From the Guidelines
Incarcerated inguinal hernias require immediate surgical intervention, especially when intestinal strangulation is suspected. The management options for an incarcerated inguinal hernia include:
- Emergency hernia repair: Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected, as delayed diagnosis can lead to septic complications and increased morbidity and mortality rates 1.
- Laparoscopic approach: Diagnostic laparoscopy may be a useful tool for assessing bowel viability after spontaneous reduction of strangulated groin hernias, and repair of incarcerated hernias can be performed with a laparoscopic approach in the absence of strangulation and suspicion of the need of bowel resection 2.
- Open preperitoneal approach: An open preperitoneal approach is preferable when there is a suspicion of the need for bowel resection 2.
- Mesh use: The use of mesh in clean surgical fields is associated with a lower recurrence rate, and prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 3.
- Biological mesh: For stable patients with strangulated hernia with bowel necrosis and/or gross enteric spillage, primary repair is recommended when the size of the defect is small, and a biological mesh may be used for repair when direct suture is not feasible 3.
- Anaesthesia: Local anaesthesia can be used, providing effective anaesthesia with less postoperative complications for emergency inguinal hernia repair in the absence of bowel gangrene, while general anaesthesia should be preferred in the case of suspected bowel gangrene and need of intestinal resection and always in the case of peritonitis 4. Some key points to consider when managing an incarcerated inguinal hernia include:
- Early diagnosis: Early diagnosis of strangulated obstruction is crucial, and signs of systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1.
- Timing of intervention: The elapsed time from onset to surgery is the most important prognostic factor, and early surgical intervention is critical to reduce morbidity and mortality rates 1.
- Bowel resection: Bowel resection may be required in some cases, and risk factors for bowel resection include lack of health insurance, obvious peritonitis, and femoral hernia 1.
From the Research
Management Options for Incarcerated Inguinal Hernia
The management of incarcerated inguinal hernia involves several approaches, including:
- Surgical repair, which is the current standard of care 5
- Watchful waiting, which may be suitable for asymptomatic or minimally symptomatic hernias 6
- The use of prophylactic antibiotics in centers with high rates of wound infection 5
- Local anesthesia, which is a suitable and economic option for open repairs 5
Surgical Repair Techniques
Several surgical repair techniques are available, including:
- Mesh repairs, which are superior to non-mesh tissue-suture repairs 5
- Lichtenstein repair and endoscopic/laparoscopic techniques, which have similar efficacy 5
- Laparoscopic herniorrhaphy, which has been shown to be effective in treating incarcerated pediatric inguinal hernia 7
- The combined laparoscopic approach, which combines intraperitoneal laparoscopic exploration with hernia reduction and total extraperitoneal (TEP) repair of the hernia 8
Considerations for Emergency Operations
In emergency operations for incarcerated inguinal hernias:
- Prosthetic repair using a mesh is not contra-indicated and appears to be safe and acceptable 9
- However, when perforation of the intestine occurs due to incarceration of an inguinal hernia, prosthetic repair using hernioplasty should not be performed due to the high risk of infection 9
- The combined laparoscopic approach offers a solution to incarceration of inguinal hernias while taking advantage of each separate approach 8