What is the appropriate management for a patient with a hernia over the scar from a recent right partial nephrectomy, presenting with abdominal pain and swelling, and a pain level of 6/10, after being evaluated in the Emergency Room (ER) with a computed tomography (CT) scan?

From the Guidelines

The patient is advised to return to the emergency department immediately for reevaluation due to worsening symptoms of increased abdominal swelling and constant pain, which may indicate a developing surgical emergency such as hernia incarceration or strangulation. The patient's history of a recent right partial nephrectomy and the presence of a hernia at the incision site, as diagnosed by CT scan on April 3,2025, are significant factors in this decision. Dr. Cammack's arrangement for a general surgery consultation is ongoing, but the patient's current symptoms take precedence. The patient reports a constant abdominal pain level of 6/10 and notes an increase in abdominal swelling and hardening since the previous visit, despite maintaining regular bowel movements. These symptoms are concerning and require prompt attention to prevent potential complications.

Given the patient's presentation, the guidelines for emergency repair of complicated abdominal wall hernias 1 are relevant. The patient's symptoms could be indicative of intestinal strangulation, which is a predictive factor for bowel strangulation, as outlined in the guidelines. Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are also predictive of bowel strangulation.

The patient's condition necessitates immediate medical attention to assess the need for emergency hernia repair. The guidelines recommend that patients undergo emergency hernia repair immediately when intestinal strangulation is suspected 1. The use of diagnostic laparoscopy may be a useful tool in assessing bowel viability after spontaneous reduction of strangulated groin hernias 1.

In terms of pain management, the patient's constant pain level of 6/10 is a concern. The guidelines for postoperative pain management in non-traumatic emergency general surgery 1 suggest a multidisciplinary approach to pain management, including the use of analgesic techniques such as intravenous, per oral, or subcutaneous routes, as well as epidural analgesia, patient-controlled analgesia, and continuous peripheral nerve blocks. However, the patient's current symptoms and potential for a surgical emergency take precedence over pain management considerations at this time.

The patient's situation requires immediate attention to prevent potential complications, and the guidelines support the decision to return to the emergency department for reevaluation. The patient's worsening symptoms and the potential for a developing surgical emergency necessitate prompt intervention, and the guidelines provide a framework for the management of complicated abdominal wall hernias and postoperative pain in emergency general surgery.

From the Research

History of Present Illness (HPI)

The patient is a follow-up case from a recent visit to the ER on 4/3/25 due to pain and swelling in her abdomen. A CT scan revealed a hernia over the scar from her recent right partial nephrectomy. The patient's doctor, Dr. Cammack, is in the process of scheduling an appointment with general surgery.

Current Symptoms

• The patient reports regular bowel movements.
• She is experiencing abdominal pain, which she rates as 6/10 and states is constant.
• The patient also reports feeling that her abdomen is swelling more and is slightly harder than before.

Previous Studies on Hernia Repair and Pain Management

• A study published in 2025 2 found that emergency hernia surgery is associated with a higher risk of mortality and morbidity compared to elective repairs.
• Another study from 2001 3 demonstrated the feasibility and safety of unmonitored local anesthesia for elective open inguinal hernia repair.
• Research from 2021 4 showed that transcutaneous electric nerve stimulation (TENS) can reduce acute postoperative pain and analgesic use after open inguinal hernia surgery.
• A 2024 study 5 found that epidural analgesia is associated with lower postoperative ileus rates after open ventral hernia repair with transversus abdominis release.
• A review published in 2025 6 discussed the importance of understanding low back pain and lumbar hernias, highlighting the need for comprehensive intervention strategies.

Recommendation

Based on the patient's symptoms and the studies mentioned above, the patient is advised to return to the ER for further evaluation and treatment.