What are the signs of incarceration and how is it managed?

Signs of Incarceration and Management

Incarceration of a hernia is a surgical emergency that requires prompt recognition and intervention to prevent strangulation and bowel necrosis.

Clinical Signs of Incarceration

Physical Examination Findings

• Pain and tenderness at the hernia site 1
• Irreducible hernia (cannot be manually reduced) 1, 2
• Erythema or skin changes over the hernia 1
• Firm, tense mass at the hernia site 2
• Symptoms of bowel obstruction if intestine is involved 2

Systemic Signs

• Nausea and vomiting (indicating possible bowel obstruction) 2
• Abdominal distension 2
• Altered vital signs (tachycardia, fever) if strangulation is developing 1

Diagnostic Approach

Initial Assessment

• Thorough physical examination of the hernia site 1
• Assessment of reducibility (careful attempt at manual reduction) 1
• Evaluation for signs of strangulation (severe pain, erythema, fever) 1

Imaging Studies

• Radiographic studies are beneficial in confirming the diagnosis 2
• Ultrasound can identify hernia contents and assess blood flow 1
• CT scan may be necessary in cases where diagnosis is uncertain 2

Management Algorithm

Immediate Management

• NPO (nothing by mouth) status 1
• IV fluid resuscitation 1
• Pain management 1
• Nasogastric tube if bowel obstruction is present 2

Attempted Reduction

• Gentle manual reduction (taxis) may be attempted in early presentation 1
• Should only be performed by experienced clinicians 1
• Avoid forceful reduction which may damage incarcerated contents 1

Surgical Management

• The high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed 2
• Emergency surgery is indicated for:
  • Failed manual reduction 1
  • Signs of strangulation 1
  • Prolonged incarceration (>6 hours) 1
• Surgical approach:
  • Exploration of hernia sac 1
  • Assessment of bowel viability 1
  • Resection of nonviable tissue if needed 1
  • Standard hernia repair 1

Post-operative Care

• Monitoring for complications 1
• Pain management 1
• Early mobilization 1
• Wound care and monitoring for infection 1

Complications of Incarcerated Hernias

Short-term Complications

• Bowel obstruction 2
• Strangulation of hernia contents 1
• Bowel ischemia and necrosis 1
• Perforation and peritonitis 1

Long-term Complications

• Recurrence of hernia 1
• Chronic pain 1
• Wound infection 1

Special Considerations

Pediatric Patients

• Incarcerated umbilical hernias in children are more common than previously thought 1
• Incarceration occurs more frequently in hernias >1.5 cm in diameter 1
• Active observation of children with umbilical hernia is necessary to prevent morbidity from incarceration 1

Rare Hernia Types

• Spigelian hernias are rare abdominal wall defects that occur at the semilunar line lateral to the rectus abdominis muscle 2
• The majority of patients with Spigelian hernias present with symptomatic incarceration of preperitoneal fat or intra-abdominal viscera 2