| Definition | Irreducible/ incarcerated hernia: a hernia that cannot be manually reduced back into the abdomen. Local signs include firmness, tenderness and erythema. The irreducible organ may be compromised i.e. Bowel = obstruction causing reduced feeding, passage of stools and flatus, vomiting, bilious vomiting. Ovary/testis/omentum= ischaemia causing tenderness and erythema. Strangulated hernia : An irreducible/ incarcerated hernia progresses to strangulation as vascular compromise becomes established. Local signs include pain and tenderness out or proportion, spreading cellulitis. Systemic signs include pyrexia, tachycardia, hypotension. In infants and neonates, this can mimic the appearance of sepsis. If in doubt, assume strangulation and treat with concommitant speed. |
| Typical presentation | A firm, tender, irreducible lump in the groin. |
| Age | Tufts series: 85% of incarceration when age <1 year |
| Incidence | Tufts series: Retrospective review of consecutive herniorrhaphy, 85/908 incarcerated. Within the incarcerated subgroup (n=85): -35% with known hernia present with incarceration. – 65% had a first presentation with incarceration -85% of incarceration when age <1 year |
| Sex | |
| Aetiology/ natural history | Tufts series: Retrospective review of consecutive herniorrhaphy, 85/908 incarcerated. Within the incarcerated subgroup (n=85): – 84% had successful manual reduction -16% had unsuccessful manual reduction, associated with a increased average length of stay (4 days) -31% significant complications ( infarction of the testis or ovary, bowel obstruction, intestinal necrosis, wound infection, and recurrent hernia) |
| Differentials | Encysted hydroecoele |
| Examination | Give analgesia A firm, tender, irreducible lump in the groin. Hernia vs hydrocoele |
| Investigations | |
| Bedside | Vital signs |
| Blds | Hb check for neonates. XMatch anticipating need for laparotomy. |
| Imaging | XRay : air in the groin , signs of bowel obstuction USS: useful when diagnosis is in doubt, but should not delay exploraton |
| Special tests | Nuclear: |
| Treatment | |
| Goals/ Principles | 1. Reduction: Reduce hernia to prevent further ischaemia to bowel or testis/ ovary 2. Hernia repair: Allow oedema at the deep ring to reduce before attempting herniorrhapy |
| Conservative | None. |
| Medical | Analgesia, analgesia, analgesia Good analgesia is essential to improve the chance of successful manual reduction. |
| Surgical | Indications |
| 1. Reduction: Manual reduction of incarcerated inguinal hernia 2. Hernia repair options after successful manual reduction If the patient is haemodynamically stable with no evidence of bowel ischaemia/ necrosis, expectant hernia repair can be done. Admit the patient and observe closely. Once groin oedema is reduced (typically 24-48 hours), proceed with hernia repair . A. Groin exploration and open herniotomy B. Laparoscopy and herniorrhaphy Options for failed manual reduction: Proceed immediately with 1. Laparoscopic reduction and hernia repair 2. Groin exploration and reduction and hernia repair 3. Laparotomy, reduction and hernia repair | |
| Op note | |
| Complications / Consent | REPERFUSION INJURY Failed reduction / reduction en mass Bowel obstruction Bowel necrosis Laparotomy Infarction of the testis/ ovary, bowel obstruction Wound infection Recurrent hernia |
| Outcome measures | Rate of manual reduction Bowel resection |
| Follow-up | Indicated, surveillance for hernia recurrence and testis atrophy. Circa 6m. |
| Key evidence | 1. Stylianos et al (Tufts, Boston) retrospective series of 908 consecutive herniorrhaphy. |
Tag: laparoscopic
Considerations when counselling parent:
- Age+ metachronous hernia risk : Chances of a metachronous hernia reduce with increasing age
- Age + recurrence risk : laparoscopic recurrence rate may be higher in older patients
- Sex of patient: consider laparoscopic for bilateral inguinal hernia in female patient
- Cost : Open surgery is more cost effective
- Surgeon learning curve
Laparoscopic inguinal hernia
Benefits of laparoscopic approach:
1. Detection of metachronous hernia
2. Reduced pain
3. Better cosmesis
Limitations
1. Longer operative time
2. Greater Cost
Complication data available from some large series:
Large series data available from Oyetunji lab, Children’s Mercy Kansas. https://pubmed.ncbi.nlm.nih.gov/33741178/
- 791 patients
- Age: median age at operation =1.9 years (IQR 0.37, 5.82).
- Time: median operative time= unilateral 21 min (IQR 16, 28), bilateral 30.5 min (IQR 23, 41).
- Complications
- Intra-op:
- Conversion to open = 3/ 791 (0.4%)
- Post-op:
- Bleeding: 4/791 (0.6%)
- Wound infection : 9/791 (1.2%) developed a wound infection
- Recurrence: 20/791 (2.5%)
- Iatrogenic ascent of testis = 10 (1.3%)
- Intra-op:
