| Herniorrhaphy Posted: 28 Sep 2010 06:04 PM PDT 
 Herniorrhaphy Definition - Repair of a herniation (protrusion) of the abdominal contents, caused by a musculofascila defect in the abdominal wall or groin area.
Discussion - In the inguinal/ femoral regions, two types of herniation commonly occur; direct or indirect.
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- Direct hernia: Usually resulting from stress, causing the peritoneum to bulge through the fascia in the groin area. The peritoneal bulge (sac) may contain abdominal viscera.
- Indirect Hernia: Caused by a congenital defect in the internal abdominal ring, causing the peritoneum to bulge along the spermatic cord. It may or may not contain abdominal viscera.
- 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.
Position - Supine, with arms extended on armboards
Incision Site - Groin area, right or left oblique.
Packs/Drapes - Laparotomy pack or minor pack
- Four folded towels
Instrumentation - Basic tray or minor tray
- Self retraining retractor
Supplies/ Equipment - Basin set
- Suction
- Needle counter
- Penrose drain
- Dissector sponges
- Sutures
- Solutions – saline, water
- Synthetic mesh
- Skin closure strips
Procedure - The surgeon begins the procedure by incising the groin.
- The incision is deepened using the Metzenbaum scissors and cautery is used to control small bleeders.
- Both blunt and sharp dissections are used to gain access to the hernia.
- After incising the fascia that lies over the spermatic cord (male), several small hemostats are placed on the edge of the incised fascia.
- If direct, the surgeon will begin the suture the defect using interrupted suture of varying materials
- If indirect, the surgeon will dissect the sac away from the cord using Metzenbaum scissors, the sac is opened and the edges grasped with hemostasis.
- The contents of the sac are pushed toward the abdomen and if small, the sac may be lighted in place.
Perioperative Nursing Considerations - The pensrose drain should be moistened with saline before use.
- Synthetic Mesh is often used to repair recurrent hernias or large ventral hernias.
- A specimen will be collected only during an indirect herniorrhaphy.
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| Breast biopsy Posted: 28 Sep 2010 05:56 PM PDT 
 Breast Biopsy Breast biopsy is necessary to confirm or rule out cancer. Needle biopsy or fine-needle biopsy can provide a core of tissue or a fluid aspirate, but needle biopsy should be restricted to fluid-filled cysts and advanced malignant lesions. Both methods have limited diagnostic value because of the small and perhaps unrepresentative specimens they provide. Open biopsy provides a complete tissue specimen, which can be sectioned to allow more accurate evaluation. A breast biopsy can usually be done on an outpatient basis under local anesthesia; however, an excisional open biopsy may require general anesthesia. In sufficient tissue is obtained and the mass is found to be a malignant tumor, specimens are sent for estrogen and progesterone receptor assays to assist in determining future therapy and the prognosis. Purpose - To differentiate between benign and malignant breast tumors.
Procedure Preparation - Make sure the patient has signed a consent form.
- Note and report all allergies.
- If the patient is to receive a local anesthesia, tell her she need not restrict food or fluids.
- If the patient is to have a general anesthesia, tell her she is to have nothing by mouth after midnight or before the procedure.
- Obtain and report abnormal results of prebiopsy studies, such as blood tests, urine tests, and radiographs of the chest.
- Explain that the test takes 15 to 30 minutes.
Implementation Needle Biopsy - Instruct your patient to undress to the waist.
- After guiding her to a sitting or recumbent position with her hands at her sides, tell her to remain still.
- The doctor then prepares the biopsy site, administers a local anesthetic, and introduces the syringe (luer-lock syringe for aspiration, Vim-Silverman needle for tissue specimen) into the lesion.
- Fluid aspirated from the breast is expelled into a properly labeled, heparinized tube; the tissue specimen is placed in a labeled specimen bottle containing normal saline solution or formalin.
- Send both specimens to the laboratory immediately. (With fine needle aspiration, a slide is made and viewed immediately under a microscope).
- Because breast fluid aspiration isn't diagnostically accurate, some doctors aspirate fluid only from cysts. If such fluid is clear yellow and the mass disappears, the aspiration is both diagnostic and therapeutic, and the aspirate is discarded. If aspiration yields no fluid or if the lesion recurs two or three times, an open biopsy is then considered appropriate.
- After the procedure, pressure is exerted on the biopsy site and, after bleeding has stopped, an adhesive bandage is applied.
Open Biopsy - The site is prepared and draped, and the patient is given a local or general anesthetic.
- An incision is made in the breast to expose the mass. A portion of tissue or the entire mass is extracted.
- Benign-appearing masses smaller than ¾" (2cm) in diameter are usually excised.
- The specimens are placed in properly labeled specimen bottles containing 10% formalin solution.
- The malignant-appearing tissue is sent for frozen suction and receptor assays.
Nursing Interventions - If the patient has received a general or local anesthetic, monitor the patient's vital signs regularly. If she has received a general anesthetic, check her vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for the next 4 hours, and then every 4 hours.
- Administer analgesics for pain, as ordered, and provide ice bags for comfort.
- Instruct the patient to wear a support bra at all times until healing is complete.
- Observe for and report bleeding, tenderness, and redness at the biopsy site.
- Provide emotional support to the patient awaiting diagnosis.
Interpretation Normal Results - Breast tissue consists of cellular and noncellular connective tissue, fat lobules, and various lactiferous ducts.
- Breast tissue is pink, more fatty than fibrous, and shows no abnormal development of cells or tissue elements.
Abnormal Results - Benign tumors may suggest fibrocystic disease, adenofibroma, intraductal papilloma, mammary fat necrosis, or plasma cell mastitis.
- Malignant tumors may suggest adenocarcinoma, cystosarcoma, intraductal and infiltrating carcinoma, inflammatory carcinoma, medullary or circumscribed carcinoma, colloid carcinoma, lobular carcinoma, sarcoma, or Paget's disease.
Precaution - Breast biopsy is contraindicated in the patient with a condition that precludes surgery.
Interfering Factors - Failure to obtain an adequate tissue specimen or to place the specimen in the proper solution container interfering with test results.
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