What is the management approach for suspected incarcerated or obstructed hernia?

Management of Incarcerated vs. Obstructed Hernia

Immediate surgical intervention is mandatory for strangulated hernias, while incarcerated hernias without signs of strangulation should be promptly evaluated for urgent surgical repair to prevent complications such as bowel necrosis. 1

Diagnostic Approach

• Initial Assessment:

  • Senior clinician should evaluate to determine if surgery is required 2
  • CT scan of abdomen and pelvis is the gold standard for diagnosis 1
  • All acute patients should be considered COVID-19 suspected until proven otherwise 2

• Key Distinctions:

  1. Incarcerated hernia: Hernia contents cannot be reduced but blood supply is intact
  2. Strangulated hernia: Blood supply to hernia contents is compromised, leading to ischemia

Management Algorithm

For Suspected Strangulation:

1. Immediate surgical intervention (within 6 hours of symptom onset) 1
2. Preoperative preparation:
   • Fluid resuscitation
   • Broad-spectrum antibiotics
   • NPO status 1
3. Surgical approach:
   • Open approach preferred for hemodynamically unstable patients or when bowel resection is anticipated 1
   • Laparoscopic approach may be considered for stable patients (associated with lower morbidity of 5-6% vs. 17-18% for open approach) 1

For Incarcerated Hernia Without Strangulation:

1. Attempt gentle reduction if appropriate and no signs of strangulation
2. If reduction fails, urgent surgical repair to prevent progression to strangulation 1
3. Surgical approach:
   • For defects >8 cm or area >20 cm²: Tension-free repair with mesh overlapping defect edge by 1.5-2.5 cm 1
   • For smaller defects: Primary repair may be appropriate

Special Considerations

Cirrhotic Patients:

• Higher risk population (16% incidence of abdominal wall hernias, up to 24% with ascites) 1
• Requires multidisciplinary approach with optimization of ascites management perioperatively 1
• Repair is NOT contraindicated but requires careful risk-benefit assessment 1

COVID-19 Pandemic Considerations:

• Non-operative management should be considered when feasible and safe, especially in COVID-19 positive patients 2
• However, life-threatening emergencies including incarcerated hernias require surgical intervention regardless of COVID status 2
• Appropriate PPE should be used, and surgery should not be delayed while waiting for swab results 2

Postoperative Care

• Monitor for at least 24 hours, focusing on:
  • Hemodynamic stability
  • Surgical site complications
  • Respiratory function 1
• Pain management:
  • Acetaminophen 500-1000 mg every 6 hours (maximum 4000 mg/day) as first-line 1
  • Avoid NSAIDs due to increased bleeding risk 1

Potential Complications

• Wound infection (4-12%)
• Incisional/port site hernia
• Respiratory complications (atelectasis)
• Bleeding
• Ileus 1
• Recurrence rates: 10.6-12.3% with mesh repair vs. 17.1% without mesh 1

Follow-up Care

• Educate patients on signs of recurrence or complications
• Instruct patients to seek immediate medical attention for:
  • Severe and constant pain
  • Redness or skin changes over the hernia site
  • Nausea, vomiting, or inability to pass gas/stool
  • Fever or general malaise 1

Common Pitfalls to Avoid

1. Delayed diagnosis: Early intervention (<6 hours from symptom onset) is associated with lower incidence of bowel resection 1
2. Inadequate imaging: CT scan is essential for accurate diagnosis and surgical planning 1, 3, 4
3. Underestimating the urgency: Intestinal strangulation can rapidly progress to necrosis and perforation with significant impact on morbidity and mortality 1
4. Inappropriate surgical approach: The choice between open and laparoscopic approaches should consider the patient's clinical status and potential risks/benefits 3