What is the management for an elderly female patient with a strangulated incisional hernia (IH) presenting with abdominal pain and fecalith discharge, ulcers, and necrosis, but normal vitals?

Management of Strangulated Incisional Hernia with Necrosis

This patient requires immediate laparotomy (Option D) for emergency surgical repair of the strangulated incisional hernia with bowel necrosis. 1

Rationale for Immediate Open Surgery

Laparotomy is the only appropriate intervention when strangulation with ulcers, necrosis, and fecalith discharge is clinically evident, regardless of normal vital signs. 1, 2

• Normal vital signs do not exclude the need for emergency intervention when clinical signs of necrosis are present 2
• Patients with confirmed intestinal strangulation and bowel compromise require urgent open surgical intervention 1
• The presence of fecalith discharge indicates bowel perforation or severe compromise, making this a surgical emergency 1

Why Other Options Are Incorrect

Dressing (Option A) is absolutely contraindicated - conservative management when necrosis is present dramatically increases mortality, as every hour of delay increases mortality by 2.4% 2

Laparoscopy (Option B) should not be attempted - laparoscopic repair is contraindicated in the presence of confirmed bowel necrosis and contamination, as conversion to open surgery will be inevitable, wasting critical time 1, 2

MRI (Option C) represents dangerous delay - additional imaging when strangulation with necrosis is clinically evident dramatically increases mortality and is not indicated 1

Intraoperative Management

During laparotomy, the surgeon must:

• Assess the extent of bowel necrosis and perform segmental resection of all non-viable bowel with adequate margins 1, 2
• For small defects in this contaminated field with bowel necrosis and gross enteric spillage, perform primary tissue repair 1
• If direct suture is not feasible for larger defects, use biological mesh (not synthetic mesh, which must be avoided in contaminated/dirty fields to prevent mesh infection) 1, 2

Antimicrobial Management

• Commence broad-spectrum intravenous antibiotics immediately, covering aerobic and anaerobic bacteria 2
• This is full antimicrobial therapy for peritonitis, not prophylaxis 1, 2
• Continue postoperative antibiotics for 3-5 days based on intraoperative findings and culture results 1, 2

Critical Pitfall to Avoid

The most dangerous error is delaying surgery for additional imaging, optimization, or attempting conservative measures when strangulation with necrosis is clinically evident - this dramatically increases mortality and morbidity 1, 2