What is the next step for a 30-year-old patient with a history of reducible inguinal hernia, who now presents with severe constant pain, persistent nausea, and a recent episode of spontaneous reduction?

Urgent Hernia Repair is Indicated

This patient requires urgent surgical repair during the same admission despite the spontaneous reduction of his hernia. 1

Clinical Reasoning

This 30-year-old patient presented with a classic history of incarcerated inguinal hernia that spontaneously reduced. The key clinical features are:

• History of reducible inguinal hernia with recent acute incarceration episode
• Severe constant pain that has now resolved after spontaneous reduction
• Persistent nausea despite reduction - this is a critical red flag
• Currently no palpable hernia or acute findings on examination

Why Urgent Surgery is Required

The World Journal of Emergency Surgery guidelines explicitly state that same-admission elective surgery is indicated for all patients who undergo successful manual reduction of a complicated hernia. 1 This applies equally to spontaneous reduction, as the underlying pathophysiology is identical.

The Danger of Persistent Nausea

The persistent nausea after spontaneous reduction suggests:

• Possible bowel ischemia that occurred during the incarceration episode 1, 2
• The bowel may have sustained injury during the strangulation that is not yet clinically apparent
• Early signs of intestinal compromise can be subtle, with hemodynamic and biochemical abnormalities appearing late 3

Risk of Missed Bowel Injury

Diagnostic laparoscopy is specifically recommended to assess bowel viability after spontaneous reduction of strangulated groin hernias. 1 The concern is that:

• Bowel that was incarcerated may have sustained ischemic injury
• Spontaneous reduction can mask ongoing intestinal compromise 4
• Delayed diagnosis increases mortality risk, particularly when treatment is delayed more than 24 hours after symptom onset 5

Why Other Options Are Incorrect

Option A (CT Scan):

While CT has high specificity (87%) for detecting complications 5, it delays definitive treatment in a patient who already has clear indication for surgery based on guidelines 1. The persistent nausea warrants direct visualization of the bowel.

Option B (Repair in 2 Days):

This violates the guideline recommendation for same-admission surgery 1. Delaying surgery risks:

• Bowel perforation from unrecognized ischemia
• Severe peritonitis and sepsis 5
• Re-incarceration with strangulation

Option D (Reassurance):

This is dangerous. The mortality rate for internal hernias with bowel ischemia can reach 20% when diagnosis is delayed 4, and persistent nausea after reduction is not a reassuring sign.

Recommended Approach

Proceed with urgent hernia repair (Option C) with the following steps:

1. Perform diagnostic laparoscopy to assess bowel viability 1
2. If bowel appears viable without contamination, proceed with prosthetic mesh repair 1, 6
3. If bowel ischemia is found, convert to open approach for bowel resection and primary tissue repair without mesh 1, 6
4. Administer antimicrobial prophylaxis given the history of incarceration 6

Laboratory Considerations

While awaiting surgery, check:

• Lactate level - values ≥2.0 mmol/L predict non-viable bowel strangulation 1, 2
• White blood cell count and differential 1
• These should not delay surgery but help guide intraoperative decision-making

The persistent nausea after spontaneous reduction is the clinical alarm that mandates urgent surgical exploration, not observation.