene-Yeboah M, Abantanga FA, Inguinal hernia disease in Africa: a
common but neglected surgical condition, West African journal of medicine,
2011 Mar-Apr;30(2):77-83.
19. Ouellette LR, Dexter WW, Inguinal hernias: value of preparticipation
examination, activity restriction decisions, and timing of surgery, current
sports medicine reports, 2006 Apr;5(2):89-92.
25
9
SIGNATURE OF THE
CANDIDATE
10 REMARKS OF THE GUIDE
11 11.1 NAME AND DESIGNATION
OF GUIDE
11.2
SIGNATURE
11.3
CO-GUIDE
11.4
SIGNATURE
11.5 HEAD OF THE
DEPARTMENT
11.6
SIGNATURE
12 12.1 REMARKS OF THE
CHAIRMAN AND PRINCIPAL.
12.2 SIGNATURE
26
27