Can an inguinal (in the groin area) scrotal hernia cause small bowel obstruction and what is its management?

Inguinal Scrotal Hernia Can Cause Small Bowel Obstruction and Its Management

Yes, inguinal scrotal hernias can cause small bowel obstruction and require prompt surgical intervention when strangulation or ischemia is present. 1

Pathophysiology and Presentation

• Inguinal scrotal hernias can lead to small bowel obstruction when bowel loops become trapped in the hernia sac, causing mechanical obstruction of intestinal contents 1
• Strangulation occurs when blood supply to the herniated bowel is compromised, leading to ischemia and potential necrosis 2
• Patients typically present with abdominal pain, distension, vomiting, and absolute constipation 2
• Physical examination reveals a tender, irreducible inguinal mass extending into the scrotum 2

Diagnostic Approach

• CT scan is the preferred imaging modality for suspected bowel obstruction due to inguinal hernia, with sensitivity and specificity exceeding 90% 3
• Plain abdominal radiographs may show dilated small bowel loops but have limited diagnostic value (sensitivity 60-70%) 1
• Laboratory tests should include complete blood count, CRP, lactate, electrolytes, and renal function tests to assess for signs of ischemia 1
• Elevated white blood cell count, CRP, and lactate may indicate bowel ischemia, though normal values cannot exclude it 1

Management Algorithm

Initial Management

• Immediate fluid resuscitation with intravenous crystalloids 3
• Nasogastric tube decompression to relieve vomiting and abdominal distension 3
• Foley catheter insertion for monitoring urine output 3
• Electrolyte monitoring and correction 3

Surgical Indications

• Emergency surgical intervention is mandatory when signs of peritonitis, strangulation, or bowel ischemia are present 1
• Irreducible inguinal hernia with symptoms of bowel obstruction requires prompt surgical exploration 2
• Failed manual reduction of an incarcerated hernia necessitates emergency surgery 1

Surgical Management

• Prosthetic repair is the treatment of choice for most complicated abdominal wall hernias including inguinal hernias 1
• In cases of bowel resection or contaminated surgical fields, suture repair is preferred over mesh due to infection risk 1
• Diagnostic laparoscopy may be useful to assess bowel viability after hernia reduction 1
• Laparoscopic approach can be used when no bowel resection is needed; otherwise, a mini-open approach is recommended 1
• If bowel ischemia is present, resection of the compromised segment with primary anastomosis is performed 1, 2

Special Considerations

• Giant or long-standing inguinal hernias may contain unusual contents such as bladder, which should be ruled out with CT imaging prior to surgery 2
• Mesh migration is a rare but serious complication that can cause bowel obstruction years after hernia repair 4, 5
• Negative laparotomies (where no cause of obstruction is found) occur in 6-40% of cases with suspected bowel obstruction 1
• Same-admission elective surgery is indicated for all patients who undergo successful manual reduction of incarcerated hernia 1

Complications to Monitor

• Dehydration with acute kidney injury 3
• Electrolyte disturbances 3
• Bowel ischemia and perforation 1, 2
• Sepsis in cases of gangrenous bowel 2
• Recurrence of hernia (8% after 1 year, 16% after 5 years with non-operative management) 1