What is the management for a non-reducible incarcerated bowel in a morbidly obese patient with multiple ventral hernia repairs?

Management of Non-Reducible Incarcerated Bowel in a Morbidly Obese Patient with Multiple Ventral Hernia Repairs

Non-reducible incarcerated bowel in a morbidly obese patient with multiple ventral hernia repairs requires immediate surgical intervention to prevent strangulation, as delayed treatment beyond 24 hours significantly increases mortality. 1

Initial Assessment and Stabilization

• Evaluate for signs of strangulation:

  • Severe pain, tenderness, erythema
  • Systemic inflammatory response syndrome (SIRS)
  • Laboratory markers: arterial lactate (elevated)
  • CT findings: significant predictors of bowel strangulation (56% sensitivity, 94% specificity) 1

• Stabilize the patient:

  • Fluid resuscitation
  • Broad-spectrum antibiotics if signs of infection
  • NPO status
  • Nasogastric decompression if bowel obstruction present

Surgical Approach Selection

Hemodynamically Unstable Patient

• Open surgical approach is preferred 1
• Midline incision over the hernia
• Identification and isolation of the hernia sac
• Reduction of incarcerated bowel
• Assessment of bowel viability with resection if necessary
• Fascial closure with non-absorbable sutures when possible

Hemodynamically Stable Patient

• Laparoscopic approach may be considered 1
• Benefits include shorter hospital stays and fewer wound infections 1
• Triangular or diamond configuration of 3-4 trocars
• Reduction of incarcerated contents
• Assessment of bowel viability with resection if necessary

Mesh Selection and Placement

• For clean fields: synthetic non-absorbable mesh 1
• For contaminated/dirty fields: biologic or biosynthetic meshes 1
• Mesh overlap should be 1.5–2.5 cm 1
• For defects >3 cm that cannot be closed primarily:
  • Biosynthetic, biologic, or composite meshes are preferred due to:
    • Lower recurrence rates
    • Higher resistance to infections
    • Lower risk of displacement 1

Special Considerations for Morbidly Obese Patients

• Longer operative times and hospital stays may be expected 2

• Higher risk of complications including:

  • Parietal wall hematomas
  • Postoperative pain
  • Respiratory complications
  • Seroma formation (reported in up to 26.58% of cases) 3

• Despite challenges, laparoscopic repair in morbidly obese patients has been shown to be feasible with:

  • Minimal morbidity 2
  • Lower recurrence rates compared to open surgery 3
  • Shorter hospital stays (average 2-3.6 days) 3, 4

Postoperative Management

• Monitor for abdominal compartment syndrome in unstable patients 1

• Multimodal analgesic regimen to minimize opioid use:

  • Acetaminophen and NSAIDs (e.g., ketorolac) as first-line treatment
  • Dexamethasone for reducing postoperative nausea and vomiting 1

• Monitor for specific complications:

  • Seroma (common in obese patients)
  • Surgical site infection
  • Recurrence
  • Bowel obstruction 1, 3

• Remove drains when drainage is less than 30-50 mL/day 1

• Consider suppressive dose of oral cephalosporin for several weeks postoperatively to decrease wound-related complications 1

Important Caveats and Pitfalls

1. Never defer repair of incarcerated hernias in morbidly obese patients, as this may result in small bowel obstruction (reported in 37.5% of deferred cases) 5

2. Be vigilant for fistulization into the abdominal wall and skin, a rare but serious complication of incarcerated ventral hernias that may complicate management 6

3. Recurrence rates may be higher in morbidly obese patients (reported up to 18.5%), so patients should be appropriately informed 4

4. Postoperative seroma formation is common (up to 26.58%) but can usually be managed conservatively 3

5. Monitor for specific complications of laparoscopic approach in obese patients, including postoperative hemorrhage and port-site hernia 3