From the Guidelines
To diagnose a strangulated inguinal hernia, a systematic clinical evaluation focusing on key signs of vascular compromise, including a thorough history, physical examination, and laboratory tests, is essential, with immediate surgical intervention required when intestinal strangulation is suspected, as supported by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.
The clinical evaluation should begin with a thorough history, noting the duration of the hernia, onset of symptoms, and presence of severe, constant pain that doesn't resolve with position changes. During physical examination, observe for a tense, tender, erythematous, or edematous hernia that cannot be reduced manually. Assess for signs of bowel obstruction including abdominal distension, vomiting, absence of bowel movements, and hyperactive bowel sounds. Check for systemic signs of strangulation such as fever, tachycardia, hypotension, and leukocytosis on laboratory testing. Evaluate for peritoneal signs including rebound tenderness and guarding, which suggest advanced strangulation.
Key laboratory tests and imaging studies can aid in diagnosis, including:
- Lactate level, which was found to be significantly associated with a lack of viability in patients with bowel strangulation [@25@]
- D-dimer assays, which can predict ischemic events, despite having low specificity [@24@]
- CT scans, which can reveal bowel wall thickening, pneumatosis intestinalis, or free fluid, with reduced wall enhancement being a significant independent predictor of bowel strangulation [@27@]
- Ultrasound, which can show decreased blood flow to the herniated contents
The irreducibility of the hernia combined with signs of intestinal obstruction and systemic inflammatory response are the hallmark triad indicating strangulation. Immediate surgical intervention is crucial when intestinal strangulation is suspected, as delayed diagnosis can lead to septic complications and high morbidity and mortality rates, as highlighted by studies such as those by Martínez-Serrano et al. and Koizumi et al. [1, @14@].
From the Research
Diagnosis of Strangulated Inguinal Hernia
To diagnose a strangulated inguinal hernia, the following steps can be taken:
- Clinical examination is the primary method for diagnosing inguinal hernias, including strangulated ones 2
- Imaging studies such as abdominal computed tomography (CT) can help confirm the diagnosis and identify any complications 3, 4
- Patients with strangulated inguinal hernias often present with symptoms such as severe pain, nausea, vomiting, and constipation, as well as a non-reducible and painful inguinal mass 2, 4
- A thorough medical history and physical examination are essential in diagnosing strangulated inguinal hernias, particularly in patients with underlying medical conditions such as ischemic heart disease, diabetes, and hypertension 2
Surgical Intervention
Surgical intervention is often necessary to treat strangulated inguinal hernias:
- Emergency surgery may be required to prevent further complications such as bowel ischemia, perforation, and peritonitis 3, 5, 4
- Various surgical techniques can be used, including open abdominal and inguinal approaches, or a combination of both 3, 6
- The use of mesh repair, such as preperitoneal mesh repair and exploratory laparotomy, can help reduce morbidity and mortality in patients with strangulated inguinal hernias 6
- In some cases, a multi-disciplinary surgical approach may be necessary to manage complex cases of strangulated inguinal hernias, including the involvement of general surgeons, urologists, and plastic surgeons 4