From the Guidelines
Reducing an incarcerated hernia is not recommended outside of a medical setting, and immediate surgical intervention is often necessary to prevent serious complications, as supported by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. When an incarcerated hernia is suspected, patients should undergo emergency hernia repair immediately, as the benefits of surgery outweigh the risks, especially in cases of suspected bowel strangulation. The timing of intervention is critical, as delayed diagnosis and treatment can lead to septic complications and high morbidity and mortality rates.
Key Considerations
- Patients with symptoms of intestinal strangulation, such as severe pain, nausea, vomiting, inability to pass gas or stool, redness or discoloration over the hernia site, and fever, should seek immediate medical attention at an emergency department.
- 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, and their presence should prompt urgent surgical evaluation 1.
- Early detection of complicated abdominal hernias is crucial to reduce mortality rates, and standardized protocols for pre-, intra-, and postoperative care can improve clinical outcomes, as demonstrated by the study by Martínez-Serrano et al. 1.
Diagnostic Approaches
- Laboratory parameters, such as lactate level, can predict the viability of strangulation in patients with bowel obstruction, with an arterial blood lactate level of 2.0 mmol/L or greater being a useful predictor of non-viable bowel strangulation 1.
- Radiological techniques, such as computed tomography (CT) scanning, can help diagnose bowel strangulation, with CT findings of reduced wall enhancement being a significant independent predictor of bowel strangulation 1.
Management
- In the hospital setting, gentle reduction may be attempted using sedation and proper technique, but often surgical intervention is necessary to prevent serious complications.
- The presence of necrosis is a significant factor affecting mortality rates, and its presence should prompt immediate surgical intervention 1.
From the Research
Reducing an Incarcerated Hernia
- The decision to reduce an incarcerated hernia depends on various factors, including the presence of bowel strangulation and the patient's overall health 2, 3.
- Manual reduction, also known as taxis, can be a safe and effective method for reducing an incarcerated hernia, especially in patients who are not good candidates for emergency surgery 2, 3.
- The GPS (Gentle, Prepared, and Safe) Taxis technique is a recommended approach for manual reduction, which should be performed within 24 hours of the onset of symptoms and in the absence of bowel strangulation 2.
- Conscious sedation guidelines should be followed during the reduction process, with careful titration of medications such as morphine and benzodiazepines to avoid oversedation 2.
- Studies have shown that manual reduction can be successful in reducing the risk and complications of anesthesia and surgery in emergency settings 2, 3.
Safety and Efficacy of Reduction
- One study found that manual reduction was successful in 60.3% of cases, with no reported complications or mortality 3.
- Another study suggested that manual reduction can be a feasible and safe maneuver pending eventual surgical treatment, with the potential to lower mortality and morbidity rates 3.
- However, the decision to reduce an incarcerated hernia should be made on a case-by-case basis, taking into account the individual patient's condition and the presence of any contraindications 2, 4, 5.