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.
All Pathways
General SurgeryEmergency
Incarcerated/Strangulated Hernia Management (WSES 2017)
Incarcerated/Strangulated Hernia Management (WSES 2017): Suspected Incarcerated/Strangulated Hernia → Initial Assessment → Signs of Strangulation? → Imm...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action 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.
03Decision 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.
04Action 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.
05Decision 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.
06Action 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.
07Decision 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.
08Action 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.
09Action 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.
10Outcome Hernia Repaired
Defect closed. Bowel preserved or resected. Plan follow-up for mesh complications, recurrence.
11Action 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.
- Path rejoins step 09Shared downstream outcome
12Action 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.
- Path rejoins step 07Shared downstream outcome
13Decision 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).
14Action 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.
15Decision Taxis Successful?
Hernia reduced? Contents returned to abdomen? Patient comfortable? If unsuccessful after 2-3 attempts, proceed to surgery.
16Action 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).
- Path rejoins step 09Shared downstream outcome
17Action Taxis Failed - Proceed to Surgery
Unable to reduce with manual pressure. Proceed to operative repair. May still have viable bowel.
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
18Warning ⚠️ 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.
Guideline Source
WSES 2017 Update Guidelines for Emergency Repair of Complicated Abdominal Wall Hernias
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Mesh choice depends on contamination level and local availability
- Laparoscopic approach requires expertise and stable patient
- Bowel viability assessment is subjective - surgeon judgment critical
- Does not address complex incisional hernias in detail
- Pediatric hernias have different considerations
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
Global: WSES guidelines widely adopted for emergency hernia repair
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Incarcerated/Strangulated Hernia Management (WSES 2017)?
The Incarcerated/Strangulated Hernia Management (WSES 2017) is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES 2017 Update Guidelines for Emergency Repair of Complicated Abdominal Wall Hernias.
What guideline is the Incarcerated/Strangulated Hernia Management (WSES 2017) based on?
This algorithm is based on WSES 2017 Update Guidelines for Emergency Repair of Complicated Abdominal Wall Hernias (DOI: 10.1186/s13017-017-0149-y).
What are the limitations of the Incarcerated/Strangulated Hernia Management (WSES 2017)?
Known limitations include: Mesh choice depends on contamination level and local availability; Laparoscopic approach requires expertise and stable patient; Bowel viability assessment is subjective - surgeon judgment critical; Does not address complex incisional hernias in detail; Pediatric hernias have different considerations. Individual patient factors may require deviation from these recommendations.
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