Overview
Definition:
Acute complicated hernia with strangulation refers to a condition where a loop of bowel or other intra-abdominal contents becomes incarcerated within a hernial sac, leading to impaired blood supply (ischemia) and potential necrosis and perforation
This is a surgical emergency requiring prompt intervention.
Epidemiology:
Inguinal hernias are the most common type to strangulate, followed by femoral, umbilical, and incisional hernias
Incidence varies based on hernia type and patient demographics
Elderly patients and those with comorbidities are at higher risk
Approximately 1-3% of all hernias will eventually strangulate.
Clinical Significance:
Strangulation leads to rapid deterioration of the patient due to bowel ischemia, infarction, perforation, peritonitis, sepsis, and potential multi-organ failure
Delayed diagnosis and management significantly increase morbidity and mortality rates
Understanding its management is crucial for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of severe, persistent abdominal pain, often localized to the hernia site
Nausea and vomiting, which may become feculent with complete bowel obstruction
Inability to reduce the hernia, which is usually tender and irreducible
Signs of systemic toxicity including fever, tachycardia, and hypotension may develop.
Signs:
A tense, tender, irreducible mass at the hernia orifice
Skin over the hernia may be erythematous and tense
Signs of bowel obstruction: distension, absent bowel sounds (late), and tympanicity
In advanced cases, signs of peritonitis such as rigidity, rebound tenderness, and guarding may be present.
Diagnostic Criteria:
No specific diagnostic criteria exist beyond clinical suspicion confirmed by imaging and intraoperative findings
Key indicators include a history of hernia, sudden onset of severe localized pain, an irreducible tender hernia mass, and signs of bowel obstruction or systemic toxicity.
Diagnostic Approach
History Taking:
Detailed history of the hernia: duration, previous episodes of incarceration or reducibility, absence of bowel movements or flatus
Assess for symptoms of bowel obstruction (nausea, vomiting, abdominal pain, distension) and systemic signs of sepsis
Assess for comorbidities and medications.
Physical Examination:
Careful inspection and palpation of all hernial orifices (inguinal, femoral, umbilical, incisional)
Assess the size, tenderness, and reducibility of the hernia
Perform a thorough abdominal examination to rule out generalized peritonitis
Check vital signs for signs of shock or sepsis.
Investigations:
Plain abdominal X-rays (supine and erect) may show dilated loops of bowel and air-fluid levels, suggestive of obstruction
CT scan of the abdomen and pelvis with intravenous contrast is the investigation of choice
it can confirm the diagnosis, identify incarcerated bowel, assess for ischemia or perforation, and reveal the contents of the hernia sac
Laboratory investigations include complete blood count (leukocytosis), electrolytes, renal function tests, and arterial blood gases if sepsis or shock is suspected.
Differential Diagnosis:
Other causes of acute abdominal pain and mass: incarcerated undescended testis, lymphadenopathy, abscess, torsion of an ovary or testis, epididymitis, strangulated lipoma or cyst, incarcerated omentum, strangulated undescended appendix
Differentiating from simple hernia recurrence or lipoma is crucial.
Management
Initial Management:
Immediate resuscitation with intravenous fluids (e.g., Ringer's lactate or normal saline) to correct dehydration and electrolyte imbalances
Nasogastric tube insertion for decompression if bowel obstruction is present
Analgesia for pain control
Broad-spectrum intravenous antibiotics should be initiated empirically, especially if peritonitis or sepsis is suspected (e.g., piperacillin-tazobactam or a combination of cephalosporin and metronidazole).
Medical Management:
Primarily supportive care aimed at stabilization
This includes fluid resuscitation, electrolyte correction, and antibiotics
Sedation may be required for patient comfort and to reduce intra-abdominal pressure
Attempts at non-operative reduction (e.g., Trendelenburg position, ice packs) are generally discouraged in cases of definite strangulation due to the risk of precipitating bowel perforation or embolization of thrombi.
Surgical Management:
Urgent surgical exploration (hernia repair) is indicated for all cases of strangulated hernia
The approach can be open or laparoscopic, depending on the surgeon's preference and expertise, and the patient's condition
The goals are to relieve the obstruction, assess the viability of the incarcerated bowel, resect compromised bowel if necessary, and repair the hernia
If bowel resection is required, the continuity of the bowel is restored by anastomosis
The hernia defect is then repaired, often using prosthetic mesh if the bowel is viable and there is no gross contamination, or by primary repair if contamination is significant.
Supportive Care:
Continuous monitoring of vital signs, urine output, and fluid balance
Regular assessment of abdominal distension, bowel sounds, and pain
Nutritional support may be required, starting with parenteral nutrition if a significant bowel resection has been performed, transitioning to enteral feeds as tolerated postoperatively
Close monitoring for signs of anastomotic leak or wound infection.
Complications
Early Complications:
Bowel perforation, peritonitis, sepsis, septicaemia, wound infection, anastomotic leak (if bowel resection performed), ileus, deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction, stroke, acute kidney injury.
Late Complications:
Recurrence of hernia, chronic pain, adhesion formation leading to bowel obstruction, incisional hernia, seroma, mesh infection (if mesh used).
Prevention Strategies:
Timely repair of all symptomatic hernias, even if not currently incarcerated, to prevent future strangulation
Patient education on recognizing symptoms of incarceration and seeking prompt medical attention
Maintaining adequate nutritional status and avoiding straining activities postoperatively can aid healing.
Prognosis
Factors Affecting Prognosis:
The most significant factor is the duration of ischemia and the extent of bowel necrosis
Delay in diagnosis and surgical intervention, presence of perforation, sepsis, and comorbidities significantly worsen the prognosis
Age and overall patient health also play a role.
Outcomes:
With prompt surgical intervention and no bowel resection, outcomes are generally excellent with low morbidity
If bowel resection is required, morbidity and mortality rates increase significantly
Mortality rates can be as high as 10-20% or more in cases with delayed treatment and peritonitis.
Follow Up:
Close follow-up is essential to monitor for signs of infection, wound healing, bowel function recovery, and potential recurrence
Patients who have undergone bowel resection require vigilant monitoring for anastomotic complications
Regular clinical review and physical examination of the hernia repair site are recommended.
Key Points
Exam Focus:
Strangulated hernia is a surgical emergency
Always suspect strangulation in a tender, irreducible hernia with acute abdominal pain
CT scan is vital for assessing bowel viability
Resuscitation, antibiotics, and urgent surgery are paramount
Assess bowel viability intraoperatively
resect non-viable bowel and perform anastomosis if necessary.
Clinical Pearls:
Never attempt prolonged or forceful manual reduction of a suspected strangulated hernia
Always perform a thorough physical examination of all hernia orifices
Broad-spectrum antibiotics are crucial, especially with signs of peritonitis
Consider laparoscopic approach in stable patients for less invasive surgery and quicker recovery, but open approach is often preferred in unstable or severely contaminated cases.
Common Mistakes:
Delaying surgery due to an assumption of simple incarceration
Inadequate resuscitation and antibiotic coverage
Incomplete assessment of bowel viability leading to missed resection
Not considering strangulation in elderly patients with vague abdominal symptoms and a reducible hernia
Inappropriate use of prosthetic mesh in grossly contaminated fields.