Incarcerated/Strangulated Hernia Management (WSES 2017)

Algorithm Steps

1. ▶

   Start

   Suspected Incarcerated/Strangulated Hernia

   Irreducible hernia with: pain at hernia site, obstructive symptoms (vomiting, distension, obstipation), overlying skin changes, systemic toxicity. Common sites: inguinal, femoral, umbilical, incisional.

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      Action

      Initial Assessment

      1) History: Duration of incarceration, prior reducibility, obstructive symptoms. 2) Exam: Tender, tense hernia; overlying erythema; peritonitis; bowel sounds. 3) Labs: WBC, lactate, BMP. 4) Imaging: CT if diagnosis uncertain - shows transition point, hernia contents, signs of ischemia.

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         Decision

         Signs of Strangulation?

         Strangulation = compromised blood supply. Signs: Constant severe pain (not colicky), overlying skin erythema/discoloration, systemic toxicity (fever, tachycardia, elevated lactate), peritonitis. SIRS + elevated CPK/D-dimer suggest bowel ischemia.

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            Action

            Immediate Emergency Surgery

            Strangulation suspected = NO attempt at reduction (may reduce dead bowel into abdomen). Proceed directly to OR. Resuscitate en route. Broad-spectrum antibiotics.

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               Decision

               Surgical Approach Selection

               Consider: Patient stability, type of hernia, surgeon expertise, contamination level. Open approach often preferred in emergency due to need for bowel assessment.

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                  Action

                  Open Surgical Repair

                  1) Incision over hernia. 2) Identify and protect sac contents. 3) Open sac, assess bowel viability. 4) Reduce viable bowel or resect necrotic segment. 5) Repair defect. 6) Mesh placement if not grossly contaminated.

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                     Decision

                     Bowel Viability Assessment

                     Check: Color (pink vs dusky/black), peristalsis, mesenteric bleeding, arterial pulsations. If questionable: Warm saline packs for 10-15 min, fluorescein injection, or second-look laparotomy in 24-48h.

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                        Action

                        Bowel Viable - Reduce & Repair

                        Return bowel to abdomen. Repair hernia defect. Mesh use: Synthetic mesh acceptable if no gross contamination. Biologic mesh or primary suture repair if contaminated field.

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                           Action

                           Postoperative Care

                           Antibiotics: Continue if contamination or bowel resection. Nutrition: Early feeding if no resection. Wound care: Higher infection risk in emergency repair. Monitor for complications: Seroma, hematoma, recurrence, mesh infection.

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                              Outcome

                              Hernia Repaired

                              Defect closed. Bowel preserved or resected. Plan follow-up for mesh complications, recurrence.

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                        Action

                        Bowel Necrotic - Resect

                        Resect nonviable segment. Primary anastomosis vs ostomy based on: Patient stability, degree of contamination, nutritional status. Hernia repair: Primary suture or biologic mesh in contaminated field. Avoid synthetic mesh if peritonitis/gross contamination.

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                  Action

                  Laparoscopic Repair

                  Consider if: Stable patient, experienced surgeon, no obvious strangulation. Advantages: Better visualization, reduced wound complications. TAPP or TEP approach. Assess bowel laparoscopically, may convert if resection needed.

         2. ◆

            Decision

            Candidate for Manual Reduction (Taxis)?

            May attempt Taxis if: <6-12 hours incarceration, no signs of strangulation, no skin changes, patient hemodynamically stable, experienced clinician. Contraindicated if: Signs of strangulation, long duration, femoral hernia (higher strangulation risk).

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               Action

               Perform Taxis (Manual Reduction)

               1) Analgesia/sedation (morphine + midazolam or ketamine). 2) Trendelenburg position for inguinal. 3) Gentle sustained pressure on hernia neck while guiding contents back. 4) Apply ice pack. 5) If successful: Observe 4-6h, plan semi-elective repair within days to weeks.

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                  Decision

                  Taxis Successful?

                  Hernia reduced? Contents returned to abdomen? Patient comfortable? If unsuccessful after 2-3 attempts, proceed to surgery.

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                     Action

                     Observation Post-Reduction

                     Monitor for 4-6 hours: Watch for signs of reduced-but-necrotic bowel (pain, peritonitis, tachycardia). Diet as tolerated. Plan elective repair within 1-2 weeks (high recurrence risk).

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                     Action

                     Taxis Failed - Proceed to Surgery

                     Unable to reduce with manual pressure. Proceed to operative repair. May still have viable bowel.

            2. ⚠

               Warning

               ⚠️ Femoral Hernia Warning

               Femoral hernias have highest strangulation rate (40-50%). Taxis generally NOT recommended for femoral hernias. Proceed directly to surgery. Small neck = rapid strangulation.