What is the diagnosis and treatment for a left inguinal (lower abdominal area) ultrasound showing an initial hernia with a small loop of bowel?

From the Guidelines

Diagnosis and treatment of a left inguinal hernia with a small loop of bowel should be done immediately with emergency hernia repair when intestinal strangulation is suspected.

Key Points

• The patient should undergo emergency hernia repair immediately when intestinal strangulation is suspected 1.
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1.
• Diagnostic laparoscopy may be a useful tool with the target of assessing bowel viability after spontaneous reduction of strangulated groin hernias 1.
• The use of mesh in clean surgical fields (CDC wound class I) is associated with a lower recurrence rate, if compared to tissue repair, without an increase in the wound infection rate 1.

Treatment Approach

• For patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection, prosthetic repair with a synthetic mesh is recommended 1.
• For patients with complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage, emergent prosthetic repair with synthetic mesh can be performed 1.
• Antimicrobial prophylaxis is recommended for patients with intestinal strangulation and/or concurrent bowel resection 1.

Important Considerations

• Early detection of bowel strangulation is crucial to reduce morbidity and mortality rates 1.
• Laparoscopic approach may be used for repair of incarcerated hernias in the absence of strangulation and suspicion of the need of bowel resection 1.
• Open management is recommended for unstable patients experiencing severe sepsis or septic shock 1.

From the Research

Diagnosis of Inguinal Hernia

• The diagnosis of an inguinal hernia can be established reliably by clinical and ultrasound examination, with a high total rate of accuracy of 93% and 94% respectively 2.
• Ultrasonography is an accurate method for evaluating inguinal hernias, with a sensitivity of 97%, a specificity of 77%, a positive predictive value of 95%, and a negative predictive value of 87% 3.
• Point-of-care ultrasound (POCUS) can reliably confirm the presence of groin hernias and identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls 4.

Treatment of Inguinal Hernia with Small Loop of Bowel

• In cases where a small loop of bowel is present in the hernia, POCUS can aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site 4.
• The presence of a hernia sac and the identification of specific ultrasound findings can help predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias 4.
• Ultrasound imaging can be used to evaluate the regional anatomy, identify subtypes of inguinal hernia, and diagnose pathologies mimicking inguinal hernia, which can inform treatment decisions 5.

Ultrasound Findings

• A "bulb-like" sign on ultrasound and computed tomography can indicate a closed loop obstruction in a Spigelian hernia, which is a rare type of hernia that can present with small bowel obstruction 6.
• Ultrasonography can be used to identify the presence of a hernia, its size, and its type, although the accuracy of these measurements can be limited 2.