What is the treatment for intestinal strangulation?

Treatment of Intestinal Strangulation

Patients with suspected intestinal strangulation must undergo immediate emergency surgical repair to prevent bowel necrosis and death. 1

Diagnostic Indicators of Strangulation

Before proceeding to surgery, recognize that clinical diagnosis is notoriously unreliable—strangulation is correctly identified preoperatively in only 25-48% of cases. 2, 3 However, certain findings increase suspicion:

• Laboratory markers: Elevated lactate, serum creatinine phosphokinase (CPK), D-dimer levels, and presence of systemic inflammatory response syndrome (SIRS) are predictive of bowel strangulation 1, 4
• Imaging: Contrast-enhanced CT findings suggesting strangulation 1, 4
• Clinical signs: Continuous abdominal pain, abdominal wall rigidity, obvious peritonitis, fever, tachycardia, and leukocytosis 4, 2
• Critical timing: Delayed diagnosis beyond 24 hours from symptom onset significantly increases mortality rates 4

Important caveat: No single clinical parameter or combination reliably confirms or excludes strangulation preoperatively. 2, 3 When complete mechanical small bowel obstruction is present, the risk of strangulation ranges from 31-42%, making early surgical intervention essential. 2, 3

Surgical Timing and Approach

Immediate Surgery Required

Operate immediately when intestinal strangulation is suspected—this is a Grade 1C strong recommendation. 1, 5 Early surgical intervention is critical because:

• Preoperative hospital stay >25 hours is associated with irreversible strangulation 3
• Symptomatic periods >8 hours increase the need for bowel resection 4
• Elapsed time from onset to surgery is the most important prognostic factor 4

Surgical Technique Selection

The surgical approach depends on the degree of contamination (CDC wound classification):

Clean-Contaminated Field (CDC Class II) - Strangulation with bowel resection but no gross spillage:

• Use emergent prosthetic repair with synthetic mesh (Grade 1A recommendation) 1, 6
• This approach shows significantly lower recurrence rates without increasing 30-day wound-related morbidity 1
• Synthetic mesh is safe even with intestinal strangulation and concurrent bowel resection when there is no gross enteric spillage 1, 5

Contaminated/Dirty Field (CDC Class III/IV) - Bowel necrosis with gross spillage or peritonitis:

• Primary tissue repair for small defects (<3 cm) 1, 6
• Biological mesh when direct suture is not feasible, with choice between cross-linked and non-cross-linked based on defect size and contamination degree 1, 6
• If biological mesh unavailable, use polyglactin mesh repair or open wound management with delayed repair 1, 6

Unstable Patients - Severe sepsis or septic shock:

• Open management is mandatory to prevent abdominal compartment syndrome 1
• Measure intra-abdominal pressure intraoperatively 1
• Attempt early definitive fascial closure only when risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1

Role of Laparoscopy

Diagnostic laparoscopy (hernioscopy) may be useful for assessing bowel viability after spontaneous reduction of strangulated groin hernias (Grade 2B recommendation). 1, 6 This technique:

• Decreases hospital stay and prevents unnecessary laparotomies 6, 4
• Allows evaluation of bowel viability without full laparotomy 4, 5

However, when strangulation is suspected or bowel resection may be needed, an open preperitoneal approach is preferable. 6 Laparoscopic repair should only be performed in the absence of strangulation and suspicion of bowel resection need. 1

Anesthesia Selection

• General anesthesia is required when bowel gangrene is suspected, intestinal resection is needed, or peritonitis is present 1, 6, 5
• Local anesthesia may be used for incarcerated hernias without bowel gangrene 6, 5

Antimicrobial Management

Administer 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC Class II/III). 6, 5 For peritonitis (CDC Class IV), full antimicrobial therapy is required. 6, 5

Critical Pitfalls to Avoid

• Never delay surgery waiting for "definitive" clinical confirmation of strangulation—by the time strangulation is clinically obvious, bowel infarction is often irreversible 2, 3
• Do not rely on absence of peritoneal signs to rule out strangulation—these findings lack sensitivity and specificity 2, 3
• Avoid attempting manual reduction of incarcerated hernias without surgical backup—spontaneous reduction may hide strangulated bowel that requires assessment 1
• Do not use synthetic mesh in the presence of gross enteric spillage or peritonitis—this significantly increases infection risk 1

Postoperative Management

For patients requiring open management due to instability:

• Attempt early definitive closure following patient stabilization 1
• When early fascial closure is not possible, progressive closure can be attempted at each surgical wound revision 1
• Cross-linked biological meshes may be considered as a delayed option for abdominal wall reconstruction 1
• When definitive fascial closure cannot be achieved, skin-only closure is viable with subsequent eventration managed later with delayed abdominal closure and synthetic mesh repair 1