What is the management for an elderly patient with a strangulated incisional hernia, presenting with abdominal pain, fecalith discharge, ulcers, and necrosis, but with normal vital signs?

Management of Strangulated Incisional Hernia with Necrosis in a 90-Year-Old Patient

This patient requires immediate emergency surgical intervention with bowel resection, primary tissue repair without mesh given the contaminated/dirty field, and broad-spectrum antibiotics. 1, 2

Immediate Surgical Intervention is Mandatory

• Emergency surgery must be performed as soon as possible when intestinal strangulation is suspected, particularly with clinical evidence of necrosis and ulceration as described in this case. 2, 3
• The presence of fecalith discharge strongly suggests bowel perforation or severe necrosis, making this a surgical emergency despite normal vital signs. 1
• Delayed surgery beyond 24 hours significantly increases mortality rates, and every hour of delay decreases survival probability by 2.4%. 1, 3
• In elderly patients (>70 years), mortality is particularly high with strangulated hernias requiring bowel resection—up to 86% in patients with small bowel necrosis. 4

Surgical Approach Selection

Open surgical repair is the appropriate approach given the clinical presentation of necrosis, ulceration, and fecalith discharge suggesting bowel perforation. 1, 3

• Laparoscopic approach is contraindicated when bowel resection is anticipated, active strangulation with bowel compromise exists, or peritonitis is present. 3
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present. 3
• The open preperitoneal approach is preferable when strangulation is suspected and bowel resection is needed. 3

Management of Necrotic Bowel

All obvious transmural necrotic bowel must be resected during the initial operation. 1

• Resection should include all visibly necrotic tissue with adequate margins to ensure viable bowel edges. 1
• Reoperation should be undertaken promptly if ongoing necrosis is suspected postoperatively. 1
• The extent of resection depends on intraoperative findings but must be complete to prevent ongoing sepsis. 1

Hernia Repair Strategy in Contaminated/Dirty Field

For this contaminated-dirty surgical field (CDC wound class III-IV), primary tissue repair is recommended for small defects (<3 cm). 1, 3

If the defect is larger and direct suture is not feasible, a biological mesh may be used. 1, 3

• The choice between cross-linked and non-cross-linked biological mesh depends on defect size and degree of contamination. 1, 3
• Synthetic mesh (polypropylene) should be avoided in this dirty field with bowel perforation and fecalith discharge, despite some studies showing acceptable outcomes in contaminated cases. 1
• If biological mesh is unavailable, polyglactin (absorbable) mesh repair or open wound management with delayed repair are viable alternatives. 1, 3

Rationale Against Synthetic Mesh in This Case

While recent research suggests polypropylene mesh can be used in contaminated fields with acceptable infection rates (26.67% wound infection, no mesh removal required), 5, 6 the presence of fecalith discharge and ulceration with necrosis indicates a dirty field (CDC class IV) with gross enteric spillage, making primary repair or biological mesh the safer choice. 1

Antibiotic Management

Broad-spectrum intravenous antibiotics must be commenced immediately covering aerobic and anaerobic bacteria. 1

• Preoperative broad-spectrum antibiotics are strongly recommended (Grade 1A) in elderly patients undergoing emergency hernia repair. 1
• Full antimicrobial therapy (not just prophylaxis) is required for patients with peritonitis from bowel perforation (CDC class IV). 3, 7
• Postoperative antibiotics should continue for 3-5 days, with discontinuation based on clinical and laboratory criteria such as fever resolution and normalization of leukocytosis. 1
• Antibiotics should be active against common bacteria causing surgical site infections in peritonitis, particularly Escherichia coli, other Enterobacteriales, and Clostridiales. 1

Additional Intraoperative Considerations

A feeding jejunostomy should be placed at the end of the operation to ensure postoperative nutritional support. 1

• Abdominal drainage is suggested in cases of complicated appendicitis with perforation/abscess/peritonitis, and this principle applies to perforated strangulated hernias. 1
• Wound protectors should be used to prevent surgical site infection. 1
• Maintain normothermia throughout the procedure to decrease SSI rates. 1

Critical Pitfalls to Avoid

• Do not delay surgery waiting for further optimization in this 90-year-old patient—normal vital signs do not exclude the need for emergency intervention when clinical signs of strangulation and necrosis are present. 1, 2
• Do not attempt non-operative management—the presence of necrosis, ulceration, and fecalith discharge are absolute contraindications to conservative treatment. 1
• Do not use synthetic mesh in this dirty field—the risk of mesh infection and need for removal outweighs potential benefits in the setting of bowel perforation. 1
• Do not underestimate mortality risk—elderly patients with strangulated hernias requiring bowel resection have mortality rates up to 40%, with 89% mortality in those admitted after 96 hours of strangulation. 4

Postoperative Monitoring

• Monitor closely for surgical site infection, which occurs in up to 26.67% of contaminated hernia repairs. 5
• Watch for signs of ongoing necrosis requiring reoperation. 1
• Assess for development of multiple organ failure, which occurred in 35% of patients with strangulated hernias requiring bowel resection in one series. 4
• Psychiatric evaluation may be warranted given the patient's age and the significant physiological stress of this operation. 1