What is the immediate management for a patient with a known inguinal hernia extending to the scrotum who suffered a motor vehicle crash and now presents with a laceration in the scrotum?

Immediate Management of Scrotal Laceration in Trauma Patient with Known Inguinal Hernia

In a trauma patient with a known inguinal hernia extending to the scrotum who now presents with scrotal laceration following a motor vehicle crash, immediate priorities are: (1) apply external pelvic compression with a pelvic binder if pelvic injury is suspected, (2) assess hemodynamic stability and control external hemorrhage from the scrotal wound, (3) perform urgent surgical exploration of the scrotum to assess for bowel injury or strangulation, and (4) obtain immediate imaging (E-FAST if unstable, CT if stable) to identify associated intra-abdominal or pelvic injuries. 1, 2

Initial Trauma Assessment and Stabilization

Hemodynamic Assessment

• Immediately assess vital signs using ATLS classification: heart rate >100 bpm, decreased blood pressure, altered mental status, or decreased urine output indicate Class II or higher hemorrhagic shock requiring urgent intervention 1
• Motor vehicle crashes are the leading cause of pelvic injury (60% of pelvic fractures), and high-energy mechanisms produce concomitant thoracic, abdominal, genitourinary, and skeletal injuries in >75% of cases 1
• Apply external pelvic compression immediately with a commercial pelvic binder around the greater trochanters if pelvic trauma is suspected, as this reduces transfusion requirements and ICU length-of-stay 1, 2, 3

External Hemorrhage Control

• Control active bleeding from the scrotal laceration with direct pressure as the first priority 1
• The scrotal wound provides a potential portal for contamination of herniated bowel if present in the scrotum 4, 5

Diagnostic Approach Based on Hemodynamic Status

For Hemodynamically Unstable Patients

• Obtain pelvic X-ray immediately upon arrival to identify fracture patterns that may contribute to hemorrhage 1, 2, 3
• Perform E-FAST within 30 minutes to detect free intraperitoneal fluid, which has 97% positive predictive value for intra-abdominal hemorrhage in pelvic trauma patients 2, 3, 6
• Proceed directly to operating room for surgical exploration if significant free fluid is identified on FAST, as patients with hemorrhagic shock and identified bleeding source require immediate bleeding control 1

For Hemodynamically Stable Patients

• Skip pelvic X-ray and proceed directly to CT scan of the entire body including pelvis with IV contrast (Grade 2- recommendation against X-ray in stable patients) 2, 3
• CT angiography identifies active bleeding with 82-89% sensitivity and can detect bowel injury, though 20% of intestinal injuries may be missed on initial CT 2, 6

Surgical Management of the Scrotal Injury

Urgent Surgical Exploration Indications

• Any scrotal laceration in the setting of known inguinoscrotal hernia requires urgent surgical exploration to assess for:
  • Herniated bowel within the scrotum that may be lacerated or ischemic 4, 7, 5
  • Strangulation of hernia contents, which can occur acutely after trauma 7, 5
  • Contamination of the peritoneal cavity through the patent processus vaginalis 5

Operative Approach

• Perform open exploration through the scrotal laceration with extension as needed to adequately visualize hernia contents 5, 8
• Assess bowel viability carefully: ischemic or perforated bowel requires resection with primary anastomosis or diversion depending on contamination level 5, 8
• In cases of bowel perforation with peritonitis, perform bowel resection first, then address hernia repair in a staged fashion after sepsis control 5
• Avoid laparoscopic approach in this emergency setting with suspected bowel injury and contamination; open preperitoneal approach is preferable when bowel resection is anticipated 1

Critical Pitfalls to Avoid

• Do not assume the scrotal swelling is only the pre-existing hernia: traumatic herniation of additional bowel or bladder can occur acutely after high-energy trauma, and the scrotal laceration may have violated herniated viscera 4, 7
• Do not delay surgical exploration to obtain extensive imaging if the patient is unstable or has signs of peritonitis (rigidity, involuntary guarding) 1, 6
• Do not perform non-therapeutic laparotomy in pelvic fracture patients without clear indication, as this increases mortality 2
• Consider bladder herniation: bladder can herniate into the inguinal canal and scrotum, and trauma may cause acute urinary retention or bladder injury requiring specific management 7

Transport and Facility Considerations

• Transport immediately to a Level I trauma center with 24/7 availability of trauma surgery, general surgery for hernia/bowel management, and interventional radiology 1, 2, 3
• Rapid transfer to a designated trauma center increases survival by 15-30% compared to non-specialized facilities 2, 3