Colon and Small Bowel—Incarcerated Hernia
Concept
Multiple etiologies, but always remember the most com- mon: hernias and adhesions. Don’t forget the possibility of a malignancy, like an obstructing proximal colon cancer and an incompetent ileocecal valve. Important to decide in your own mind how long you will manage a small bowel obstruction non-operatively and what you will do intra-op with any compromised or nonviable small bowel.
Way Question May be Asked?
“63 y/o female evaluated in the ED for vomiting and abdominal distension. AXR reveal multiple air/fluid levels.
What do you want to do?” Could be asked with a more subtle picture of SBO, or may jump right into a discussion of management decisions. Don’t spend too much time on H+P if your examiner clearly doesn’t want you to.
How to Answer?
History
Pain Distension
Previous abdominal surgery Nausea/vomiting
Physical Exam
Vital signs (dehydration, fever)
Full exam especially checking for hernias Hyperactive bowel sounds
Peritoneal signs
Diagnostic Tests
Full labs (elevated WBC of peritonitis)
Abdominal x-rays (3 views, look at gas pattern)
CT scan (IV/PO contrast)
+/− SBFT in cases of PSBO that persist over 48 h
Surgical Treatment
(1) NGT/NPO/IVF (always!) (2) Serial labs/examinations
(3) Volume resuscitation (remember significant third space losses into GI tract!)
(4) Peritoneal signs or suggestion of hernia strangulation→ OR
(a) If OR for incarcerated hernia, can do through preperitoneal or traditional inguinal approach (b) If can’t reduce incarcerated femoral hernia,
divide inguinal ligament (if strangulated, con- trol strangulated contents and make lower mid- line incision)
(c) Make sure to control sac and open under direct vision
(d) If contents of hernia drop into abdominal cavity, explore either through preperitoneal incision by opening peritoneum, or using laparoscope (e) Don’t use mesh in situations where possible
ischemia (contamination) (f) If hernia contents ischemic, try:
warm packs over area and come back after her- nia repaired
if still ischemic, resect with primary anastomosis
Common Curveballs
Hernia will be incarcerated/strangulated
Strangulated hernia will reduce with induction general anesthesia
Will need to divide inguinal ligament to free femoral hernia
Will need to perform bowel resection PSBO will fail non-operative management Asked to describe inguinal anatomy
21 Part 1.qxd 10/19/05 2:51 AM Page 21
Won’t be able to use mesh (know at least one non-mesh repair)
Pt will have sliding hernia
SBFT/CT scan won’t identify point of obstruction Pt will have malignancy
Might need to open sac/incision ring to reduce hernia
Clean Kills
Trying to perform laparoscopically (only if you have fellowship training in TAPPs and even then, this is a risky answer!)
Not placing NGT or volume resuscitating pt
Not dividing inguinal ligament to free incarcerated femoral hernia
Not performing bowel resection for obviously ischemic bowel
Not knowing how to describe any non-mesh hernia repairs
Getting into discussion of using absorbable mesh (Surgissis or Alloderm) in contaminated field with necrotic bowel
Not inspecting bowel that was incarcerated
Performing bowel resection through inguinal incision (some surgeons have successfully done this but not a safe board answer)
22 Colon and Small Bowel—Incarcerated Hernia
Part 1.qxd 10/19/05 2:51 AM Page 22
