CASE STUDY:

INCARCERATED VENTRAL
HERNIA REPAIR
Rachel Chan

Hernia

A weakness or tear in the

abdominal fascia or musculature
Materials from large/small
intestines, ovaries or bladder can
push out of abdomen and form a
bump
Tends to occur near the abdominal
wall near the groin

What causes a hernia?

Heavy lifting
Persistent cough or sneeze
Straining during bowel movements
Smoking or habits that worsen COPD
Long term use of oral steroids

Thinning of skin and tissues

Peritoneal dialysis (PD)

Congenital predisposition
Athletes (soccer, rugby, and ice hockey)
More common in men

Women have protective tissues

Signs/symptoms

Visible or touchable lump

May be presented with or without pain

Reaction to pressure on an intraabdominal organ

Advanced hernia

May cause pain, nausea, vomiting, fever

Types of hernia
External protrusion:
Sports hernia
Ventral hernia

Internal protrusion:
Diaphragmatic hernia
Hiatal hernia

Treatment options
1. Reduce the hernia

Reducible/nonreducible
hernia
Incarcerated hernia-trapped
where its protruded so it
cant be pushed back to
where it belongs
Strangulated hernia

2. Surgical interventions

Laparoscopic surgery or
open approach
Herniorrhaphy or
hernioplasty

Case study

Patient S.B.
56 y.o. male
African American
Vendor
Lives with wife
Islamic, speaks Arabic besides English
Does not eat pork due to religious
reasons

Report on admission

Admitting diagnosis: ventral hernia with

obstruction
Physical condition: pain from hernia
associated with nausea and vomiting

Social/ General health

history

Social history

Vendor -> unemployed

Denies alcohol abuse
Admits to using methadone for pain control

General health history

Reported to exercise daily before his pain

worsened
Nausea and vomiting associated with abdominal pain
Appetite decreased when pain worsened
Could not sleep well due to pain
Natural teeth; good dentition

Physical history

Medications prior to admission: clonidine

and methadone (not prescribed)

Noncompliant with cardiac medications

Past medical Hx: HTN, afib

Past surgical Hx:

Exploratory splenectomy and gastric

surgery for gun shot wound (1991)
Ventral hernia repair with mesh (2002)

Physical history, cont.

Ht: 511 / 180 cm

Wt: 232 lb /105 kg
BMI 32

Obesity Class I

Calorie requirement

MSJ: 1900 kcal

Kcal: 1600-2100 kcal (15-20 kcal/kg)
Pro: 84-105g protein (0.8-1.0 g/kg)
PSU 2003b (while on vent): 1980 kcal

Hospital course

History: Worsening abdominal pain x2

weeks, associated with nausea and
vomiting
Admitting diagnosis: incarcerated ventral
hernia
Treatment plan: exploratory laparotomy
Hospital course: open procedure
secondary to adhesions and mesh was
replaced
Discharge: homecare and follow-up
doctor and INR appointments

Timeline
Date

POD
#

Events

4/19

Exploratory laparotomy, lysis of adhesions and repair of

incarcerated ventral hernia with mesh

4/20

Critical care unit (CCU), NPO, await bowel movement (BM)

4/23

Emesis overnight due to eating. Worsening respiratory

status, 4 SOB episodes, changes in mental status, intubated
at 1530. Ileus. - flatus/BM.

4/24

Unable to wean from vent. TPN recommended due to

prolonged ileus and not able to estimate # of days pt would
remain on vent.

4/25

Vent dependent respiratory failure. Acute kidney injury. NPO.

TPN

4/26

Extubated. Placed nasogastric tube (NGT) for suctioning.

NPO. TPN.

4/29

10

Discontinue TPN. Started on clear liquid. Tolerated diet.

+flatus/BM. N/V.

4/30

11

Advanced diet to full liquid. +BM.

Labs
4/22

4/23

4/24
(VDRF
)

4/27
(VDRF
)

4/29

4/30

5/6

Na

134

140

144

147

149

143

138

4.3

3.8

2.8

3.3

4.1

4.6

Cl

101

102

102

105

112

108

102

25

24

30

31

29

26

27

14

12

11

13

24

30

21

27

27

11

1.2

1.9

1.1

1.2

1.4

1.4

76

124

110

151

117

105

94

Ca

8.2

8.1

8.4

8.6

9.1

Phos

2.3

3.1

2.8

4.1

3.4

Mg

2.1

2.4

2.3

2.3

2.2

1.9

PAB

8.1

10.2

CO2
Anion
gap
BUN
Cr
Glucos
e

PES statements
1.

2.

Altered gastrointestinal (GI) function

related to alteration in gastrointestinal
tract function as evidenced by ileus,
abdominal distention, abdominal pain,
and exploratory laparotomy.
Obesity related to excessive energy
intake as evidenced by BMI >30.

Nutrition interventions
Date

Diet
order/
Events

Nutrition interventions

4/19-4/23

NPO

none

4/24

Intubated
day#2

TPN. Propofol (16.1mL/hr x 1.1kcal/mL x 24hr = 425 calories

from fat). Recommendations: 105 g protein (420 calories),
1100 non-protein calories, micronutrients per PharmD. Check
TPN labs.
Total calories= 1945 calories (18.5 kcal/kg)

4/25

Intubated
day #3

TPN. Propofol (12.7 mL/hr x 1.1kcal/mL x 24 hr = 337

calories). Recommendations: 105 g protein (420 calories),
1130 non-protein calories, micronutrients per PharmD. Check
TPN labs.
Total calories= 1887 calories (17.9 kcal/kg)

4/29

Clear liquid

Discontinue TPN. +flatus/BM. N/V. Tolerated diet.

Recs: >75% of meals, check PAB, diet tolerance

4/30

Full liquids

Surgery ok to advance.
Recs: Full liquid per surgery, check PAB, monitor and follow-up

5/1

Cardiac

Fair to good intake. Tolerating diet well. Showed limited

interest but was receptive to education Wife stated she tries
to remind patient when they eat out, which they do often.
Provided handout.

TPN calculations
Figure out protein calories and non-protein
calories (NPC)
2. Grams of protein x 4 kcal/kg
3. Then subtract that number from total kcal=
NPC
Ex: 140 g pro x 4 kcal/kg= 560 calories from
pro
2200 kcal (total kcal)-560 cal= 1640 NPC
TPN order for S.B. (April 26th)
105 grams of protein, 1100 NPC,
micronutrients per PharmD
1.

Intervention

Nutrient delivery:

Nutrition education based on pts history

Maintain weight: 15-20 kcal/kg= 1600-2100 kcal

HTN- low Na diet
Handout

Coordination of nutrition care

Pharmacist- S.B was placed on heparin then

bridged to Coumadin. He received education on
the importance of adhering to his Coumadin
regimen and dietary restrictions when he is on
Coumadin

Monitor/Evaluation

PO intake
Bowel movements
Nutrition education

Low Na diet

Clinical improvements

Complications
Admissio Date
n

Reason for admission

April 19th- May 6th

Incarcerated ventral hernia

May 11th- May 13th Bleeding from wound

May 18th- May 29th Pulmonary edema

QUESTIONS