What is the treatment for an incarcerated hernia?

From the Guidelines

Incarcerated hernias require immediate surgical intervention to prevent complications and reduce morbidity and mortality risks. The treatment involves emergency surgery to release the trapped tissue and repair the hernia defect, as recommended by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. Before surgery, patients should be stabilized with IV fluids, pain management, and antibiotics if infection is suspected. The surgical approach depends on the hernia location and patient factors, with options including open or laparoscopic techniques.

Some key factors to consider in the treatment of incarcerated hernias include:

• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1
• Early detection of progression from an incarcerated hernia to a strangulated hernia is difficult to achieve by either clinical or laboratory means 1
• Signs of SIRS including fever, tachycardia, and leukocytosis, as well as abdominal wall rigidity, are considered common indicators of strangulated obstruction 1
• CPK appears to be a relatively reliable indicator of early intestinal strangulation 1
• Elevated D-dimer levels measured upon admission were found to correlate strongly with intestinal ischaemia 1
• Lactate level was the only laboratory parameter significantly associated with a lack of viability (P < 0.01, Mann–Whitney U test) 1

During surgery, the surgeon will reduce the hernia contents, assess tissue viability, remove any necrotic tissue, and repair the defect using either primary closure or mesh reinforcement. Post-operative care includes pain management with medications like acetaminophen, NSAIDs, or opioids if necessary, early mobilization, and monitoring for complications such as infection, recurrence, or chronic pain. Patients typically stay in the hospital for 1-3 days and should avoid heavy lifting (>10 pounds) for 4-6 weeks. Prompt treatment is essential because incarcerated hernias can progress to strangulation, where blood supply to the trapped tissue is cut off, leading to tissue death and potentially life-threatening complications like bowel perforation, peritonitis, and sepsis. Delaying treatment significantly increases morbidity and mortality risks, as shown in studies by Martínez-Serrano et al. and Koizumi et al. 1.

From the Research

Incarcerated Hernia Treatment

• Incarcerated hernias are a common issue facing general surgeons, and their management is crucial to prevent complications such as ischemia and necrosis of hernia contents 2, 3.
• The treatment of incarcerated hernias often requires emergency surgery, and the choice of surgical method depends on various factors, including the type of hernia, patient's condition, and the presence of complications such as bowel strangulation or necrosis 2, 3.
• Open preperitoneal tension-free repair is a commonly used surgical method for incarcerated femoral hernias, and mesh placement is often used to reduce the risk of recurrence 2, 4.
• However, the use of mesh in patients with incarcerated or strangulated hernias is controversial, especially in cases where bowel resection is required 4, 5.
• Studies have shown that mesh repair can be safe and effective in reducing recurrence rates, even in cases with concomitant bowel resection, but the risk of surgical site infections and other complications must be carefully considered 4, 5.

Risk Factors for Complications

• Advanced age, concomitant diseases, and high American Society of Anesthesiologists (ASA) scores are risk factors for morbidity and mortality in patients undergoing surgery for incarcerated hernias 3.
• Long incarceration time is an independent risk factor for ischemia and necrosis of hernia contents, and prompt surgical intervention is essential to prevent these complications 2.
• Bowel resection is a significant risk factor for postoperative complications, including surgical site infections and major morbidity 5.

Surgical Outcomes

• The outcomes of mesh and anatomic repairs in patients with acutely incarcerated or strangulated hernias have been compared in several studies, and the results suggest that mesh repair can be safe and effective in reducing recurrence rates 4.
• However, the incidence of surgical site infections and other complications must be carefully considered, and further studies are needed to fully evaluate the safety and efficacy of mesh repair in these patients 4, 5.