What is the management of a patient with a tender inguinal mass, anorexia, and vomiting, considering options like laparoscopic (lap) hernia repair and open hernia repair?

Management of a Patient with Tender Inguinal Mass, Anorexia, and Vomiting

Patients with a tender inguinal mass accompanied by anorexia and vomiting should undergo immediate emergency hernia repair due to high suspicion of intestinal strangulation. 1

Initial Assessment and Diagnosis

• Symptoms of anorexia and vomiting combined with a tender inguinal mass strongly suggest intestinal strangulation, which requires immediate surgical intervention 1, 2
• Systemic inflammatory response syndrome (SIRS), elevated lactate levels, and serum creatinine phosphokinase (CPK) are predictive of bowel strangulation and should be assessed immediately 1
• Delayed diagnosis (>24 hours) significantly increases mortality rates in patients with strangulated hernias 1, 3

Surgical Approach Selection

Open Hernia Repair

• Open approach is strongly recommended for patients with signs of peritonitis or hemodynamic instability 1, 4
• Provides better access for bowel assessment and potential resection when strangulation is suspected 2
• Local anesthesia can be used in the absence of bowel gangrene, providing effective anesthesia with fewer cardiac and respiratory complications 1

Laparoscopic Hernia Repair

• May be considered in hemodynamically stable patients without signs of strangulation or need for bowel resection 1, 4
• Associated with shorter hospital stays (mean difference -3.00 days) and lower recurrence rates compared to open repairs 3
• Can be useful for diagnostic purposes to assess bowel viability after spontaneous reduction of strangulated hernias 1

Surgical Management Algorithm

1. Hemodynamically unstable patient OR signs of peritonitis:

   • Immediate open surgical approach 1, 4
   • General anesthesia 1

2. Hemodynamically stable patient WITHOUT obvious strangulation:

   • Consider laparoscopic approach if surgeon has appropriate expertise 1, 4
   • Early intervention (<6 hours from symptom onset) is associated with lower incidence of bowel resection 3

3. Mesh selection based on surgical field:

   • Clean surgical field (CDC class I): Use synthetic mesh 1, 4
   • Clean-contaminated field with intestinal strangulation but no gross spillage (CDC class II): Synthetic mesh can still be used 1, 4
   • Contaminated/dirty field with bowel necrosis or peritonitis (CDC class III/IV): Primary repair for small defects (<3 cm); biological mesh when direct suture not feasible 1, 5

Postoperative Management

• Administer empiric antimicrobial therapy for strangulated hernias due to risk of intestinal bacterial translocation 1, 4
• 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection 4
• Monitor for potential complications including wound infection, chronic pain, and recurrence 2, 4

Common Pitfalls to Avoid

• Delaying surgical intervention when intestinal strangulation is suspected significantly increases morbidity and mortality 1, 2
• Attempting forceful manual reduction can lead to mass reduction of an incarcerated hernia, potentially causing intestinal obstruction that may present days after the procedure 6
• Overlooking contralateral hernias, which are present in 11.2-50% of cases 1, 4
• Underestimating the severity of symptoms in patients with anorexia and vomiting, which strongly indicate strangulation requiring immediate surgical intervention 1, 7