Immediate Hernia Repair in Acute Trauma Setting
No, do not repair the inguinal hernia at this time—focus exclusively on damage control for life-threatening injuries, establish urinary drainage if needed, and defer definitive hernia repair until the patient is hemodynamically stable and all acute traumatic injuries have been addressed. 1, 2
Prioritize Life-Threatening Injuries First
In the context of a motor vehicle crash with scrotal laceration and known inguinal hernia:
Apply a pelvic binder immediately if pelvic trauma is suspected, positioned around the great trochanters, as this reduces transfusion requirements and improves outcomes in severe pelvic trauma 1, 2
Perform E-FAST upon hospital arrival to detect intra-abdominal bleeding, which has 97% positive predictive value for hemorrhage in trauma patients 2
Obtain CT scan with IV contrast if hemodynamically stable to evaluate for associated injuries including bladder, bowel, or vascular injuries that commonly accompany complex trauma 1
Address Genitourinary Injuries Before Hernia
The scrotal laceration takes precedence over the pre-existing hernia:
Inspect for urethral injury given the scrotal involvement—obtain retrograde urethrography if urethral injury is suspected before catheter placement 1
Establish urinary drainage via suprapubic catheter if perineal/scrotal injuries are present, as recommended for associated perineal trauma 1
Repair the scrotal laceration as part of initial wound management, but do not attempt hernia repair during this acute phase 1
Why Defer Hernia Repair
Damage control principles apply: In unstable polytrauma patients, temporary urinary drainage and wound management should be performed with delayed definitive repair once clinical status improves 1
The hernia is a chronic condition: Unlike the acute traumatic injuries requiring immediate attention, the pre-existing inguinal hernia does not constitute an emergency unless there are signs of strangulation (irreducibility, tenderness, erythema, systemic symptoms) 3
Surgical timing matters: Symptomatic periods >8 hours and delayed treatment >24 hours significantly increase morbidity and mortality—but this applies to strangulated hernias, not chronic reducible hernias 3, 4
Assess for Hernia Complications
Before deferring repair, confirm the hernia is not strangulated:
Check for signs of incarceration/strangulation: Firm, tender, irreducible mass; overlying skin erythema or warmth; peritoneal signs; systemic symptoms (fever, tachycardia, leukocytosis) 3, 4
If strangulation is present: Emergency hernia repair becomes mandatory to prevent bowel necrosis, but this would be performed as part of exploratory laparotomy for the trauma, not as an isolated hernia repair 3, 4
Laboratory markers: Elevated lactate ≥2.0 mmol/L, elevated CPK, D-dimer, and WBC predict bowel strangulation if present 3
Definitive Management Plan
Repair the hernia electively 1-2 weeks after full recovery from acute injuries, once the patient is hemodynamically stable and all traumatic wounds have healed 3
Use mesh repair as the standard approach for non-complicated inguinal hernias when performing delayed repair 4
Consider laparoscopic approach (TEP or TAPP) for the scrotal hernia during elective repair, though a combined laparoscopic and open approach may be needed given the scrotal extension 4, 5
Critical Pitfalls to Avoid
Do not attempt hernia repair during initial trauma resuscitation—this violates damage control principles and increases morbidity in unstable patients 1
Do not miss associated injuries: Scrotal hernias in trauma can mask bowel ischemia or bladder involvement, requiring thorough evaluation with CT imaging 6
Do not delay if true strangulation develops—this requires immediate surgical intervention regardless of other injuries 3, 4
Monitor for compartment syndrome: Traumatic inguinal herniation with bowel in the scrotum can occur with high-energy trauma and requires urgent assessment 7