Management of Abdominal Hernias

Immediate surgical intervention is necessary when intestinal strangulation is suspected in patients with abdominal hernias. 1

Assessment and Diagnosis

Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, elevated lactate, CPK, and D-dimer levels are predictive of bowel strangulation and should prompt immediate surgical intervention 1
Diagnostic laparoscopy may be useful for assessing bowel viability after spontaneous reduction of strangulated groin hernias 1
When clinical diagnosis is uncertain, imaging studies such as ultrasonography or CT can help confirm the diagnosis and identify potential complications 2, 3

For incarcerated hernias without strangulation or need for bowel resection, laparoscopic repair may be performed 1
Synthetic mesh repair is recommended for patients with intestinal incarceration without signs of strangulation (CDC wound class I), as it is associated with lower recurrence rates compared to tissue repair 1

For patients with intestinal strangulation without gross enteric spillage (CDC wound class II), emergent prosthetic repair with synthetic mesh can be safely performed 1
For stable patients with strangulated hernia with bowel necrosis or gross enteric spillage (CDC wound class III/IV):
- Primary repair is recommended when the defect is small (<3 cm) 1
- When direct suture is not feasible, a biological mesh should be used 1
- If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1

For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 1
Intra-abdominal pressure should be measured intraoperatively in these cases 1
After patient stabilization, early definitive closure of the abdomen should be attempted, with primary fascial closure when tension or risk of intra-abdominal hypertension is minimal 1
When definitive fascial closure cannot be achieved, skin-only closure is viable with subsequent repair of the eventration at a later stage 1

Component separation technique is a useful and cost-effective option for repairing large midline abdominal wall hernias 1
For diaphragmatic hernias, the surgical approach (abdominal, thoracic, or combined) depends on the chronicity of the condition and presence of complications 1
In stable patients with complicated diaphragmatic hernias, a minimally invasive approach is suggested 1

For patients with intestinal incarceration without ischemia or bowel resection (CDC wound class I), short-term prophylaxis is recommended 1
In patients with intestinal strangulation and/or concurrent bowel resection (CDC wound classes II and III), 48-hour antimicrobial prophylaxis is recommended 1
Full antimicrobial therapy is recommended for patients with peritonitis (CDC wound class IV) 1

Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 1
General anesthesia should be preferred when bowel gangrene is suspected or intestinal resection is needed 1

Delayed diagnosis of strangulated obstruction can lead to septic complications and increased mortality 1
Mortality rates are higher in patients whose treatment is delayed for more than 24 hours after onset of acute complications 1
Bridging meshes often result in bulging or recurrences when used for large defects 1
Risk factors for bowel resection include lack of health insurance, obvious peritonitis, and femoral hernias 1