Can multiple hernias be repaired simultaneously during emergency surgery for an incarcerated hernia?

From the Guidelines

Multiple hernias can be repaired simultaneously during urgent surgery for an incarcerated hernia, but this decision should be made on a case-by-case basis, prioritizing the patient's stability and minimizing surgical risk. The primary focus is always on addressing the incarcerated hernia first to relieve the obstruction or strangulation, as delayed diagnosis can lead to septic complications and high morbidity and mortality rates 1.

Key Considerations

• The patient's clinical condition, including the presence of systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate, serum creatinine phosphokinase (CPK), and D-dimer levels, which are predictive of bowel strangulation 1.
• The surgeon's judgment regarding the safety of performing additional repairs during the same procedure, taking into account the extent of contamination, operative findings, and the patient's overall health status.
• The potential benefits of avoiding a second surgery and anesthesia exposure, which may outweigh the risks of additional repair in stable patients with minimal contamination.

Surgical Approach

• The decision to repair multiple hernias simultaneously should be based on patient-specific factors, including the extent of contamination, operative findings, and the surgeon's judgment regarding the safety of performing additional repairs during the same procedure 1.
• In cases with significant contamination from bowel perforation, hemodynamic instability, or other complications, the surgeon may defer repairing non-urgent hernias to minimize operative time and reduce infection risk.
• Early detection of complicated abdominal hernias is crucial to reduce morbidity and mortality rates, and surgeons should prioritize prompt intervention in cases of suspected bowel strangulation 1.

Evidence-Based Decision Making

• The 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias recommends immediate surgical intervention in cases of suspected bowel strangulation, as the benefits outweigh the risks of surgery 1.
• A retrospective study published in 2014 by Koizumi et al. demonstrated that the elapsed time from onset to surgery was the most important prognostic factor in cases of strangulated inguinal and femoral hernias 1.
• Another study published in 2007 by Derici et al. found that the presence of necrosis was the only factor that significantly affected mortality rates in cases of incarcerated abdominal wall hernias 1.

From the Research

Repairing Multiple Hernias During Urgent Surgery

• The provided studies do not directly address the question of repairing multiple hernias at the same time during urgent surgery for incarcerated hernia 2, 3, 4, 5, 6.
• However, the studies discuss the use of mesh repair in urgent hernia repair surgeries, which may be relevant to the question of repairing multiple hernias.
• A study published in 2016 found that polypropylene mesh can be safely used in urgent groin hernia repair surgeries, even in patients undergoing bowel resection 2.
• Another study published in 2015 found that prosthetic mesh could be used in incarcerated hernia repair when no bowel resection is performed, the duration of symptoms is less than 24 hours, and the fluid in the hernia sac is clear 3.
• There is no direct evidence to suggest that multiple hernias should be repaired at the same time during urgent surgery, but the use of mesh repair in these situations may be considered based on individual patient factors.

Considerations for Mesh Repair

• The presence of bacteria in the hernia sac is a significant risk factor for surgical site infection after incarcerated hernia repair 3.
• The use of prophylactic antibiotics, such as cefazolin, may not significantly reduce the risk of wound infection in mesh herniorrhaphy 4.
• The role of taxis (hernia reduction) in the management of incarcerated hernias is still debated, but it may be a feasible and safe maneuver pending eventual surgical treatment 5.

Current Management Options

• A review article published in 2020 discusses the current assessment and management options for incarcerated ventral and inguinal hernias, but does not specifically address the question of repairing multiple hernias at the same time during urgent surgery 6.