What is the best course of action for a patient presenting with an abdominal hernia, considering their age, sex, and medical history?

Management of Abdominal Hernia

Patients with abdominal hernias should undergo immediate emergency surgical repair when intestinal strangulation is suspected, as delayed diagnosis beyond 24 hours significantly increases mortality risk. 1

Emergency vs. Elective Management

Immediate Surgical Intervention Required When:

• Intestinal strangulation is suspected based on clinical signs of systemic inflammatory response syndrome (SIRS), including fever, tachycardia, leukocytosis, or abdominal wall rigidity 1
• Contrast-enhanced CT findings demonstrate reduced bowel wall enhancement, intestinal wall thickening with target enhancement, or lack of enhancement after contrast injection 1, 2
• Laboratory markers show elevated lactate, serum creatinine phosphokinase (CPK), or D-dimer levels 1
• Symptomatic period exceeds 8 hours, as this significantly affects morbidity rates 1

The evidence strongly demonstrates that elapsed time from symptom onset to surgery is the most important prognostic factor, with treatment delays beyond 24 hours associated with higher mortality rates. 1

Watchful Waiting May Be Considered When:

• Asymptomatic or minimally symptomatic male inguinal hernia patients can be managed conservatively, as their risk of hernia-related emergencies is low 3
• However, the majority will eventually require surgery, so surgical risks and watchful waiting strategy must be discussed 3

Diagnostic Approach

Clinical Assessment:

• History and physical examination are usually sufficient for diagnosis in most groin hernias 4
• Look for groin pain (sometimes severe), burning, gurgling, or aching sensation, and heavy or dragging sensation that worsens with activity 4
• Examine for bulge or impulse while patient coughs or strains 4

Imaging When Indicated:

• Contrast-enhanced CT scan is the gold standard for diagnosing complicated abdominal hernias, with 14-82% sensitivity and 87% specificity 1, 2
• CT findings predictive of strangulation include reduced wall enhancement (56% sensitivity, 94% specificity), bowel wall thickening, and lack of contrast enhancement 1, 2
• Point-of-care ultrasound is useful for evaluating suspected hernias in stable patients 2
• Imaging is rarely warranted for straightforward inguinal hernias but should be obtained when strangulation is suspected 4

Surgical Approach Selection

For Emergency Complicated Hernias:

Open vs. Laparoscopic Decision Algorithm:

1. Unstable patients or signs of strangulation/perforation → Laparotomy approach (abdominal approach) 1

2. Stable patients without strangulation → Laparoscopic approach may be performed if:

   • No suspicion of bowel resection needed 1
   • Surgeon has appropriate expertise 1
   • Benefits include lower wound infection rates without higher recurrence 1

3. After spontaneous reduction of strangulated groin hernias → Diagnostic laparoscopy is useful to assess bowel viability 1

Common Pitfall: Do not attempt laparoscopic repair when bowel resection is anticipated; use open preperitoneal approach instead. 1

Mesh Selection Based on Contamination Level

Clean Surgical Field (CDC Class I):

• Prosthetic repair with synthetic mesh is recommended for intestinal incarceration without strangulation or bowel resection 1
• Associated with lower recurrence rates without increased wound infection 1

Clean-Contaminated Field (CDC Class II):

• Emergent prosthetic repair with synthetic mesh can be performed for intestinal strangulation and/or bowel resection without gross enteric spillage 1
• Significantly lower risk of recurrence regardless of hernia defect size 1

Contaminated Field (CDC Class III):

• Primary repair recommended when defect is small (<3 cm) 1
• Biological mesh may be used when direct suture not feasible 1
• Choice between cross-linked and non-cross-linked biological mesh depends on defect size and contamination degree 1

Dirty Field (CDC Class IV - Peritonitis):

• Primary repair for small defects (<3 cm) 1
• Biological mesh if primary closure not feasible 1
• If biological mesh unavailable, polyglactin mesh repair or open wound management with delayed repair are alternatives 1

Management of Unstable Patients

Damage Control Surgery Principles:

• Open management recommended for patients with severe sepsis or septic shock to prevent abdominal compartment syndrome 1
• Intra-abdominal pressure should be measured intraoperatively 1
• Following stabilization, attempt early definitive closure only when risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1

Progressive Closure Strategy:

• When early definitive fascial closure not possible, progressive closure can be gradually attempted at every surgical wound revision 1
• Cross-linked biological meshes may be considered as delayed option for abdominal wall reconstruction 1
• When definitive fascial closure cannot be achieved, skin-only closure is viable with subsequent eventration managed later with delayed abdominal closure and synthetic mesh repair 1

Antibiotic Management

• Short-term prophylaxis for intestinal incarceration without ischemia or bowel resection (CDC Class I) 1
• 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC Classes II and III) 1
• Antimicrobial therapy (not just prophylaxis) for patients with peritonitis (CDC Class IV) 1

Anesthesia Considerations

• Local anesthesia can be used for emergency inguinal hernia repair in absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 1
• General anesthesia suggested over regional in patients aged 65 and older, as it may be associated with fewer complications including myocardial infarction, pneumonia, and thromboembolism 3

Special Population Considerations

Female Patients:

• Laparo-endoscopic repair suggested when expertise available to decrease chronic pain risk and avoid missing femoral hernia 3
• Female gender is a risk factor for hernia incarceration/strangulation 3

Pregnant Patients:

• Watchful waiting suggested as groin swelling often consists of self-limited round ligament varicosities 3
• Ultrasound or MRI preferred over CT to avoid radiation exposure 2, 5

Critical Pitfalls to Avoid

• Never delay surgery beyond 24 hours when strangulation suspected, as this significantly increases mortality 1
• Do not rely on clinical examination alone in obese patients or those with significant weight loss, as examination is notoriously unreliable 2
• Avoid using plug repair techniques as incidence of erosion is higher with plug versus flat mesh 1
• Do not assume normal chest X-ray excludes diaphragmatic hernia, as false negatives occur in 11-62% of cases 2, 6