From the Guidelines
I strongly recommend immediate surgical consultation for repair of the patient's paraumbilical hernias, as the patient's symptoms have worsened and the condition is likely to progress, potentially leading to complications such as incarceration or strangulation. The patient's reports of intestinal protrusion and constant pain despite using a hernia belt, along with the physical examination revealing two golf ball-sized masses, suggest a significant progression of the condition since the 2023 ultrasound.
According to the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1, patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection (clean surgical field) can undergo prosthetic repair with a synthetic mesh, which is associated with a lower recurrence rate and no increase in wound infection rate.
The current situation, with the patient experiencing constant pain and intestinal protrusion, indicates a need for prompt surgical evaluation to prevent potential complications. The use of a hernia belt is not a long-term solution and may not prevent incarceration or strangulation.
The ordered follow-up ultrasound will help determine if bowel is now involved in the herniation, which would increase surgical urgency. Paraumbilical hernias typically do not resolve spontaneously in adults and tend to enlarge over time, making definitive repair the standard of care for symptomatic cases like this one.
Key points to consider in the surgical approach include:
- The use of mesh in clean surgical fields is associated with a lower recurrence rate 1
- Diagnostic laparoscopy may be a useful tool in assessing bowel viability after spontaneous reduction of strangulated groin hernias 1
- Repair of incarcerated hernias can be performed with a laparoscopic approach in the absence of strangulation and suspicion of the need of bowel resection 1
Overall, prompt surgical consultation and repair are essential to prevent potential complications and improve the patient's quality of life.
From the Research
Patient Assessment and Diagnosis
- The patient is a 63-year-old male with complaints of abdominal hernia pain and reports that sometimes his intestines come up through the hernia.
- Two big masses, each the size of a golf ball, were noted in the patient's umbilical area.
- The patient has been wearing a hernia belt since 2023 and has a history of umbilical hernias, with an ultrasound showing defects in the left and right paraumbilical regions 2, 3.
Hernia Management and Treatment
- The patient's symptoms and history suggest a possible incarcerated hernia, which requires prompt medical attention 4, 5.
- Elective repair of groin hernias is recommended to prevent incarceration and strangulation, which can lead to significant morbidity and mortality 5.
- Management of incarcerated hernias involves assessment and decision-making in a short time frame, with options for patient optimization limited 6.
- Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair 3.
Diagnostic Imaging and Follow-up
- Ultrasonography is a useful diagnostic tool for hernias, particularly in cases where the diagnosis is uncertain or in patients with recurrent hernias 2, 3.
- The patient will undergo an abdominal ultrasound to compare with the previous one and schedule a follow-up appointment to review the ultrasound notes.
- Magnetic resonance imaging may be used in cases where clinical suspicion is high despite negative ultrasound findings 3.