From the Guidelines
Initial inguinal hernia with a small loop of bowel requires prompt surgical evaluation and possible emergency repair. The presence of a small loop of bowel in the hernia sac, as shown on ultrasound, increases the risk of bowel strangulation, which is a surgical emergency.
Diagnosis and Treatment
- The diagnosis of bowel strangulation can be challenging, but signs of systemic inflammatory response syndrome (SIRS), such as fever, tachycardia, and leukocytosis, as well as abdominal wall rigidity, are considered common indicators of strangulated obstruction 1.
- Laboratory tests, such as lactate levels, can also be useful in predicting bowel strangulation, with levels above 2.0 mmol/L indicating a high risk of non-viable bowel 1.
- Imaging studies, such as computed tomography (CT) scans, can also aid in the diagnosis of bowel strangulation, with findings of reduced wall enhancement being highly predictive of strangulation 1.
- The treatment of choice for an initial inguinal hernia with a small loop of bowel is surgical repair, which can be performed using a laparoscopic or open approach 1.
- In cases where bowel resection is necessary, suture repair is preferred due to the risk of mesh infection 1.
- Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, but general anesthesia is preferred in cases of suspected bowel gangrene or peritonitis 1.
Key Considerations
- Early diagnosis and treatment of bowel strangulation are critical to preventing complications and improving outcomes 1.
- The use of prosthetic mesh in emergency hernia repair is controversial, and the decision to use mesh should be made on a case-by-case basis, taking into account the risk of infection and other factors 1.
- Diagnostic laparoscopy can be a useful tool in assessing bowel viability after reduction of complicated hernias 1.
In summary, an initial inguinal hernia with a small loop of bowel requires prompt surgical evaluation and possible emergency repair to prevent complications and improve outcomes. The diagnosis and treatment of bowel strangulation can be challenging, but a combination of clinical evaluation, laboratory tests, and imaging studies can aid in diagnosis, and surgical repair can be effective in treating the condition.
From the Research
Diagnosis of Inguinal Hernia
- Inguinal hernia is the most prevalent type of abdominal wall hernia, with indirect inguinal hernia being twice as common as direct inguinal hernia 2.
- The diagnosis of inguinal hernia can be established reliably by clinical and ultrasound examination, with a high total rate of accuracy of 93% and 94% respectively 3.
- However, the accuracy of clinical and ultrasound examination in differentiating between lateral and medial hernia, and in determining the size of the hernia, is lower, at 54%, 62%, and 50%, 53% respectively 3.
Treatment of Inguinal Hernia
- Symptomatic patients with inguinal hernia often require surgical intervention, although surgical intervention is not always necessary, such as with a small, minimally symptomatic hernia 4.
- The treatment approach for inguinal hernia depends on the size and type of the hernia, as well as the presence of any complications, such as strangulation or incarceration 4, 5.
- In cases where the hernia is strangulated, prompt exploration of the inguinal canal is necessary, and resection of the gangrenous small bowel and primary anastomosis can be safely performed through the same inguinal incision 5.
Role of Ultrasound in Diagnosing Inguinal Hernia
- Ultrasound is a convenient imaging tool for diagnosing inguinal hernia, with advantages such as portability and absence of radiation 2.
- Ultrasound can be used to diagnose inguinal hernia, particularly in cases where the diagnosis is uncertain, or in cases of recurrent hernia or suspected hydrocele 4.
- Ultrasound can also be used to diagnose other conditions, such as Amyand's hernia, which is a rare condition where the vermiform appendix is present in an inguinal hernia 6.