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.

• Pain

  It is a painful condition requiring emergency surgery. [symptoma.com]

  The pain was very bad; it was worse than the other hernia pain. I'm still home, with pain because he had to open me from the top of my stomach to the beginning of my private part. And he put "staples" in. [wisegeek.com]

  Pain In certain patients, an abdominal hernia can cause sensations of pain within the abdomen as a symptom of this condition. [livestrong.com]

• Inguinal Hernia

  In the left groin there is an inguinal hernia with a fluid filled small bowel loop. There is no significant effect during compression suggesting a nonreducible inguinal hernia. [sonoworld.com]

  K40 Inguinal hernia Includes: bubonocele inguinal hernia: · NOS · direct · double · indirect · oblique scrotal hernia K40.0 Bilateral inguinal hernia, with obstruction, without gangrene K40.1 Bilateral inguinal hernia, with gangrene K40.2 Bilateral inguinal [apps.who.int]

  (A) Incarcerated inguinal hernia; (B) incarcerated umbilical hernia. [ncbi.nlm.nih.gov]

  Keywords Hernia Repair Inguinal Hernia Incisional Hernia Inguinal Hernia Repair Laparoscopic Repair These keywords were added by machine and not by the authors. [link.springer.com]

• Weakness

  Weaknesses can also occur in the abdominal wall later in life, especially after an injury or abdominal surgery. In men, the weak spot usually occurs in the inguinal canal, where the spermatic cord enters the scrotum. [mayoclinic.org]

  Fat or part of the small intestine slides through the weakness into the inguinal canal, causing a hernia. [gi.surgery.ucsf.edu]

  An abdominal wall hernia is an opening or area of weakness in the abdominal wall through which abdominal contents can protrude. An abdominal wall hernia causes a noticeable bulging but little discomfort. [msdmanuals.com]

  In other cases, strains or injuries create a weak spot in the muscle wall, and part of a nearby organ can be pushed into the weak spot so that it bulges and becomes a hernia. [kidshealth.org]

• Swelling

  This may cause pain, nausea, vomiting, and abdominal swelling (distension). The loop of intestine can swell and become tightly trapped (strangulated) in the hernia, which causes the tissue to die (gangrene). [hartfordhealthcare.org]

  Another differential is an acute hydrocele commonly seen in children as a painful scrotal swelling with an acute onset simulating incarcerated hernia. [symptoma.com]

• Gangrene

  } } } } without gangrene K40.4 Unilateral or unspecified inguinal hernia, with gangrene Inguinal hernia NOS with gangrene K40.9 Unilateral or unspecified inguinal hernia, without obstruction or gangrene Inguinal hernia (unilateral) NOS [apps.who.int]

  […] umbilical hernia, without gangrene Irreducible umbilical hernia, without gangrene Strangulated umbilical hernia, without gangrene K42 Includes: paraumbilical hernia Excludes1: omphalocele (Q79.2) Guidelines: Diseases of the digestive system (K00-K95) [aapc.com]

  […] hernia with obstruction, without gangrene K44.1 Diaphragmatic hernia with gangrene K44.9 Diaphragmatic hernia without obstruction or gangrene K45 Other abdominal hernia K45.0 Other specified abdominal hernia with obstruction, without gangrene K45.1 Other [icd10data.com]

  The loop of intestine can swell and become tightly trapped (strangulated) in the hernia, which causes the tissue to die (gangrene). If the intestine becomes strangulated, immediate surgery is needed. [hartfordhealthcare.org]

• Cough

  Certain activities, such as coughing or sitting or standing for prolonged periods of time, may exacerbate painful abdominal hernia symptoms in some patients. [livestrong.com]

  In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period. [mayoclinic.org]

  […] or sneezing The factors that increase your risk of developing a hernia include: a personal or family history of hernias being overweight or obese a chronic cough chronic constipation smoking, which can trigger a chronic cough Conditions such as cystic [healthline.com]

  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. [symptoma.com]

  Smoking can cause coughing, which can put pressure on your abdomen and lead to an inguinal hernia, or worsen symptoms in one that you already have. (2) See a doctor when you have a persistent cough. [everydayhealth.com]

• Aspiration

  Clinical examination found circulatory instability, a peritoneal abdomen and increased leucocyte count and C-reactive protein on laboratory reports, with several litres of fluid aspirated after insertion of a nasogastric tube. [academic.oup.com]

  A hydrocele from fluid accumulation in the distal sac usually resolves spontaneously but sometimes requires aspiration. Prognosis This is generally very good, depending on comorbidity. [patient.info]

  This usually resolves spontaneously but sometimes must be aspirated. A femoral hernia as a sequela of inguinal hernia repair may have been overlooked initially. [emedicine.medscape.com]

• Vomiting

  Nausea or Vomiting If a piece of the intestine becomes trapped within the abdominal wall due to an abdominal hernia, blood flow to the intestine may be cut off, explains the Merck Manual. [livestrong.com]

  There is a sudden increase in the size of the hernia with severe pain and symptoms of bowel obstruction (vomiting and abdominal distension). [books.mcai.org.uk]

  A patient suffering Richter hernia may present with vomiting, but the bowel may not be obstructed though it may be incarcerated or strangulated. [symptoma.com]

  This may cause pain, nausea, vomiting, and abdominal swelling (distension). The loop of intestine can swell and become tightly trapped (strangulated) in the hernia, which causes the tissue to die (gangrene). [hartfordhealthcare.org]

• Nausea

  This may cause pain, nausea, vomiting, and abdominal swelling (distension). The loop of intestine can swell and become tightly trapped (strangulated) in the hernia, which causes the tissue to die (gangrene). [hartfordhealthcare.org]

  Symptoms of a strangulated hernia are as follows: Extreme tenderness and redness in the area of the bulge Sudden pain that worsens in a short period of time Fever Rapid heart rate Left untreated, nausea, vomiting, and severe infection can occur. [sharecare.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]

• Abdominal Pain

  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]

  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]

  CASE REPORT A 72-year-old woman was admitted to the emergency department complaining of diffuse abdominal pain that she had had for two days. Over that period, she had developed a lower left quadrant abdominal mass. [scielo.br]

• Acute Abdomen

  Available from: http://emedicine.medscape.com/article/189563-overview [Accessed 08 March 2011] Merck Manuals: Professional Edition, Gastrointestinal Disorders, Acute Abdomen and Surgical Gastroenterology, Hernias of the Abdominal wall. [fastbleep.com]

  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]

  Acute abdomen. Intestinal obstruction. Tomography. Surgery. RESUMO CONTEXTO: A hérnia de Spiegel é uma rara hérnia da parede abdominal com uma taxa de encarceramento de cerca de 20%. [scielo.br]

  PubMed Google Scholar Boele Van Hensbroek P, Wind J, Dijkgraaf MG,et al: Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. [wjes.biomedcentral.com]

• Severe Abdominal Pain

  Presentation 85 year old female patient with severe abdominal pain. [sonoworld.com]

  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]

  Symptoms range from mild abdominal discomfort, distension, nausea, constipation to severe abdominal pain, fever and an irreducible hernia [ 3 ]. [academic.oup.com]

  Identification of the presence of incarceration: incarcerated hernia is associated with poor prognosis, and it should be thus suspected with any of the following clinical manifestations: (I) severe abdominal pain, with persistent pain during the interim [ncbi.nlm.nih.gov]

• Ulcer

  （＝decubitus ulcer） defect１．欠損、２．欠陥 deformity 変形 degenerative spondylolisthesis変性脊椎すべり症 dermatome１．皮膚知覚帯、２．ダーマトーム、採皮刀（器） device装置、器具 disability能力低下〈リハ〉、能力障害〈リハ〉 disarticulation関節離断［術］ disc１．円板、２．関節円板、３．椎間板 discharge１．放電、発射、２．分泌［物］、排出［物］、３．退院 discitis椎間板炎 [tokyo-med.ac.jp]

  In the most serious situations, the stomach may develop ulcers, bleeding or twisting that could result in decreased blood flow and perforation of the stomach. [fcbsurgicalspecialists.com]

• Suggestibility

  There is no significant effect during compression suggesting a nonreducible inguinal hernia. The first image shows a dilatated bowel loop proximal to where the loop enters the inguinal hernia. [sonoworld.com]

  In this case there is apparent inflammation in the herniated fat strongly suggesting that strangulation is present. [radiopaedia.org]

  […] of the gallbladder.1 Epigastric distress coming on shortly after meals, pain in the right hypochondrium with scapular radiation, eructation and even jaundice have been described either with or without organic changes in the biliary tract.2 Orndoff3 suggested [jamanetwork.com]

  I suggest you have it examined by your doctor. The fact that you have been symptomatic for your hernia and it seemed to have an episode of being incarcerated for a week will make me suggest that surgical correction should be considered. [pinoyexchange.com]

• Hunger

  It started as a mild pain such as a hunger pang. 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]

• Tingling

  Sometimes people experience sharp, tingling pain in a specific area near the incision after it has healed. The pain usually resolves with time. Medicine may be injected in the area if the pain continues. Injury to internal organs. [gi.surgery.ucsf.edu]

  The focus of examination should include inner thigh pain and history of inability to straighten the thigh, as well as the unique Howship-Romberg (HR) syndrome of obturator hernia: tingling pain of the inner thigh (symptoms caused by compression of the [ncbi.nlm.nih.gov]

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.

• Staphylococcus Aureus

  In aseptic hernia repair, Staphylococcus aureus from the exogenous environment or the patient’s skin flora is typically the source of infection. [wjes.biomedcentral.com]

• Polyps

  Sinkaset saw colon polyps patients in 2014–2019, but we couldn’t determine whether he was a top doctor for the condition nationwide. Learn more. [amino.com]

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.

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%.

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].

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.

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:

• Smoking
• Chronic cough
• Sudden weight gain
• Chronic constipation
• Heavy weight lifting

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

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.

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]:

• Easily reducible hernia
• Incarcerated hernia
• Strangulated hernia

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].

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.

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