What is the recommended management approach for a chronically incarcerated hernia?

Management of Chronically Incarcerated Hernia

For chronically incarcerated hernias without signs of strangulation, proceed with elective surgical repair using synthetic mesh via a laparoscopic approach when feasible, as this provides the lowest recurrence rates without increasing infection risk. 1

Initial Assessment and Risk Stratification

The critical first step is distinguishing chronic incarceration from acute strangulation, as this fundamentally changes management urgency:

• Assess for strangulation indicators: Check for systemic inflammatory response syndrome (SIRS), obtain contrast-enhanced CT imaging, and measure serum lactate, CPK, and D-dimer levels—all are predictive of bowel strangulation 1
• Laboratory thresholds: Arterial lactate ≥2.0 mmol/L is a useful predictor of non-viable bowel 1
• CT findings: Reduced bowel wall enhancement has 56% sensitivity and 94% specificity for strangulation 1
• Clinical markers: Elevated WBC count and fibrinogen levels are significantly predictive of morbidity 1

If any signs of strangulation are present, this becomes a surgical emergency requiring immediate intervention 1

Management Algorithm Based on Clinical Presentation

For Chronic Incarceration WITHOUT Strangulation

Elective surgical repair is recommended using the following approach:

• Mesh repair is mandatory: Synthetic mesh repair in clean surgical fields (CDC wound class I) is associated with significantly lower recurrence rates (0% vs 19% with tissue repair) without increasing wound infection risk 1, 2
• Laparoscopic approach preferred: Both TAPP and TEP techniques can be used for incarcerated hernias when there is no suspicion of bowel necrosis or need for resection 1, 2
• Laparoscopic advantages include: Lower wound infection rates (P<0.018), ability to identify occult contralateral hernias (present in 11.2-50% of cases), and no increase in recurrence rates 2
• Short-term antimicrobial prophylaxis is recommended for intestinal incarceration without evidence of ischemia 1

For Incarceration WITH Strangulation (Emergency)

Immediate surgical intervention is mandatory 1, 3:

• Timing is critical: Early intervention (<6 hours from symptom onset) is associated with significantly lower incidence of bowel resection (OR 0.1, p<0.0001) 3
• Diagnostic laparoscopy may be useful to assess bowel viability after spontaneous reduction of strangulated hernias 1
• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed 1, 2

Mesh Selection Based on Surgical Field Classification

The choice of mesh depends entirely on the degree of contamination encountered:

Clean Field (CDC Class I)

• Use synthetic mesh: This is a Grade 1A recommendation for intestinal incarceration without signs of strangulation or concurrent bowel resection 1

Clean-Contaminated Field (CDC Class II)

• Synthetic mesh can still be used: Even with intestinal strangulation and/or bowel resection without gross enteric spillage, emergent prosthetic repair with synthetic mesh is associated with significantly lower recurrence risk 1
• 48-hour antimicrobial prophylaxis is recommended 1

Contaminated Field (CDC Class III) or Dirty Field (CDC Class IV)

• Primary tissue repair for small defects (<3 cm): When the defect is small, direct suture is recommended 1
• Biological mesh when primary repair not feasible: Choose between cross-linked and non-cross-linked biological mesh based on defect size and contamination degree 1
• Alternative options if biological mesh unavailable: Polyglactin mesh repair or open wound management with delayed repair 1
• Full antimicrobial therapy is required for peritonitis 1

Special Considerations for Unstable Patients

For patients with severe sepsis or septic shock:

• Open management is mandatory to prevent abdominal compartment syndrome 1
• Measure intra-abdominal pressure intraoperatively 1
• Attempt early definitive closure following patient stabilization, but only when risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1
• Progressive closure at each revision: When early definitive fascial closure is not possible, attempt gradual closure at every surgical wound revision 1
• Skin-only closure is viable: When definitive fascial closure cannot be achieved, skin-only closure with subsequent delayed abdominal closure and synthetic mesh repair is acceptable 1

Anesthesia Selection

• Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 1, 2, 4
• General anesthesia required when bowel gangrene is suspected, intestinal resection is needed, or peritonitis is present 2, 4

Critical Pitfalls to Avoid

• Never delay repair of strangulated hernias: Delayed diagnosis (>24 hours) is associated with significantly higher mortality rates 2
• Do not overlook contralateral hernias: Laparoscopic approach allows visualization of the contralateral side to identify occult hernias present in up to 50% of cases 2
• Avoid inadequate mesh overlap: Ensure at least 5 cm mesh overlap for successful outcomes 5
• Do not use synthetic mesh in contaminated/dirty fields: This increases infection risk without benefit 1