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Incarcerated Hernia

A hernia is defined as a protrusion of any tissue through a defect in the wall that encloses it. An incarcerated hernia is a form of hernia that cannot be reduced when pushed back through the weakened wall.


Presentation

The most common presentation of hernia is a swelling or bugle at an unusual area in the body. Depending on the type of hernia, it can either be reducible in nature or irreducible. No attempt should be made by the patients to manually reduce the hernia. Peritoneal symptoms and occlusion in the intestine may indicate a femoral hernia incarceration. A hernia protruding from midabdominal region that is located centrally is called an umbilical hernia, which if associated with altered sensorium and obesity pose high risk of incarceration. 

An incarcerated hernia may cause the following signs and symptoms:

  • Painful swelling or bulge or enlargement of a previous hernia or defect.
  • Cannot be reduced.
  • If accompanied with nausea, vomiting, it points to possible signs of bowel obstruction.
  • Peritoneal signs and intestinal obstruction are suggestive of incarcerated femoral hernia.

A strangulated hernia presents as follows:

  • All the symptoms of incarcerated hernia along with a toxic appearance of the patient.
  • If severe ischemia occurs, it may present as an overall systemic toxicity proving fatal.
  • If a patient still complains of significant amount of pain after ruling incarceration and strangulation, differential diagnosis must be looked into.

In female infants who may present with an incarcerated hernia is actually a solid mass in the labia majora, which is the ovary and not the intestine. This solid mass has an “almond-like” feeling to it and is the most common incarcerated intraabdominal organ in female children.

Another differential is an acute hydrocele commonly seen in children as a painful scrotal swelling with an acute onset simulating incarcerated hernia. To differentiate incarcerated hernia and hydrocele, palpation of cord structures at internal ring is carried out. If it is mobile, non tender, rubbery in consistency with defined margins, it is considered to be a hydrocele.

Most hydroceles are seen in scrotal region, but another variant is the abdominoscrotal hydrocele which extends from the abdominal cavity through the inguinal canal into the scrotum. In infants, digital rectal examination along with inspection of the internal ring helps differentiate incarcerated hernia from hydrocele. Furthermore, these children would require surgery, especially if intraabdominal structures cause obstruction or mass effect on other organs.

Inguinal Mass
  • We conclude that although very rare, dermoid cyst of the spermatic cord should be considered as a part of the differential diagnosis in patients presenting with an irreducible inguinal mass of a long course.[ncbi.nlm.nih.gov]
  • He came to the Emergency Department due to abdominal pain associated with a painful left inguinal mass, but he was not able to specify when the symptoms had appeared.[elsevier.es]
  • Differential Diagnosis: Not all inguinal masses are hernias.[fastbleep.com]
  • Inguinal masses that resemble hernias may be the result of adenopathy (infectious or malignant), an ectopic testis, or lipoma. These masses are solid and are not reducible. A scrotal mass may be a varicocele, hydrocele, or testicular tumor.[merckmanuals.com]
Collapse
  • Within 45 minutes, I was an the verge of collapsing into unconsciousness. ginsberg05 Post 2 While many people are born with abdominal hernias, some may experience them later in life.[wisegeek.com]
Abdominal Pain
  • A strangulated ventral hernia causes severe abdominal pain, fever, rapid heart rate and abdominal tenderness. Vomiting often occurs because the strangulated area blocks passage of digested material.[livestrong.com]
  • Report of Case A 68-year-old white man, awoke at 6 am on Dec 16, 1965, with severe crampy lower abdominal pain, nausea and vomiting. Associated with this was the sudden enlargement of a preexisting right groin hernia. There had been[jamanetwork.com]
  • Presentation 85 year old female patient with severe abdominal pain.[sonoworld.com]
  • If symptoms of abdominal pain become progressively worse, contact a doctor immediately as such sensations can indicate a hernia-related complication called strangulation.[livestrong.com]
  • Symptoms range from mild abdominal discomfort, distension, nausea, constipation to severe abdominal pain, fever and an irreducible hernia [ 3 ].[academic.oup.com]
Severe Abdominal Pain
  • Presentation 85 year old female patient with severe abdominal pain.[sonoworld.com]
  • A strangulated ventral hernia causes severe abdominal pain, fever, rapid heart rate and abdominal tenderness. Vomiting often occurs because the strangulated area blocks passage of digested material.[livestrong.com]
  • Symptoms range from mild abdominal discomfort, distension, nausea, constipation to severe abdominal pain, fever and an irreducible hernia [ 3 ].[academic.oup.com]
Acute Abdomen
  • The PSH presented with acute abdomen requiring explorative laparatomy and debridement. Large hernias may over time predispose to stretching of ligaments and mobilization of otherwise immobile structures with damage to these structures.[academic.oup.com]
  • Available from: [Accessed 08 March 2011] Merck Manuals: Professional Edition, Gastrointestinal Disorders, Acute Abdomen and Surgical Gastroenterology, Hernias of the Abdominal wall. Available from: [Accessed 08 March 2011][fastbleep.com]
Muscle Rigidity
  • Peritonitis, infection of the lining that covers the abdominal wall and the abdominal organs, causes severe, continually worsening abdominal pain with muscle rigidity and tightness along with fever, vomiting and fast pulse.[livestrong.com]
Encephalopathy
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Case 3-2019: A 70-Year-Old Woman with Fever, Headache, and Progressive Encephalopathy Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura Randomized[nejm.org]

Workup

Physical examination is a must before proceeding ahead with other investigations. During this examination, the surgeon evaluates whether the protrusion is reducible or not. Sometimes they reduce as soon as the patient lies down during the physical examination and when they don’t, even after manipulation, they are considered as irreducible hernia. After physical examination, ultrasound is the next best step for it.

When a physician suspects incarcerated hernia or strangulated hernia the following investigations are advised:

  • Chest X-ray to exclude free air (rare)
  • Abdominal X-rays help in diagnosing any obstruction and identifing where and which part of bowel is affected.
  • Lastly, a Color Doppler ultrasonography can be done to differentiate between strangulation and incarceration.
Pneumoperitoneum
  • The requirement of general anesthesia and the need to generate a pneumoperitoneum may be limiting factors in patient selection.[ncbi.nlm.nih.gov]
  • Plain film abdominal x-ray showed not only a large part of the small intestine, but also the stomach located in the PSH with signs of pneumoperitoneum (Fig. 1 ).[academic.oup.com]

Treatment

Manual reduction is indicated in the presence of non-strangulated hernia [10]. According to a prospective study that was carried out, surgeons were always correct about when to reduce an incarcerated hernia and when not to but strangulation can still be missed [11] [2].

A patient presenting with hernia would undergo reduction depending on the type and severity of the hernia (incarceration or strangulation). Though reduction can be done in an emergency department as well, a surgeon must always be consulted for following reasons [12] [13] [14]:

  • Inability to reduce the hernia
  • Patient looking toxic arising suspicion for strangulated bowel requiring immediate admission and evaluation
  • Comorbid risks for sedation, individuals with risk factors should have a surgeon present for the initial reduction attempt

Treatment course depends on the type and site of hernia. Umbilical hernias are rare in the pediatric age group and therefore reduce risk of incarceration. John Hopkins Hospital has reported that only 7 cases of incarcerated pediatric umbilical hernia were seen over 15 years as opposed to 101 cases in adults during the same time period with omentum being the most common incarcerated organ being involved.

Elective outpatient repair is advised in cases of paraumbilical hernia which proceed to incarceration since these defects do not close spontaneously and lead to painful strangulation. Preperitoneal fat in an epiplocele may also be incarcerated causing immense pain.

Other hernias like spigelian hernia, interparietal, supravesical, lumbar, obturator, sciatic, and perineal hernias should also be repaired as they hold high chances of incarceration. Richter hernias are known to get strangulated without any presenting symptoms of classical incarceration or obstruction.

Irreducible hernias develop when an organ is trapped outside the natural anatomical space and gets swollen. Surgery is the main stay for irreducible hernias. During this surgery the intestine or the protruding organ is pushed back through the weakened defect to prevent future hernia. The procedure is called herniorrhaphy or laparoscopy. Irreducible hernia should be treated to prevent immediate complications like gangrene and necrosis.

Surgery has been the gold standard for treatment of hernia and no conservative method is approved till date. Irreducible hernia is a serious condition and life threatening if left untreated and hence has to be done immediately.

Prognosis

Early detection of a hernia is important to avoid incarceration and strangulation. When the bowel is obstructed, blood supply can be compromised, which if overlooked could cause bowel perforation and peritonitis. If the trapped bowel decreases in size it causes continuous ischemia and necrosis with poor prognosis mandating surgery to prevent further complication like sepsis and perforation.

Hernias tend to recur 5 years post surgery. Children younger than 1 year and the elderly show high chances of recurrence. Patients who have an increased intraabdominal pressure are at high risk. Other factors like growth failure and malnutrition, prematurity, seizure disorder, or chronic respiratory problems also account for recurrences.

Though elective herniorrhaphy in kids have showed good results with low rate of morbidity; incarceration is still a concern. After reviewing 908 consecutive cases of children awaiting elective surgery for an inguinal hernia for their incidence and consequences; 85 presented with incarcerated hernia. Out of these 85 patients, 30 were known cases of inguinal hernia that lead to later forming incarceration and out of these 30 patients, 25 patients are awaiting elective hernia repair. The time taken from an outpatient visit for development of incarceration was just 8 days, while time taken from development of hernia and first outpatient visit to surgery was 22 days. About 85% of children that suffered with incarceration were mostly infants under 1 year. Manual reduction proved successful in 71% of these 85 patients. Patients that were admitted had a mean hospital stay of 2.5 days, but increased to 4 days in 14 children who underwent emergency surgery after unsuccessful attempts at reducing the hernia.

Some of the complication such as infarction of testis or ovary, obstruction to bowel, intestinal necrosis, wound infection and recurrent hernia were seen in 26 patients out of the 85 patients.

Incarceration can be prevented and the risk for emergency surgeries reduced. Patients that are scheduled for hernia repair surgeries may not initially present with incarceration but are still at high risk and must be operated as soon as a diagnosis of incarceration is made. Maximum number of such cases were seen in infants (less than 12 months) comprising of about 35%.

Etiology

Incarcerated hernia occurs when abdominal contents protrude through a defect and aren't reducible manually or spontaneously. One form of hernia that is at high risk of incarceration is a femoral hernia. They originate below the inguinal ligament and travel through the transversalis fascia and femoral canal [6].

Epidemiology

Femoral hernia is a common form of irreducible hernia. Most of the cases of incarcerated hernia occur in pediatric patients. 50% are seen in infants less than 6 months while 10-20% is seen in overall pediatric age group [7]. As per a survey conducted over 110 children aged below 4 years who suffered from inguinal hernia, 61 of them suffered from incarcerated hernia at some point of time in their lives, with the highest incidence in youngest infants. The bowel wasn’t trapped in any of these cases. These children received short-term conservative care without adverse reactions.

Sex distribution
Age distribution

Pathophysiology

The femoral hernia occurs below the inguinal ligament in the femoral canal. Medial to the femoral canal is the femoral vein and lateral to it the lacunar ligament or Gimbernat ligament. Since the canal is a narrow space, femoral hernias tend to get strangulated and incarcerated [8].

Another hernia where only the antimesenteric border of the bowel protrudes is called Richter hernia. It can be seen in association with other abdominal hernias. A patient suffering Richter hernia may present with vomiting, but the bowel may not be obstructed though it may be incarcerated or strangulated. Richter hernia pose a great threat as the trapped bowel may get reduced in the abdominal cavity which could lead to peritonitis and perforation [9].

Some of the factors and risks for irreducible hernia are listed as follows:

All these factors cause strain on abdominal muscles which increase the abdomen-related hernias. 

Prevention

All hernias can be prevented except congenital hernias. The best way to prevent hernia is to never let it happen in the first place. Therefore it is important to make the best lifestyle choices by avoiding strenuous exercise such as lifting heavy objects because it leads to an increase in pressure on the abdominal muscles leading to development of hernia.

Smoking habits are another important cause and hence quitting should be considered. Patients suffering from chronic cough and sneezing should treat it right away as this adds to formation of hernia. Being obese is another important factor that leads to hernia and hence weight loss should be taken into consideration.

Summary

A hernia occurs when there is a weak portion in the existing wall of the body through which an organ bulges out. They frequently develop in the groin area and the intestine is the most common organ that bulges out. When the hernia cannot be manipulated through the defect it is called an incarcerated or irreducible hernia, which may be significantly painful. It is an emergency situation requiring immediate and prompt referral to a surgeon. Not all irreducible hernias cause significant pain, but once swelling or inflammation set in, it poses risk to cut the blood supply to the hernia.

Hernia is classified as follows depending on the reduction [1]:

Incarcerated hernia

This form of hernia that cannot be reduced when pushed back through the weakened wall. The incarcerated hernia could either contain bowel, omentum or any other abdominal content. The skin over the hernia can appear normal and bowel sounds can be heard in case of intestinal involvement. If the opening through which the hernia occurs is small or has adhesions, then it can lead to incarceration. Though these hernias aren't reducible manually and an attempt can cause immense pain, they can be reduced under anesthesia [2] [3].

Signs and symptoms of incarcerated hernias include:

  • Enlargement of an existing hernia which doesn’t reduce either spontaneously or manually through the defect.
  • Nausea, vomiting and symptoms of bowel obstruction are seen sometimes.
  • Pain my occur.

When hernia cannot be reduced manually even after proper anesthesia, surgical reduction becomes necessary to prevent strangulation [4] [5].

Patient Information

Hernia is defined as protrusion or bulging of an organ through a defect in the walls of the body that encloses it. The most common type of hernia is seen in the groin where the intestine is the protruding organ. Hernias are either reducible or irreducible. When the hernia cannot be pushed back and gets trapped, it is called as incarcerated hernia. It is a painful condition requiring emergency surgery. The best way to prevent hernia is by avoiding strenuous exercise and situations involving continuous coughing for longer period of times or sneezing since they add to increased abdominal pressure forcing the contents to come out of their natural area. Avoiding an irreducible hernia can save from a lot of complications and its necessary to diagnose it in time.

References

Article

  1. Perrott CA. Inguinal hernias: room for a better understanding. Am J Emerg Med. 2004 Jan. 22(1):48-50.
  2. Kauffman HM Jr, O'Brien DP. Selective reduction of incarcerated inguinal hernia. Am J Surg. 1970 Jun. 119(6):660-73.
  3. Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg. 1993 Apr. 28(4):582-3.
  4. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991 Oct. 78(10):1171-3.
  5. Hair A, Paterson C, Wright D, Baxter JN, O'Dwyer PJ. What effect does the duration of an inguinal hernia have on patient symptoms? J Am Coll Surg. 2001 Aug. 193(2):125-9.
  6. Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg. 1998 Sep. 68(9):650-4.
  7. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. 1993 Jun. 73(3):413-26.
  8. Bobrow RS. The hernia. J Am Board Fam Pract. 1999 Jan-Feb. 12(1):95-6.
  9. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia--a condition seldom thought of and hence seldom sought. Int J Colorectal Dis. 2012 Feb. 27(2):133-41
  10. Smith G, Wright JE. Reduction of gangrenous small bowel by taxis on an inguinal hernia. Pediatric Surgery International. 2004/01. 11:582-583.
  11. Askew G, Williams GT, Brown SC. Delay in presentation and misdiagnosis of strangulated hernia: prospective study. J R Coll Surg Edinb. 1992 Feb. 37(1):37-8.
  12. Eubanks S. Hernias. Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. .
  13. Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med. 2006 Feb. 30(2):155-7.
  14. Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med. 1999 May-Jun. 17(3):515-6.

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Last updated: 2018-06-22 04:40