What is the management for a 90-year-old female with a strangulated incisional hernia, ulcers, and necrosis, presenting with abdominal pain and fecalith discharge?

Management of Strangulated Incisional Hernia in a 90-Year-Old

This patient requires immediate laparotomy (Option D) for emergency surgical repair of the strangulated incisional hernia with bowel necrosis. 1

Rationale for Immediate Open Surgery

Patients must undergo emergency hernia repair immediately when intestinal strangulation is suspected, and the presence of ulcers, necrosis, and fecalith discharge confirms bowel compromise requiring urgent intervention. 1

Why Laparotomy is Mandatory

• Strangulation with confirmed necrosis necessitates open surgical access to assess the full extent of bowel compromise, perform necessary bowel resection, and manage the contaminated surgical field. 1

• The presence of fecalith discharge indicates bowel perforation or severe necrosis, creating a contaminated or dirty surgical field (CDC wound class III or IV), which contraindicates laparoscopic approaches when bowel resection is anticipated. 2

• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed, as laparoscopic repair is contraindicated in cases where bowel resection is anticipated or active strangulation with bowel compromise exists. 2

Why Other Options Are Inappropriate

Laparoscopy (Option B) - Contraindicated

• Laparoscopic approach should only be used for incarcerated hernias without strangulation and no suspicion of bowel necrosis or need for bowel resection. 2

• The presence of confirmed necrosis and fecalith discharge makes laparoscopy inappropriate, as it cannot adequately manage the extensive bowel compromise and contaminated field. 1, 2

Dressing (Option A) - Dangerous Delay

• Delayed diagnosis and treatment of strangulated hernias is associated with significantly higher mortality rates, and any delay to perform conservative management would be life-threatening. 3

• Conservative management with dressing has no role when bowel strangulation and necrosis are confirmed. 1

MRI (Option C) - Unnecessary Delay

• The diagnosis is already clinically established with visible necrosis and fecalith discharge; imaging would only delay mandatory surgical intervention. 1

• Elapsed time from onset to surgery is the most important prognostic factor in strangulated hernias, making any diagnostic delay potentially fatal. 3

Surgical Management Algorithm

Intraoperative Decisions

• Assess the extent of bowel necrosis and perform segmental resection of all non-viable bowel. 1

• For contaminated fields (CDC wound class III) with bowel necrosis and gross enteric spillage, primary repair is recommended when the defect is small (<3 cm). 1

• When direct suture is not feasible, biological mesh may be used, with the choice between cross-linked and non-cross-linked biological mesh depending on defect size and degree of contamination. 1

• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives. 1

Special Considerations for This 90-Year-Old Patient

• For unstable patients experiencing severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome, with intraoperative measurement of intra-abdominal pressure. 1

• Given the patient's age and contaminated field, assess hemodynamic stability carefully - if unstable, prioritize damage control surgery with temporary closure. 1

• Following stabilization, attempt early definitive closure of the abdomen when the risk of excessive tension or recurrent intra-abdominal hypertension is minimal. 1

Antimicrobial Management

• Full antimicrobial therapy is required for patients with peritonitis (CDC class IV), not just prophylaxis. 2

• Continue antibiotics postoperatively based on intraoperative findings and culture results. 2

Critical Pitfalls to Avoid

• Never delay surgery for additional imaging or conservative measures when strangulation with necrosis is clinically evident - this dramatically increases mortality. 1, 3

• Do not attempt laparoscopic repair in the presence of confirmed bowel necrosis and contamination - conversion to open is inevitable and wastes critical time. 2

• Avoid synthetic mesh in contaminated/dirty fields - use biological mesh or plan staged repair to prevent mesh infection. 1