What is the treatment for an inguinal fat-containing hernia with evidence of necrosis?

Treatment of Inguinal Fat-Containing Hernia with Evidence of Necrosis

Immediate emergency surgical intervention is mandatory for inguinal hernias with evidence of necrosis, as delayed treatment beyond 24 hours significantly increases mortality rates. 1, 2

Timing of Surgical Intervention

Operate as soon as possible—every hour of delay increases mortality by 2.4%. 3 The presence of necrosis is an absolute indication for emergency surgery and represents the single most important factor affecting mortality in multivariate analysis. 1 Early intervention (within 6 hours of symptom onset) dramatically reduces the need for bowel resection compared to delayed surgery. 4

• Do not delay surgery for additional imaging or optimization when necrosis is clinically evident—this dramatically increases mortality and morbidity. 5, 3
• Symptomatic periods lasting longer than 8 hours significantly increase morbidity rates. 1
• Normal vital signs do not exclude the need for emergency intervention when clinical signs of necrosis are present. 3

Surgical Approach Selection

Open surgical repair is the appropriate approach for inguinal hernias with confirmed necrosis. 3

• Laparoscopic repair should not be attempted when necrosis is present—it wastes critical time as conversion to open surgery will be inevitable. 5
• However, if there is uncertainty about tissue viability after spontaneous reduction, diagnostic laparoscopy (hernioscopy) can be used to assess bowel viability. 2, 6
• General anesthesia is required when tissue necrosis or peritonitis is suspected. 3

Management of Necrotic Tissue

All necrotic tissue must be completely resected during the initial operation. 5, 3

• Resection should include adequate margins to ensure viable tissue edges. 3
• For fat necrosis specifically, all devitalized tissue must be excised—the hernia repair itself is not the priority in the emergency setting if the patient is compromised. 7
• Reoperation should be undertaken promptly if ongoing necrosis is suspected postoperatively. 3

Hernia Repair Strategy in Contaminated Fields

The choice of repair technique depends on the degree of contamination:

• For clean-contaminated fields (necrotic fat without gross spillage): Prosthetic repair with synthetic mesh can be performed safely. 2, 4

• For contaminated-dirty fields (with tissue breakdown and spillage):

  • Primary tissue repair is recommended for small defects (<3 cm). 5, 2, 3
  • Biological mesh may be used for larger defects when direct suture is not feasible. 5, 3
  • Synthetic mesh must be avoided in contaminated/dirty fields to prevent mesh infection requiring removal. 5, 3

• When mesh can be used, mesh repairs are superior to tissue-suture repairs with lower recurrence rates (OR 0.34). 4

Antibiotic Management

Broad-spectrum intravenous antibiotics must be commenced immediately upon diagnosis. 3

• Coverage should include aerobic and anaerobic bacteria. 3
• This is full antimicrobial therapy for infection/peritonitis, not prophylaxis. 5, 3
• Continue postoperative antibiotics for 3-5 days, with discontinuation based on clinical improvement and culture results. 5, 3

Additional Intraoperative Considerations

• Use wound protectors to prevent surgical site infection. 3
• Maintain normothermia throughout the procedure to decrease infection rates. 3
• Consider abdominal drainage in cases with significant contamination or peritonitis. 3
• Consider feeding jejunostomy placement for postoperative nutritional support in severe cases. 3

Critical Pitfalls to Avoid

• Never attempt conservative management when necrosis is present—this is an absolute contraindication to non-operative treatment. 3
• Do not use synthetic mesh in contaminated fields with tissue necrosis and spillage—the risk of mesh infection outweighs benefits. 5, 3
• Do not delay surgery waiting for "optimization"—the presence of necrosis mandates immediate intervention regardless of other factors. 3
• Early detection of strangulation progressing to necrosis is difficult by clinical or laboratory means alone, so maintain high clinical suspicion. 1