From the Guidelines
The treatment for a high grade small bowel obstruction secondary to bowel incarceration within a right inguinal hernia requires immediate emergency surgical intervention, as the benefits of surgery clearly outweigh the risks in this scenario, according to the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.
Initial Management
Initial management includes:
- Fluid resuscitation with intravenous crystalloids, such as normal saline or lactated Ringer's, at a dose of 1-2 L bolus followed by maintenance, to prevent dehydration and hypovolemia.
- Nasogastric tube placement for decompression to relieve abdominal distension and vomiting.
- Nothing by mouth status to reduce the risk of aspiration and allow the bowel to rest.
- Administration of broad-spectrum antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours or cefazolin 2g IV plus metronidazole 500mg IV, to prevent infection.
- Pain management with opioid analgesics, like morphine 2-4mg IV every 4 hours or hydromorphone 0.5-1mg IV every 4 hours, to control pain and discomfort.
Definitive Treatment
The definitive treatment is emergency hernia repair surgery, typically through an open approach, which involves:
- Reduction of the incarcerated bowel to relieve the obstruction.
- Assessment of bowel viability to determine if any segments need to be resected.
- Resection of any necrotic segments to prevent further complications.
- Hernia repair with mesh reinforcement if no contamination exists, to prevent recurrence.
- Primary repair without mesh may be preferred if bowel necrosis is present, to avoid infection.
Postoperative Care
Postoperatively, patients require:
- Continued fluid management to prevent dehydration and hypovolemia.
- Gradual advancement of diet once bowel function returns, to prevent malnutrition and promote healing.
- Pain control with opioid analgesics, to manage pain and discomfort.
- Monitoring for complications, such as wound infection, recurrence, or ileus, to promptly address any issues that may arise.
This condition requires urgent attention, as delayed treatment can lead to bowel strangulation, perforation, peritonitis, and sepsis, significantly increasing morbidity and mortality, as highlighted by the study by Martínez-Serrano et al. 1.
From the Research
Treatment Options for High Grade Small Bowel Obstruction
- Surgical intervention is often required for high-grade small bowel obstruction, especially in cases of strangulation or incarceration 2.
- In cases of bowel incarceration within a right inguinal hernia, hernia sac laparoscopy (hernioscopy) can be a useful alternative to unnecessary laparotomy or standard laparoscopy to evaluate the viability of the incarcerated hernia content 3.
- Nonoperative management can be considered for some cases of high-grade small bowel obstruction, but it is associated with a higher recurrence rate and shorter time to recurrence compared to operative intervention 4.
Surgical Approaches
- Laparotomy is often required for cases of high-grade small bowel obstruction, especially in cases of strangulation or incarceration 5, 6.
- Hernia repair using prosthetic tension-free technique can be performed after reducing the incarcerated hernia content 3.
- Primary repair of the hernia defect can be performed in some cases, such as in the case of a Spigelian hernia 6.
Diagnostic Tools
- Computed tomography (CT) imaging can be a valuable adjunct in diagnosing high-grade small bowel obstruction and identifying the cause of the obstruction, such as a Spigelian hernia 4, 6.
- Ultrasound can also be used as a diagnostic tool for high-grade small bowel obstruction 2.
- Plain radiographs can be ordered, but they cannot exclude the diagnosis of high-grade small bowel obstruction 2.