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Obstructed inguinal hernia — Clinical Guidelines

Overview

Obstructed inguinal hernia occurs when the hernial sac becomes tightly constricted, leading to bowel obstruction and potential complications such as incarceration and strangulation. Prompt diagnosis and management are crucial to prevent bowel ischemia and necrosis 2 5.

Diagnosis

Clinical presentation includes severe pain, swelling, and inability to reduce the hernia manually 2.

Imaging studies (CT, ultrasound) may be necessary to assess bowel viability and extent of obstruction 25.

Preoperative risk stratification for bowel resection is essential 2.

Management

First-line Treatment: Emergency surgical intervention is often required for incarcerated hernias to relieve obstruction and prevent complications 2 5.

Surgical Techniques: Open repair with mesh placement (e.g., Trans Rectus Sheath Extra-Peritoneal Procedure - TREPP) under local anesthesia with sedation can be feasible and effective 3 11.

Anesthesia Approaches: Local anesthesia with monitored anesthesia care sedation is suitable for complex, comorbid patients 1.

Pain Management: Pre-emptive use of N-acetylcysteine may reduce postoperative pain 6.

Sedation Agents: Dexmedetomidine shows promise as a safer sedation option compared to propofol in infants 9 12 16.

Postoperative Care: Attention to postoperative nausea and vomiting (PONV) management, especially in outpatient settings 13.

Special Populations

Pediatrics: Caudal anesthesia with sedation is beneficial for high-risk neonates undergoing hernia repair 18 20.

Infants: Dexmedetomidine sedation combined with local anesthesia can minimize cardiorespiratory risks 9.

Elderly and Comorbid Patients: Local anesthesia with monitored anesthesia care sedation supports safer surgical outcomes 1.

Key Recommendations

Emergency Surgical Intervention: Immediate surgical repair is recommended for incarcerated inguinal hernias to prevent bowel ischemia 2 (Evidence: Strong).

Use of Local Anesthesia with Sedation: Local anesthesia with monitored anesthesia care sedation is appropriate for complex patients undergoing inguinal hernia repair 1 (Evidence: Moderate).

Consider Dexmedetomidine for Sedation in Infants: Dexmedetomidine provides safer sedation compared to propofol in infants undergoing hernia repair 9 12 16 (Evidence: Moderate).

Preoperative Risk Assessment: Evaluate preoperative risk factors to guide management and potential need for bowel resection 2 (Evidence: Moderate).

Postoperative PONV Prophylaxis: Implement strategies to manage postoperative nausea and vomiting, particularly in outpatient settings 13 (Evidence: Weak).

References

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Algorithm for management of an incarcerated inguinal hernia in the emergency settings with manual reduction. Taxis, the technique and its safety. Hernia : the journal of hernias and abdominal wall surgery 2021. link 6 Mulkens CE, Staatsen M, van Genugten L, Snoeker BAM, Vissers KCP, Bruhn J et al.. Postoperative pain reduction by pre-emptive N-acetylcysteine: an exploratory randomized controlled clinical trial. Regional anesthesia and pain medicine 2021. link 7 Karavokyros IG, Kirkilessis GI, Schizas D, Chelidonis G, Pikoulis E, Griniatsos J. Emergency inguinal hernioplasties in a tertiary public Hospital in Athens Greece, during the economic crisis. BMC surgery 2019. link 8 Liu J, Zhai Z, Chen J. The Use of Prosthetic Mesh in the Emergency Management of Acute Incarcerated Inguinal Hernias. Surgical innovation 2019. link 9 Bong CL, Tan J, Lim S, Low Y, Sim SW, Rajadurai VS et al.. Randomised controlled trial of dexmedetomidine sedation vs general anaesthesia for inguinal hernia surgery on perioperative outcomes in infants. British journal of anaesthesia 2019. link 10 de Souza PMF, Ferreira LC, Marinari LFS, Brandão JCM, Carneiro PS, Garcia DPC et al.. Pain during and after-hernioplasty in raquidian or locorregional anesthesia by locking peripheral nerves. Hernia : the journal of hernias and abdominal wall surgery 2019. link 11 Tanaka R, DeAsis F, Vigneswaran Y, Linn J, Carbray J, Denham W et al.. Video review program enhances resident training in laparoscopic inguinal hernia: a randomized blinded controlled trial. Surgical endoscopy 2018. link 12 Mishina T, Aiba T, Hiramatsu K, Shibata Y, Yoshihara M, Aoba T et al.. Comparison between dexmedetomidine and midazolam as a sedation agent with local anesthesia in inguinal hernia repair: randomized controlled trial. 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Surgical endoscopy 2010. link 24 Taheri R, Shayeghi S, Razavi SS, Sadeghi A, Ghabili K, Ghojazadeh M et al.. Efficacy of bupivacaine-neostigmine and bupivacaine-tramadol in caudal block in pediatric inguinal herniorrhaphy. Paediatric anaesthesia 2010. link 25 Storm DW, Drinis S. Radiographic diagnosis of a large inguinal hernia involving the urinary bladder and causing obstructive renal failure. Urology 2008. link 26 Al-Ansari K, Sulowski C, Ratnapalan S. Analgesia and sedation practices for incarcerated inguinal hernias in children. Clinical pediatrics 2008. link 27 Holzheimer RG, Gresser U. Inguinal hernia vs. arthritis of the hip in sporting adolescents--case report and review of the literature. European journal of medical research 2007. link 28 Olsha O, Feldman A, Odenheimer DB, Frankel D. Local anesthesia for inguinal hernia repair in adolescents. Hernia : the journal of hernias and abdominal wall surgery 2007. link 29 Puri V, Felix E, Fitzgibbons RJ. Laparoscopic vs conventional tension free inguinal herniorrhaphy: 2005 society of American Gastrointestinal Endoscopic Surgeons (SAGES) annual meeting debate. Surgical endoscopy 2006. link 30 Ouellette LR, Dexter WW. Inguinal hernias: value of preparticipation examination, activity restriction decisions, and timing of surgery. Current sports medicine reports 2006. link 31 Goldman RD, Balasubramanian S, Wales P, Mace SE. Pediatric surgeons and pediatric emergency physicians' attitudes towards analgesia and sedation for incarcerated inguinal hernia reduction. The journal of pain 2005. link 32 Steele P, Annear P, Grove JR. Surgery for posterior inguinal wall deficiency in athletes. Journal of science and medicine in sport 2004. link80257-3) 33 Porrero JL, Hidalgo M, Sanjuanbenito A, Sanchez-Cabezudo C. The Shouldice herniorrhaphy in the treatment of inguinal hernias: a prospective study on 775 patients. 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Aspects of hernia surgery in Wales. Annals of the Royal College of Surgeons of England 1995. link 40 Varshney S, Burke D, Johnson CD. Two-layer repair of the transversalis fascia is sufficient for inguinal hernia repair. Annals of the Royal College of Surgeons of England 1995. link 41 Rudkin GE, Maddern GJ. Peri-operative outcome for day-case laparoscopic and open inguinal hernia repair. Anaesthesia 1995. link 42 Adler MW. Changes in local clinical practice following an experiment in medical care: evaluation of evaluation. Journal of epidemiology and community health 1978. link 43 Abramson JH, Gofin J, Hopp C, Makler A, Epstein LM. The epidemiology of inguinal hernia. A survey in western Jerusalem. Journal of epidemiology and community health 1978. link 44 Adler MW, Waller JJ, Creese A, Thorne SC. Randomised controlled trial of early discharge for inguinal hernia and varicose veins. Journal of epidemiology and community health 1978. link 45 Adler ME. 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Obstructed inguinal hernia