How can the percentage of incarcerated hernias be reduced?

Reducing the Percentage of Incarcerated Hernias

Early detection and prompt surgical intervention of hernias are the most effective means of reducing the rate of incarcerated hernias and associated mortality. 1

Risk Factors for Hernia Incarceration

Understanding risk factors is crucial for prevention:

• Patient-specific factors:

  • Female gender (especially for femoral hernias)
  • Advanced age (≥65 years)
  • Presence of comorbid diseases
  • High ASA scores (III-IV)
  • Lack of health insurance 1, 2
  • Femoral hernias (highest risk of strangulation) 1, 3

• Time-related factors:

  • Longer duration of symptoms
  • Delayed hospital presentation (>24 hours from symptom onset) 1
  • Symptomatic periods lasting longer than 8 hours 2

Prevention Strategies

1. Elective Repair of Asymptomatic Hernias

• Elective repair should be performed whenever possible for groin hernias to prevent incarceration 4
• The only exception is for asymptomatic or minimally symptomatic male inguinal hernias, where watchful waiting may be considered with proper patient education 3
• Femoral hernias should receive timely mesh repair due to their high risk of incarceration 3

2. Early Diagnosis and Intervention

• Implement standardized protocols for early detection of complicated abdominal hernias 1
• Physical examination alone can confirm diagnosis in most patients with appropriate signs/symptoms 3
• When necessary, use ultrasound, dynamic MRI, CT scan, or herniography for confirmation 3

3. Manual Reduction (Taxis)

• Taxis can be a safe first-line approach for incarcerated hernias when performed by experienced clinicians 5, 6
• Benefits include:
  • Reduced need for emergency surgery
  • Better conditions for later elective repair
  • Lower mortality and morbidity rates
  • Particularly valuable during resource constraints (e.g., COVID-19 pandemic) 6
• Protocol for taxis:
  • Attempt gentle manual reduction
  • Monitor pain using Visual Analogue Scale (VAS)
  • Observe for 24 hours after successful reduction
  • Schedule elective repair within one month 6
  • Proceed to emergency surgery if reduction fails or pain persists

4. Surgical Approach

• Mesh repair is recommended as first choice for elective repairs 1, 3
• Both open (Lichtenstein) and laparoscopic approaches (TEP, TAPP) are effective 3
• For recurrent hernias after anterior repair, posterior approach is recommended 3
• For parastomal hernias:
  • Place stomas through the rectus muscle to minimize hernia formation 1
  • Avoid using transverse colon for stomas due to higher risk of hernia and prolapse 1
  • Small, reducible parastomal hernias can be managed with a hernia belt 1

5. Specialized Care

• Surgeons should be experienced in hernia repair techniques
• High surgical volume per surgeon is more important than center volume 3
• Development of "Hernia Centers" and certification of "expert hernia surgeons" is recommended 3
• Multi-disciplinary teams should manage complex cases 3

Management of Incarcerated Hernias

When incarceration occurs:

1. Immediate surgical intervention when intestinal strangulation is suspected 1
2. Look for signs of strangulation:
   • Systemic inflammatory response syndrome (SIRS)
   • Elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels
   • Contrast-enhanced CT findings suggesting bowel compromise 1
3. For parastomal hernias:
   • Recognize that incarcerated parastomal hernia is a surgical emergency 1
   • Elective repair is indicated for significant pouching issues, pain, or recurrent bowel obstruction 1

Pitfalls and Caveats

• Early detection of progression from incarceration to strangulation is difficult by clinical or laboratory means alone 1
• Mortality is significantly higher in patients whose treatment is delayed for more than 24 hours 1
• Recurrence after parastomal hernia repair is common (>25% at 2 years) 1
• Moving the stoma site during parastomal hernia repair is no longer recommended due to high risk of hernia at the new location 1
• Taxis should be performed carefully to avoid bowel injury; emergency surgery is indicated if reduction is unsuccessful or pain persists 6

By implementing these strategies systematically, healthcare systems can significantly reduce the percentage of incarcerated hernias and improve patient outcomes.