What is the diagnosis for an inguinal hernia containing small and large bowel, without evidence of obstruction?

From the Guidelines

An inguinal hernia containing small and large bowel without obstruction requires surgical repair, though timing depends on symptom severity, and a laparoscopic approach may be considered in the absence of strangulation and suspicion of the need of bowel resection, as recommended by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.

Key Considerations

• The hernia contains both small and large intestine, which increases the risk of complications compared to hernias containing only fat or omentum.
• Intestinal hernias carry a higher risk for future obstruction or strangulation, making repair advisable even if minimally symptomatic.
• Patients should avoid heavy lifting (over 10-15 pounds) and strenuous activities that increase intra-abdominal pressure until repair.
• Surgical options include open or laparoscopic approaches, with mesh reinforcement typically used for durability.

Recommendations

• For mild cases, elective surgical repair can be scheduled while managing discomfort with acetaminophen or NSAIDs as needed.
• While awaiting surgery, patients should seek immediate medical attention if they develop severe pain, nausea, vomiting, or inability to reduce the hernia, as these suggest strangulation or obstruction requiring emergency intervention.
• The use of mesh in clean surgical fields is associated with a lower recurrence rate, and prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1.

Important Findings

• Diagnostic laparoscopy may be a useful tool for assessing bowel viability after spontaneous reduction of strangulated groin hernias, as recommended by the WSES guidelines 1.
• The choice between a cross-linked and a non-cross-linked biological mesh should be evaluated depending on the defect size and degree of contamination, as recommended by the WSES guidelines 1.
• Antimicrobial prophylaxis is recommended for patients with intestinal strangulation and/or concurrent bowel resection, as well as for patients with peritonitis 1.

From the Research

Inguinal Hernia Containing Small and Large Bowel

• An inguinal hernia containing small and large bowel without evidence of obstruction is a complex condition that requires careful management 2.
• The presence of both small and large bowel loops in the hernia sac can make surgical repair challenging, and the choice of technique is crucial to prevent complications 3, 2.
• Studies have reported successful repair of giant inguinoscrotal hernias containing intestinal segments using the Lichtenstein tension-free hernioplasty technique 2.

Surgical Techniques

• Open-mesh repair is a commonly used technique for inguinal hernia repair, and it has been shown to have several advantages over laparoscopic procedures, including lower recurrence rates and fewer complications 4.
• Laparoscopic repair is also a viable option, especially for patients with recurrent or bilateral inguinal hernias, and it offers advantages such as less chronic postoperative pain and faster return to normal activities 5, 6.
• The choice of surgical technique depends on various factors, including the size and type of hernia, patient-related factors, and the surgeon's experience and preference 4.

Classification and Diagnosis

• Inguinal hernias can be classified into different types, including indirect, direct, scrotal, and femoral hernias, and each type has its own characteristics and treatment options 4.
• A simple and easy-to-use classification system can help evaluate the outcome of hernia repair and guide treatment decisions 4.
• Accurate diagnosis and classification of inguinal hernias are essential for effective management and prevention of complications 4.