What is the best course of action for a patient with a long-standing incarcerated incisional hernia and an enterocutaneous fistula following a cesarean section (C-section)?

Management of Enterocutaneous Fistula with Incarcerated Incisional Hernia Post-Cesarean Section

This patient requires urgent laparotomy (Option B) to address the enterocutaneous fistula and long-standing incarcerated incisional hernia, as incarcerated hernias with bowel involvement mandate immediate surgical intervention to prevent bowel necrosis and septic complications. 1, 2

Clinical Assessment and Urgency

The presence of fecal discharge indicates an established enterocutaneous fistula, which combined with a long-standing incarcerated incisional hernia represents a contaminated surgical field (CDC wound class III or IV). 1 The skin excoriation and redness suggest ongoing contamination and potential infection. This clinical scenario demands immediate surgical source control rather than conservative management with dressings alone. 1

Immediate surgical intervention is mandatory when intestinal involvement is confirmed, as delayed treatment beyond 24 hours dramatically increases mortality risk. 3, 4

Why Laparotomy Over Laparoscopy

• Laparotomy is the definitive approach because this patient has:

  • An established enterocutaneous fistula requiring bowel resection and fistula takedown 1
  • A long-standing incarcerated hernia with likely adhesions and bowel compromise 1, 2
  • A contaminated/dirty surgical field (CDC class III-IV) requiring extensive debridement 1

• Laparoscopic intervention is contraindicated in this setting because:

  • Bowel resection is anticipated for fistula management 2
  • Active contamination with fecal discharge precludes minimally invasive approaches 2
  • The inability to adequately assess and repair complex abdominal wall defects with bowel involvement 2

Surgical Management Algorithm

Intraoperative Steps

1. Source Control and Debridement

   • Perform laparotomy with complete exploration of the abdominal cavity 1
   • Resect the enterocutaneous fistula with involved bowel segments 1
   • Debride all necrotic tissue and contaminated material to healthy tissue 1
   • Create tension-free bowel anastomosis after adequate resection 1

2. Hernia Repair Strategy Based on Defect Size

   • For small defects (<3 cm): Primary repair with non-absorbable sutures is recommended 1, 2
   • For larger defects: Biological mesh should be used when direct suture is not feasible 1, 2
   • The choice between cross-linked and non-cross-linked biological mesh depends on defect size and degree of contamination 1, 2

3. Alternative Options if Biological Mesh Unavailable

   • Polyglactin (absorbable) mesh repair 1
   • Open wound management with delayed repair 1
   • Avoid synthetic mesh in this contaminated field due to high infection and fistula recurrence risk 1, 5

Temporary Abdominal Closure Considerations

If the patient is hemodynamically unstable or has severe contamination requiring damage control surgery:

• Negative pressure therapy (NPT) should be employed for temporary abdominal closure 1
• Early definitive fascial closure within 4-7 days reduces mortality (12.3% vs 24.8%) and complications compared to delayed closure 1
• NPT with continuous fascial traction achieves the best results for delayed fascial closure and reduces entero-atmospheric fistula risk 1

Critical Perioperative Management

• Antimicrobial therapy: Full therapeutic antibiotics (not just prophylaxis) are required for peritonitis and contaminated fields (CDC class IV) 2
• Nutritional support: Construct feeding jejunostomy during the operation for postoperative enteral nutrition 1
• External drainage: Adequate drainage of the surgical site is essential 1

Common Pitfalls to Avoid

• Never attempt simple dressing management for an enterocutaneous fistula with incarcerated hernia, as this leads to ongoing sepsis, malnutrition, and increased mortality 3, 4
• Do not use synthetic polypropylene mesh in contaminated fields, as this significantly increases the risk of mesh infection and recurrent fistula formation 5, 6, 7
• Avoid delayed surgical intervention, as each hour of delay increases mortality by 2.4% in patients with compromised bowel 3
• Do not perform laparoscopic repair when bowel resection is anticipated or active contamination is present 2

Expected Outcomes and Follow-up

• Biological mesh in contaminated fields shows acceptable outcomes with proper technique, though long-term follow-up is essential 5
• The incidence of recurrent incisional hernia is significantly reduced with mesh implantation even in contaminated fields (4-5% with mesh vs 28-34% without mesh) 7
• Monitor for wound infection, recurrent fistula formation, and hernia recurrence in the postoperative period 8, 6