What is the management for a patient with an obstructing hernia and acute perforation of the small bowel?

Management of Obstructing Hernia with Small Bowel Perforation

Emergency surgical intervention is mandatory for a patient with an obstructing hernia and acute perforation of the small bowel, requiring immediate exploratory laparotomy, bowel resection, and hernia repair.

Initial Assessment and Resuscitation

• Immediate priorities:

  • Aggressive fluid resuscitation with IV crystalloids
  • Broad-spectrum antibiotics to cover gram-negative and anaerobic bacteria
  • Correction of electrolyte abnormalities
  • Nasogastric tube placement for decompression
  • Urinary catheter for output monitoring

• Laboratory studies: Complete blood count, comprehensive metabolic panel, lactate, coagulation studies, blood type and cross-match

Surgical Management

Operative Approach

• Open approach is strongly recommended over laparoscopic in cases of free perforation with generalized peritonitis 1, 2
• The presence of free gas throughout the abdomen and free fluid in the pelvis indicates peritonitis requiring immediate surgical exploration

Surgical Steps

1. Midline laparotomy to gain adequate exposure
2. Control contamination - thorough peritoneal lavage with warm saline
3. Assess bowel viability - examine the entire small bowel from ligament of Treitz to ileocecal valve
4. Resection of perforated/necrotic segment with adequate margins of viable tissue
5. Primary anastomosis if patient is hemodynamically stable and contamination is controlled
6. Consider temporary stoma in cases of:
   • Hemodynamic instability
   • Severe peritoneal contamination
   • Poor tissue quality
   • Multiple comorbidities

Hernia Management

• Wide-mouthed anterior hernia (70mm) requires repair after controlling contamination
• In contaminated fields, suture repair is preferred over mesh due to risk of mesh infection 1
• Consider component separation technique for large defects if primary closure is not possible 1

Special Considerations

Damage Control Surgery

• For unstable patients, consider damage control approach:
  • Limited resection of necrotic bowel
  • Control of contamination
  • Temporary abdominal closure
  • Planned second-look operation after 24-48 hours 1

Anastomosis vs. Stoma

• Colorectal anastomosis should be avoided in patients with suspected or confirmed peritonitis due to high risk of complications 1
• Hartmann procedure is preferred over primary anastomosis in cases of severe contamination 1

Postoperative Care

• ICU admission for close monitoring
• Continued broad-spectrum antibiotics
• Ongoing fluid resuscitation and hemodynamic support
• Serial physical examinations to detect early complications
• Early mobilization when appropriate
• Gradual advancement of diet when bowel function returns

Potential Complications

• Septic shock
• Anastomotic leak
• Wound infection/dehiscence
• Residual/recurrent abdominal abscess
• Enterocutaneous fistula
• Recurrent hernia

Follow-up Management

• If skin-only closure was performed due to inability to achieve definitive fascial closure, plan for delayed abdominal closure with synthetic mesh repair after resolution of infection 1
• Consider CT scan with oral contrast if clinical deterioration occurs to evaluate for anastomotic leak or abscess
• Percutaneous drainage for any residual abscesses 1

Pitfalls to Avoid

• Delaying surgical intervention in the presence of perforation and peritonitis
• Attempting laparoscopic repair in the setting of generalized peritonitis
• Using prosthetic mesh in a contaminated field
• Overlooking other areas of bowel compromise beyond the obvious perforation
• Inadequate source control of peritoneal contamination

By following this algorithmic approach, the patient with an obstructing hernia and small bowel perforation can receive timely and appropriate surgical intervention to address both the perforation and the hernia, minimizing morbidity and mortality.