What assessment and plan should I write for a patient who underwent umbilical hernia repair on [DATE], fell one month ago, and now has left-sided upper and lower abdominal quadrant discomfort and tenderness over the umbilicus with an otherwise normal examination?

Assessment and Plan: Post-Umbilical Hernia Repair with New Abdominal Pain Following Trauma

Assessment

This patient requires urgent CT imaging to rule out hernia recurrence, mesh-related complications, or intra-abdominal injury from the fall. 1

Differential Diagnosis (in order of clinical priority):

• Hernia recurrence or incarceration – The combination of umbilical tenderness one month post-trauma in a patient with prior hernia repair raises immediate concern for recurrent hernia, particularly given that primary suture repairs carry 19-54% recurrence rates 2
• Mesh-related complications – Including mesh migration, hematoma, seroma, or late mesh infection (occurs in 1.9-5% of repairs) 3, 4
• Traumatic intra-abdominal injury – Blunt trauma can cause delayed presentation of solid organ injury, bowel injury, or internal bleeding 1
• Incisional complications – Late hematoma or abscess formation at the surgical site 4

Key Clinical Features Supporting Urgent Imaging:

• Left-sided pain distribution suggests pathology beyond the umbilical repair site, raising concern for intra-abdominal process 1
• Trauma history one month ago creates risk for delayed complications including occult bowel injury or evolving hernia incarceration 1
• Umbilical tenderness in a post-repair patient warrants evaluation for recurrence or mesh complication 3, 5

Plan

Immediate Diagnostic Workup

Order CT abdomen and pelvis with IV contrast immediately – This is the gold standard for evaluating post-surgical abdominal pain and can identify hernia recurrence, mesh complications, intra-abdominal collections, and traumatic injuries with high sensitivity 1, 6

Obtain complete blood count and inflammatory markers – Elevated WBC, lactate, CPK, or D-dimer may indicate bowel ischemia, strangulation, or intra-abdominal infection 3

Critical CT Findings to Assess:

• Hernia recurrence or incarceration – Look for bowel loops or omentum protruding through the fascial defect 6
• Mesh position and integrity – Assess for mesh migration (can occur months to years post-repair), mesh folding, or displacement 5
• Bowel complications – Evaluate for bowel wall thickening, lack of contrast enhancement (suggests ischemia), pneumatosis, or free air 1, 6
• Fluid collections – Identify hematomas (38% incidence), seromas (19% incidence), or abscesses (15% wound infection rate) 4
• Signs of strangulation – Absence of bowel wall enhancement, "whirlpool sign," or mesenteric vessel engorgement 3, 6

Risk Stratification Based on Vital Signs

Monitor for early warning signs of serious complications:

• Tachycardia ≥110 bpm is the earliest physiologic sign of intra-abdominal complications and should never be dismissed, even if it's the only abnormal vital 3
• Fever ≥38°C plus tachycardia mandates urgent surgical evaluation for deep infection or abscess 3
• Normal vitals do not exclude significant pathology but lower immediate surgical urgency 3

Management Algorithm Based on CT Results:

If Hernia Recurrence WITHOUT Complications:

• Elective surgical repair with mesh (if not previously used) – Mesh reduces recurrence to 0-4.3% versus 19-54% with suture alone 3, 2
• Refer to general surgery within 1-2 weeks 3

If Incarcerated Hernia:

• Attempt manual reduction ONLY if: onset <24 hours, no signs of strangulation (no fever, minimal pain), and stable vitals 3
• If reduction successful: urgent elective repair within days 3
• If reduction fails or contraindicated: emergency surgical consultation 3

If Strangulated Hernia (any of: SIRS, elevated lactate/CPK/D-dimer, bowel wall non-enhancement on CT):

• Emergency surgery immediately – Delayed treatment >24 hours significantly increases mortality 3
• NPO, IV fluids, broad-spectrum antibiotics, surgical consultation stat 1, 3

If Mesh-Related Complication:

Hematoma (most common at 38%): 4

• Small, stable hematomas: observe with serial exams
• Expanding hematoma causing wound tension: surgical evacuation with mesh inspection 3

Seroma (19% incidence): 4

• <100 mL: observe, avoid repeated aspiration (increases infection risk) 3

• 100 mL or symptomatic: consider drain placement rather than serial aspiration 3

Mesh infection (1.9-5% incidence): 3

• Superficial infection: antibiotics alone (72% success without mesh removal) 3
• Deep infection with systemic signs: 72.7% require complete mesh explantation 3

Mesh migration (rare but serious): 5

• Presents as persistent abdominal pain, bleeding per rectum, or bowel symptoms months to years post-repair 5
• Requires surgical exploration, adhesiolysis, and possible bowel resection 5

If Traumatic Injury Identified:

• Manage per trauma protocols based on specific findings 1
• Surgical consultation for any free fluid, solid organ injury, or bowel injury 1

If CT Negative:

• Consider ultrasound as adjunct if CT equivocal for small fluid collections 1
• Outpatient follow-up in 1 week with repeat exam 3
• Return precautions: increasing pain, inability to reduce any bulge, fever, vomiting, or tachycardia 3

Critical Pitfalls to Avoid:

• Do not dismiss isolated tachycardia – It may be the only early sign of serious complications including mesh infection or bowel ischemia 3
• Do not delay imaging – Post-surgical patients with new abdominal pain and trauma history require cross-sectional imaging to exclude life-threatening complications 1
• Do not attempt manual reduction if >24 hours since symptom onset, signs of strangulation present, or severe pain 3
• Do not routinely remove mesh for superficial infections – 72% respond to antibiotics alone 3
• Consider mesh migration even with late presentation – Can occur months to years after repair and presents with vague symptoms 5

Disposition:

• Admit if: any signs of strangulation, incarcerated hernia that cannot be reduced, tachycardia ≥110 bpm, fever ≥38°C, or CT shows complications requiring intervention 3
• Discharge with close follow-up if: CT negative, vitals normal, pain controlled, and patient reliable for return precautions 3