What is the management for a patient with intractable abdominal pain due to a computed tomography (CT) scan showing a fat-containing periumbilical hernia?

Management of Fat-Containing Periumbilical Hernia with Intractable Abdominal Pain

A patient with intractable abdominal pain and CT-confirmed fat-containing periumbilical hernia requires urgent surgical repair, as intractable pain indicates potential incarceration or impending strangulation that can progress to bowel ischemia and perforation. 1

Immediate Assessment and Decision-Making

Clinical Evaluation

• Intractable pain is a red flag that distinguishes this from an asymptomatic or minimally symptomatic hernia, suggesting the hernia contents may be incarcerated or at risk for strangulation 1
• Examine for peritoneal signs (guarding, rebound tenderness) which would indicate progression to bowel compromise or perforation 2
• Assess for signs of bowel obstruction (vomiting, inability to pass flatus, abdominal distension) 3

Radiological Interpretation

• CT scan has already confirmed the diagnosis, which is the gold standard for hernia evaluation 4
• Review the CT specifically for signs of bowel ischemia: bowel wall thickening >4mm, pneumatosis intestinalis, portal venous gas, or lack of bowel wall enhancement 5
• Look for free intraperitoneal air suggesting perforation 5

Surgical Management Algorithm

Timing of Surgery

Proceed to urgent surgical repair given the intractable nature of the pain, as this indicates the hernia is symptomatic and at high risk for complications 1, 6

• Do not delay surgery even if peritoneal signs are absent, as clinical examination can be unreliable and close monitoring with early surgical intervention is mandatory in patients with persistent abdominal pain 1
• If CT shows signs of bowel ischemia, perforation, or the patient develops peritonitis or hemodynamic instability, proceed to emergency laparotomy immediately 5

Surgical Approach Selection

For hemodynamically stable patients without peritonitis:

• Laparoscopic repair is preferred as it reduces postoperative complications and facilitates better visualization 1
• Laparoscopic approach allows assessment of hernia contents and viability of any incarcerated tissue 7

For unstable patients or those with peritonitis:

• Open repair via laparotomy is mandatory 1
• This allows for bowel resection if ischemia or perforation is encountered 3

Intraoperative Management

• Reduce the hernia contents and assess viability of any incarcerated fat or bowel 2
• If bowel is involved and appears ischemic or perforated, perform segmental resection with primary anastomosis or ostomy depending on contamination level 3
• Mesh reinforcement is strongly recommended to prevent recurrence, as suture repair alone has unacceptably high recurrence rates 6
• For laparoscopic repair, use composite mesh; for open onlay technique, standard polypropylene mesh is suitable 6

Critical Pitfalls to Avoid

• Never adopt a "wait and see" approach with intractable pain, as delayed operation can lead to bowel perforation, peritonitis, and sepsis with significantly worse outcomes 3
• Do not be falsely reassured by absence of peritoneal signs on physical examination, as these can be unreliable in hernia patients 1
• Do not delay surgery for additional imaging if clinical suspicion is high and CT has already confirmed the hernia 1
• Be aware that mesh complications (migration, erosion) can occur months to years later, though this is rare 8

Postoperative Considerations

• Monitor for common complications including seroma formation, surgical site infection, and early recurrence 6
• Address modifiable risk factors: smoking cessation, weight management, and control of conditions causing increased intra-abdominal pressure 6
• Close follow-up is essential as recurrence can occur due to suture tension, improper mesh fixation, or increased intra-abdominal pressure 1