What is the management for a proximal sigmoid colon at the left inguinal canal entrance?

Management of Proximal Sigmoid Colon at the Left Inguinal Canal Entrance

This represents an incarcerated inguinal hernia containing sigmoid colon, which requires urgent surgical intervention with reduction of the hernia contents, assessment of bowel viability, and appropriate resection if compromised, followed by hernia repair. 1, 2

Immediate Assessment and Diagnosis

Confirm the diagnosis and assess for complications:

• Obtain CT imaging to definitively identify sigmoid colon within the inguinal canal and evaluate for bowel obstruction, perforation, or ischemia 2, 3
• Look specifically for signs of strangulation: bowel wall thickening, lack of contrast enhancement, free air, or fluid collections suggesting perforation 2, 3
• Check for underlying pathology: diverticulitis or malignancy can present within incarcerated hernias and dramatically alter management 4, 2, 3
• Obtain blood gas and lactate levels to assess for bowel ischemia, though normal values do not exclude ischemia 5

Surgical Management Algorithm

For viable sigmoid colon after reduction:

• Reduce the incarcerated sigmoid colon and assess viability intraoperatively 1, 2
• If the bowel is viable and no perforation exists, perform primary hernia repair (Bassini or tension-free mesh technique) 1
• Consider elective sigmoid resection later if recurrent volvulus or megacolon is identified 5

For compromised or perforated sigmoid colon:

• Perform sigmoid resection (Hartmann procedure with end colostomy) if bowel is necrotic, perforated, or if diverticulitis/malignancy is present 6, 4, 2, 3
• Do NOT place mesh in contaminated fields - defer definitive hernia repair and perform simple tissue repair (Bassini or Marcy method) to avoid mesh infection 4, 2, 3
• Plan staged hernia repair after colostomy takedown once contamination has resolved 2
• If malignancy is discovered, perform appropriate oncologic resection with lymph node dissection through a separate transabdominal incision 3

Critical Pitfalls to Avoid

Do not assume the hernia is the primary problem:

• The sigmoid colon may harbor underlying pathology (perforated diverticulitis, cancer) that caused the incarceration rather than simple mechanical obstruction 6, 4, 2, 3
• Always inspect the bowel carefully for perforation, diverticulitis, or masses once reduced 4, 2, 3

Avoid mesh in contaminated fields:

• Fecal contamination from perforation or diverticulitis mandates tissue-only repair with delayed definitive hernia reconstruction 4, 2, 3
• Mesh infection rates are unacceptably high in contaminated settings 1

Recognize this is NOT typical sigmoid volvulus:

• While the provided guidelines address sigmoid volvulus management extensively [5-5,7], sigmoid colon in an inguinal hernia represents a distinct entity requiring hernia-specific surgical principles
• Endoscopic decompression has no role in incarcerated inguinal hernias 5, 7

Special Considerations

Right-sided presentation is exceptionally rare:

• Sigmoid colon in a right inguinal hernia is extremely unusual and should raise suspicion for massive colonic redundancy or malrotation 6, 1

Mortality and morbidity:

• Emergency surgery for incarcerated hernia with bowel compromise carries significant mortality risk (12-20%) similar to emergency sigmoid volvulus surgery 7
• Surgical site infections are the most common complication (up to 43%) 7