How should a firm abdomen with hernia and purple discoloration be managed?

Examination and Management of a Firm Abdomen with Hernia and Purple Discoloration

A firm abdomen with hernia and purple discoloration should be treated as a surgical emergency requiring immediate intervention, as this presentation strongly suggests strangulation with potential bowel ischemia and necrosis. 1

Initial Assessment

• Immediate visual inspection: Evaluate the extent of purple discoloration, which indicates compromised blood supply and potential strangulation
• Gentle palpation: Assess firmness, tenderness, and irreducibility of the hernia
• Vital signs: Check for signs of systemic involvement (tachycardia, hypotension, fever)
• Do not attempt forceful reduction: This could worsen tissue damage or cause perforation in already compromised tissue

Diagnostic Workup

1. CT scan with contrast enhancement: Gold standard for diagnosing complicated hernias with a sensitivity of 14-82% and specificity of 87% 1

   • Look for specific signs:
     • "Collar sign" (constriction of herniating organ at rupture level)
     • "Dependent viscera" sign (no space between organs and chest wall)
     • Signs of ischemia: intestinal wall thickening, lack of contrast enhancement, parietal pneumatosis

2. Laboratory studies:

   • Complete blood count: Leukocytosis suggests inflammation/infection
   • Lactate levels: Elevated in bowel ischemia
   • Liver function tests: Important if ascites is present

Surgical Management

Immediate surgical intervention is mandatory for hernias with purple discoloration indicating strangulation. 1

Approach Selection:

• Open surgical approach: Preferred for unstable patients or when bowel resection is anticipated 2
• Laparoscopic approach: Consider only in stable patients without signs of necrosis 2

Surgical Procedure:

1. Exploration and assessment of bowel viability
2. Resection of necrotic tissue if present
3. Hernia repair:
   • For contaminated surgical fields (perforation/bowel resection): Primary suture repair is preferred 1
   • For clean fields: Prosthetic mesh repair is the treatment of choice 1
   • For defects larger than 8 cm or area >20 cm²: Tension-free repair with mesh with 1.5-2.5 cm overlap 2
   • Consider biosynthetic, biologic, or composite meshes due to lower recurrence rates and higher resistance to infections 1

Special Considerations

For Patients with Ascites:

• Higher risk of complications with reported odds ratios of:
  • Emergency surgery: 10.32
  • Child-Pugh-Turcotte class C: 5.52
  • ASA score ≥3: 8.65
  • MELD score ≥20: 2.15 2
• Perioperative optimization of ascites management may reduce wound dehiscence and hernia recurrence 2

Risk Factors for Strangulation:

• Femoral hernias have higher risk of strangulation compared to other types 3, 4
• Short duration hernias (<1 year) have higher complication rates 4
• Advanced age is a significant risk factor 4

Postoperative Care

• Monitoring: Observe for at least 24 hours for hemodynamic stability, surgical site complications, and respiratory function 2
• Pain management: Acetaminophen 500-1000 mg every 6 hours as first-line treatment; tramadol 50-100 mg every 6-8 hours as second-line 2
• Avoid NSAIDs: Especially in patients with ascites or cirrhosis 2
• Follow-up: Monitor for recurrence and complications; 5-year recurrence rates approximately 10.6-12.3% with mesh repair compared to 17.1% without mesh 2

Common Pitfalls to Avoid

• Delayed intervention: Purple discoloration indicates advanced strangulation; mortality increases 10-fold with strangulation 3
• Forceful reduction attempts: Can worsen tissue damage or cause perforation
• Overlooking other causes: Firm abdomen may be due to other pathologies (bowel obstruction, peritonitis)
• Inadequate resection: Ensure complete removal of all non-viable tissue
• Inappropriate mesh selection: In contaminated fields, primary suture repair is safer than mesh placement 1