What is the treatment for an incarcerated hernia (hernia that is trapped and cannot be pushed back into the abdomen)?

From the Guidelines

Incarcerated hernia is a medical emergency that requires immediate surgical intervention to prevent complications such as strangulation, which can lead to tissue death and increased morbidity and mortality. The condition occurs when a portion of intestine or other tissue becomes trapped in a hernia and cannot be pushed back into place, characterized by severe pain, nausea, vomiting, and inability to have bowel movements or pass gas. If suspected, one should go to the emergency room immediately, as delayed diagnosis can result in the need for bowel resection with prolonged recovery and increased complication rate 1.

Key Considerations

• The benefits of immediate surgical intervention outweigh the risks, especially in cases of suspected intestinal strangulation 1.
• 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 complicated abdominal hernias may be the best means of reducing the rate of mortality, and delayed diagnosis can lead to septic complications 1.
• The elapsed time from onset to surgery is the most important prognostic factor, and early surgical intervention is critical to prevent complications 1.

Treatment and Management

• Treatment almost always involves surgery to release the trapped tissue and repair the hernia defect.
• While waiting for medical care, patients should not eat or drink anything, as surgery may be needed promptly.
• Patients should not attempt to push the hernia back in themselves, as this could cause further damage.
• After surgical repair, patients typically need to avoid heavy lifting for 4-6 weeks and follow their surgeon's specific instructions for recovery to prevent recurrence.

Evidence-Based Recommendations

• The 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias recommends immediate surgical intervention in cases of suspected intestinal strangulation, with a grade 1C recommendation 1.
• The use of mesh in hernia repair is recommended, even in potentially contaminated fields, as it can reduce the rate of recurrence and is safe for repairing acutely incarcerated hernias 1.

From the Research

Incarcerated Hernia Overview

• An incarcerated hernia occurs when the hernia becomes trapped and cannot be pushed back into the abdomen, which can lead to serious complications such as ischemia and necrosis of the hernia contents 2, 3.
• The management of incarcerated hernias is a common issue facing general surgeons, and it requires prompt decision-making with limited options for patient optimization 3.

Risk Factors for Ischemia and Necrosis

• Incarceration time more than 9 hours is an independent risk factor for ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients 2.
• Duration from symptoms to surgery, Neutrophil to Lymphocyte ratio (NLR), and urea are predictive factors of intestinal necrosis in patients with incarcerated femoral hernias 4.
• Preoperative haematological inflammatory markers such as NLR, PLR, and SII values can indicate strangulation and possible intestinal resection in incarcerated abdominal wall hernias 5.
• Hyponatremia, lower bicarbonate, elevated glucose, elevated white blood cell count, and skin changes are significant variables associated with ischemic bowel in patients with incarcerated hernias 6.

Surgical Management

• Open preperitoneal tension-free repair is the most commonly used surgical method for emergency incarcerated femoral hernia patients 2.
• The utilization rate of laparoscopic repair is lower in patients with ischemia and necrosis of hernia contents compared to those without 2.
• Mesh placement is more common in patients without ischemia and necrosis of hernia contents compared to those with 2.

Complications and Outcomes

• Ischemia and necrosis of hernia contents can increase bowel resection rate and prolong operation and hospital stay 2.
• Bowel ischemia and bowel necrosis are significantly higher in patients with incarcerated femoral hernias compared to those with incarcerated inguinal hernias 4.
• Advanced age, female gender, incisional hernias, and the presence of bowel obstruction are statistically significant in terms of strangulation 5.