Should a patient with an incarcerated hernia be sent to the Emergency Department (ED)?

From the Guidelines

A patient presenting to a primary care office with an incarcerated hernia should be sent to the emergency department immediately. An incarcerated hernia occurs when part of the intestine or abdominal tissue becomes trapped in the hernia sac and cannot be pushed back into the abdominal cavity. This condition requires urgent evaluation as it can progress to strangulation, where blood supply to the trapped tissue is cut off, potentially leading to tissue death within hours 1. According to the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias, patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected (grade 1C recommendation) 1.

Key Considerations

• The risk of bowel necrosis, perforation, peritonitis, and sepsis increases significantly with delayed treatment, making timely intervention crucial 1.
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation (grade 1C recommendation) 1.
• Early detection of progression from an incarcerated hernia to a strangulated hernia is difficult to achieve by either clinical or laboratory means, presenting a large challenge in early diagnosis 1.

Recommended Course of Action

• The patient should be sent to the ED for immediate evaluation and potential surgical intervention.
• While waiting for transport, the provider can administer pain medication if needed, but should not attempt forceful reduction in the office setting.
• The patient should be kept NPO (nothing by mouth) in anticipation of possible emergency surgery.
• At the ED, the patient will receive appropriate imaging (typically CT scan), pain management, and surgical consultation.

Prognostic Factors

• The elapsed time from onset to surgery is the most important prognostic factor (P < 0.005) 1.
• Symptomatic periods lasting longer than 8 h, the presence of comorbid disease, high American Society of Anesthesiologists (ASA) scores, the use of general anaesthesia, the presence of strangulation, and the presence of necrosis significantly affect morbidity rates 1.

From the Research

Incarcerated Hernia Management

• The patient presenting to the PCP office with an incarcerated hernia requires immediate attention due to the high morbidity and mortality associated with this condition, as highlighted in 2.
• Studies suggest that manual reduction of incarcerated hernias, also known as taxis, can be a safe and effective method to delay the need for surgery, especially in high-risk patients or when emergency surgical facilities are not available 3, 4, 5.
• The decision to perform manual reduction or send the patient to the ED for emergency surgery depends on various factors, including the presence of concomitant symptoms and signs of bowel strangulation, the patient's overall health, and the time elapsed since the onset of symptoms 3, 4, 5.
• If manual reduction is attempted, it is crucial to follow safe sedation guidelines and monitor the patient closely for any complications, as noted in 3 and 4.
• In cases where manual reduction is unsuccessful or not feasible, emergency surgery is necessary to prevent further complications, as emphasized in 2 and 6.
• The patient's age, type of hernia, and presence of coexisting diseases are also important factors to consider when determining the best course of action, as discussed in 2 and 5.