Paul N. Rogers
“You can judge the worth of a surgeon by the way he does a hernia.”
(Thomas Fairbank, 1876–1961)
Acute Groin Hernia
In the Western World many more hernias are now repaired electively than was formerly the case. In spite of this, surgeons are frequently confronted by acute groin hernias and it is important to know how to deal with them.
A word about terminology: groin hernias,inguinal or femoral,may be describ- ed as reducible,irreducible,incarcerated,strangulated,obstructed.This terminology can be confusing and the words, which have come to mean different things to dif- ferent people, are much less important than the concepts that underlie the recogni- tion and management of acute hernia problems.The important concept to be grasped is that any hernia that becomes painful, inflamed, tender and is not readily reducible should be regarded as a surgical emergency.
Presentation
Patients may present acutely in one of two ways:
Symptoms and signs related directly to the hernia itself
Abdominal symptoms and signs, which at first may not seem to be related to a hernia
The first mode of presentation usually means pain and tenderness in the irreducible and tense hernia. A hernia, which was reducible, may suddenly become irreducible. The problem is obvious as shown in > Fig. 22.1.
The second mode of presentation will be much more insidious.Beware the vomiting old lady!Treated at home for several days by the primary care physician as a case of gastro-enteritis she eventually comes under the care of the surgeons due to intractable emesis. By this stage she is dehydrated and in need of much resuscita- tion. It is surprisingly easy in these circumstances to miss the small femoral hernia barely palpable in the groin, trapping just enough small bowel as is required to
achieve obstruction. No abdominal symptoms or signs are present and the plain abdominal radiographs are non-diagnostic. None of these difficulties saves you from the embarrassment of the following morning’s round when the hernia is dis- covered.
Hernias are still one of the commonest causes of small bowel obstruction
(> Chap. 21). A careful search must be made for them in all cases of actual or
suspected intestinal obstruction. This may mean meticulous, prolonged and dis- agreeable palpation of groins which have not seen the light of day,let alone soap and water, for a long time. In most cases, however, the diagnosis is obvious with a clas- sical bowel obstruction and a hernia stuck in the scrotum.
Beware the Richter’s hernia – typical of femoral hernias, where only a portion of the circumference of the bowel is strangulated.Because the intestinal lumen is not completely blocked, presentation is delayed and non-specific.
Preparation
Surgery for acute groin hernia problems should be carried out without undue delay, but these patients must not be rushed to surgery without careful assessment and preparation (> Chap. 6). As we suggested earlier, some patients may be in need of quite a bit of resuscitation on admission to hospital.
Fig. 22.1. “This must be strangulated, eh?”
Analgesia is an important part of the management of these patients. Opiate analgesia and bed rest with the foot of the bed slightly elevated may successfully manage a painful obstructed hernia of short duration. Gentle attempts at reduction of such a hernia are justified once the analgesics have taken effect. A successful reduction of the hernia means that emergency surgery at unsociable hours may be traded for a semi-elective procedure on the next available routine list – a benefit for both patient and surgeon. Note that manual reduction of the incarcerated hernia should be attempted only in the absence of signs of intestinal strangulation; it should be gently performed,to avoid “reduction en masse”– when the herniated bowel with the constricting ring are reduced together,with persisting symptoms of strangulation.
The Operation Inguinal Hernia
An inguinal incision is a satisfactory approach. Even if a bowel resection is re- quired it is possible to deliver sufficient length of intestine through the inguinal canal to carry this out.
The main difference in dissection in an emergency hernia operation compared to an elective procedure is the moment at which the hernial sac is opened. In the emergency situation the hernia will often reduce spontaneously as soon as the con- stricting ring is divided.The site of constriction may be the superficial inguinal ring, in which case the hernia reduces when external oblique is opened. It is recommen- ded, therefore, that the sac be opened and the contents grasped for later inspection before the constricting tissues are released. If the hernia reduces before the sac contents are inspected it is important that they are subsequently identified and retrieved so that a loop of non-viable gut is not inadvertently left in the abdomen.
Retrieval of reduced sac contents can be an awkward business via the internal ring and occasionally a formal laparotomy may be required to inspect matters properly.
It is for these reasons that great care should be taken to secure the sac contents for inspection as soon as possible during the procedure.
If the hernial sac contains omentum only, then any tissue which is necrotic or of doubtful viability should be excised, ensuring meticulous hemostasis in the process. If, on the other hand, bowel is involved, then any areas of questionable viability should be wrapped in a warm moist gauze pack and left for a few minutes to recover. Irretrievably ischemic gut should be resected. If there is a small patch of necrosis that does not involve the whole circumference of the bowel then this can sometimes be dealt with by invagination rather than by resorting to resection.In this situation the injured bowel wall is invaginated by a seromuscular suture,taking bites on the viable bowel on either side of the defective area of gut.
Occasionally, particularly if a bowel resection has been necessary, edema of the herniated gut makes its replacement in the abdomen difficult. Maneuvers such as putting the patient into a marked Trendelenburg position and gently compres- sing the eviscerated gut, covered by a large moist gauze swab, will almost invariably allow the bowel to be replaced in the abdomen.It is possible to minimize the chances of this difficulty arising if care is taken during any bowel resection not to have any more gut outside the abdomen than is absolutely necessary.Very rarely the hernia- ted viscera won’t return to the abdomen without pulling on it from within; in such instances La Rocque’s maneuver may be useful: extend the skin incision up and laterally; then extend the split of the external oblique aponeurosis and follow this with a muscle splitting incision of internal oblique and transverse muscles above the internal ring. Though this incision you enter the peritoneal cavity and reduce the hernial content simply by pulling on it from within.
The question of the type of hernia repair to be employed is a matter for the individual surgeon, with one proviso. In these days of tension-free hernia repair, it seems imprudent to place large amounts of mesh in the groin if necrotic gut has had to be resected. In this situation some other type of repair seems advisable to obviate the misery of infected mesh.
Femoral Hernia
You can approach the acute femoral hernia from below the inguinal canal, from above, or through it.
With the low approach, you place the incision below the inguinal ligament, directly over the bulge.You find the hernial sac and open it, making sure to grasp its contents for proper inspection.Strangulated omentum may be excised,viable bowel is reduced back into the peritoneal cavity through the femoral ring. When the ring is tight, and usually it is, you can stretch it with your small finger, inserted medially to the femoral vein. You can resect non-viable small bowel through this approach and even anastomose its ends, but pushing the sutured or stapled anastomosis back into the abdomen is like trying to squeeze a tomato into a cocktail glass. Therefore, when bowel has to be resected, it is advisable to do it through a small right lower quadrant muscle splitting laparotomy (as for appendectomy).
Some authorities favor an approach via the inguinal canal but we can see little merit in this approach, which must disrupt the anatomy of the canal and presum- ably risk subsequent inguinal hernias.
Yet another approach is McEvedy’s. This involves an approach to the extra- peritoneal space along the lateral border of the lower part of rectus abdominis. The skin incision may be vertical,in line with the border of rectus,or oblique/horizontal.
A vertical skin incision has the merit of allowing extension to a point below the
inguinal ligament and this may be helpful in reducing stubborn hernias, allowing traction from above and compression from below. Once the space behind the rectus muscle has been accessed the hernia can usually be freed from behind the inguinal ligament.The peritoneum can be opened as widely as necessary to permit inspection of the contents of the hernial sac and to carry out intestinal resection if necessary.
All above approaches are reasonable provided the contents of the hernial sac are examined and dealt with appropriately. As with inguinal hernias the implanta- tion of large amounts of mesh should be avoided in patients who have contamina- tion of the operative field with intestinal contents. With this caveat the choice of repair is not different from what you would do in the elective situation.
Incisional Hernias
Incisional hernias are common but most are asymptomatic except for the unsightly bulge and discomfort they sometimes produce.It is the small incisional hernias with the tight neck, which become acutely symptomatic – incarcerating omentum or intestine.
The presentation is well known to you: an old “silent” hernia or abdominal scar, which has now become painful. When bowel has been incarcerated there may be associated symptoms of small bowel obstruction (> Chap. 21). The hernia itself is tense, tender and non-reducible. It is important to distinguish between intestinal obstruction caused by the incisional hernia or simply associated with it. The latter situation, which is not uncommon, implies that the patient suffers SBO due to adhesions for example, and the obstructed and distended loops of bowel invade the long-standing incisional hernia. On examination, the bowel-filled tender hernia may mimic incarceration.It is for this reason that the contents of any hernia asso- ciated with obstruction must be examined carefully at operation to ensure that the hernia truly is the cause of the obstruction.(This applies to all kinds of hernias.
We recall a case of obstruction that was addressed by reducing and repairing a tense femoral hernia, only for the obturator hernia, which was the true cause of the obstruction, to be discovered at laparotomy many days later when the patient failed to recover from the first operation.)
Any “acute” incisional hernia is a surgical emergency.This is also true with other types of abdominal wall hernias, such as paraumbilical or epigastric ones.
(It should be noted that epigastric hernias rarely, if ever, cause trouble. They only contain extraperitoneal fat from the falciform ligament,and for this reason need not be repaired routinely in the absence of symptoms.) At operation the hernial sac has to be entered to evaluate the incarcerated contents that are to be reduced or resected depending on the findings. The surgical findings should explain the clinical pre-
sentation.For example,if you do not find strangulated omentum or bowel in the sac, you have to retrieve the whole length of the intestine in search for distal SBO. If you find pus within the sac you have to look for the source. We have seen patients operated upon for a “strangulated incisional hernia” when the underlying diagno- sis was perforated appendicitis.
After the contents of the hernia have been dealt with identify the fascial margins of the defect. Use your conventional “best” repair but do not forget that placing a mesh in a contaminated field is potentially problematic. Bear in mind also that leaving non-absorbable mesh in contact with the gut leads to difficulties and disasters later. In a critically ill patient, when the repair is deemed complex or is judged to significantly increase the intra-abdominal pressure – we would simply close the skin – leaving the patient with a large incisional hernia.Remember – patients do not die from the hernia but from its intestinal complications or a closure that is too tight(> Chaps. 36 and 38).
“Always explore in cases of persistent vomiting if a lump, however small, is found occupying one of the abdominal rings and its nature is uncertain.”(Augustus Charles Bernays, 1854–1907)
