What is the management for a patient with suspected complete mechanical bowel obstruction likely secondary to an incarcerated incisional hernia, presenting with severe hypogastric pain, no bowel movement, no flatus, and vomiting?

Management of Complete Mechanical Bowel Obstruction Secondary to Incarcerated Incisional Hernia

This patient requires immediate surgical consultation and emergency operative repair, as the combination of complete obstruction (no flatus, no bowel movement), persistent vomiting, and severe pain for 5 days indicates high risk of bowel strangulation and ischemia. 1, 2

Immediate Resuscitation and Stabilization

• Begin aggressive IV crystalloid resuscitation immediately to correct dehydration and electrolyte imbalances from 5 days of obstruction and vomiting 3
• Insert nasogastric tube for gastric decompression to prevent aspiration pneumonia and relieve symptoms of obstruction 3
• Place Foley catheter to monitor urine output and assess adequacy of fluid resuscitation 3
• Obtain urgent laboratory studies: complete metabolic panel, lactate level (elevated lactate suggests bowel ischemia), complete blood count (leukocytosis with elevated absolute neutrophil count suggests strangulation), coagulation profile, and renal function 1, 3, 2

Urgent Diagnostic Imaging

• CT scan with IV contrast is mandatory and should be obtained immediately (>90% diagnostic accuracy for bowel obstruction and can identify signs of ischemia) 1, 3
• Look specifically for: reduced bowel wall enhancement (56% sensitivity, 94% specificity for strangulation), free fluid, pneumatosis intestinalis, portal venous gas, closed-loop obstruction, and mesenteric edema 1
• CT will confirm the level of obstruction, identify the incarcerated hernia, and assess for bowel ischemia or perforation 3, 2

Emergency Surgical Management

Emergency surgical repair must be performed immediately upon diagnosis because:

• Complete obstruction with no flatus/no bowel movement for 2+ days indicates high-grade obstruction requiring surgery 4
• Symptoms persisting >8 hours (this patient has 5 days) are associated with significantly higher morbidity 1
• Incarcerated hernias have the highest risk of strangulation among all causes of bowel obstruction (57.2% of bowel ischemia cases, 42.8% of necrosis cases, 50% of perforation cases) 2
• Delayed treatment beyond 24 hours significantly increases mortality (can reach 25% if delayed) 1, 3
• Time from symptom onset to surgery is the most important prognostic factor (P<0.005) 1

Surgical Approach Selection

• Open preperitoneal approach is preferable when bowel resection is anticipated (as in this case with 5-day history and high strangulation risk) 1
• Diagnostic laparoscopy may be useful to assess bowel viability if spontaneous reduction occurs or if the clinical picture is unclear 4, 1
• However, laparoscopic approach should only be attempted if there is no strangulation and the surgeon has appropriate expertise to minimize operative time 4

Intraoperative Management

• Assess bowel viability carefully after reducing the incarcerated hernia 4, 1
• If clear segmental ischemia is present in a hemodynamically stable patient: perform limited intestinal resection and primary anastomosis 4
• If extended intestinal ischemia/peritonitis in hemodynamically unstable patient: perform damage control surgery with open abdomen approach 4
• Mesh repair strategy:
  • If bowel is viable and field is clean: synthetic mesh reinforcement with 1.5-2.5 cm overlap of defect edge 1
  • If bowel resection required with contaminated field: biological mesh is preferred for larger defects, or primary suture repair for smaller defects (avoid synthetic mesh due to 21% infection rate in contaminated fields) 4, 1

Critical Pitfalls to Avoid

• Never delay surgery waiting for "conservative management" in complete obstruction with incarcerated hernia - this patient has already waited 5 days with progressive symptoms 1, 2
• Do not use absorbable prosthetic materials as they lead to inevitable hernia recurrence 1
• Avoid synthetic mesh if bowel resection is performed in contaminated field 1
• Do not underestimate the severity - incarcerated hernias require immediate surgery when intestinal strangulation is suspected to avoid intestinal ischemia 4

Documentation of History of Present Illness

Chief Complaint: 5-day history of severe hypogastric pain with complete bowel obstruction

History of Present Illness: This patient presents with a 5-day progressive history concerning for complete mechanical bowel obstruction secondary to incarcerated incisional hernia. Five days prior to admission, the patient developed acute onset severe hypogastric pain rated 10/10 in severity. The patient self-medicated with buscopan (hyoscine butylbromide) which provided only temporary relief. Three days prior to admission, the hypogastric pain persisted and the patient noted complete absence of bowel movements and inability to pass flatus, indicating complete obstruction. Two days prior to admission, the patient developed nausea and vomited food contents twice. On the day prior to admission, vomiting continued with two additional episodes of food content, still with no bowel movement or flatus passage. Hours prior to admission, the patient had two more episodes of vomiting food contents with persistent inability to pass stool or gas, prompting presentation for emergency evaluation and management. The duration of symptoms (>120 hours), complete obstruction (no flatus/no bowel movement for 3 days), and progressive vomiting indicate high probability of bowel strangulation requiring immediate surgical intervention. 1, 2