What is Strangulated Hernia?
Hernias are unusual bulges or openings in the abdominal wall’s protective layer. These anomalies can occur anywhere there is a weak spot within the protective layer of the abdomen. Hernias are typically found in the belly button area (umbilical) and the groin (inguinal, femoral).
Hernias are categorized into two types: reducible and incarcerated. A hernia is considered reducible if the contents inside the hernia can be moved back into the abdomen. However, if these contents cannot be moved back, the hernia is deemed incarcerated.
Strangulated hernia is a more serious condition where the contents inside the hernia do not get enough blood supply due to a blockage, which often happens when there is a small opening in the muscles with a large amount of contents within the hernia.
Hernias can also develop within the abdomen, which may occur due to twisting of the mesentery (a fold of the abdominal membrane) or from an obstruction such as adhesions (bands of scar-like tissue). These internal hernias can lead to a condition called strangulated bowel, which is a serious situation that needs immediate surgical intervention.
What Causes Strangulated Hernia?
Hernias occur due to various reasons. They can either be due to natural conditions present at birth or can develop from weakening of the stomach wall due to a wound or injury. Common types of hernias including belly button (umbilical) and groin (inguinal) hernias can exist right from birth and can grow bigger over time. Hernias can also form from a weakness in the stomach wall caused by previous surgeries, a condition known as “incisional hernias”. This can occur at any spot where an incision was made, including sites of keyhole surgery (laparoscopic surgery).
Some health conditions can increase the risk of developing hernias. For example, people who have disorders related to tissues like Marfan syndrome or Ehlers-Danlos syndrome, which weaken the strength of tissues, are at a higher risk of getting hernias. Conditions that increase pressure in the stomach region, including pregnancy, constipation, chronic obstructive pulmonary disease (COPD or lung disease), or long-term coughing can also lead to the formation of hernias.
Whether people who often do heavy lifting are at a higher risk of developing hernias is a topic of debate and needs more research.
Risk Factors and Frequency for Strangulated Hernia
Hernias are a common health problem, with around 5% of people expected to develop an abdominal wall hernia during their lifetime. Different types of hernias are more prevalent in different genders and locations; for example, men are about seven times more likely to have inguinal hernias, which are also the most common type of groin hernia for both men and women. Women, on the other hand, are more likely to develop femoral and umbilical hernias.
Additionally, groin and femoral hernias occur more frequently on the right side, likely because of certain biological processes. Age and ongoing strain on the abdominal wall can also increase the likelihood of developing hernias. There is a 1%-3% estimated risk over a person’s lifetime of a hernia becoming trapped (incarcerated) or losing its blood supply (strangulated). It’s also important to know that femoral hernias can become incarcerated around 30% of the time, thus immediate surgical repair is recommended once it’s discovered.
Signs and Symptoms of Strangulated Hernia
Hernias can develop due to a history of trauma, heavy lifting, or a persisting bulge. Patients usually notice a protruding lump and experience pain, especially when lifting or straining. In severe cases, when the trapped part of the bowel starts to lose its blood supply (strangulation), symptoms like nausea, vomiting, and constipation may occur. If the blood supply to the bowel is cut off entirely (ischemia), patients can have intense pain and may even start showing signs of severe infection (sepsis) such as low blood pressure and a fast heart rate.
Before touching the abdominal wall, it’s crucial to visually examine the area overlying the hernia. The presence of red or dusky skin might indicate a strangulated hernia, a surgical emergency. If any changes in skin are noticed, an immediate surgical consultation should be sought without attempting to reduce the hernia. A key aspect of hernia evaluation includes asking the patient to increase abdominal pressure, also known as the Valsalva maneuver.
The patient should be examined in both sitting and standing positions. During abdominal pressure increase, a bulge or weakening of the abdominal muscles suggests the presence of a hernia. In males, a technique is used to check for inguinal hernias while standing. This involves holding the scrotum and placing a finger within the external inguinal ring to feel for a bulge, which should press against the finger during the Valsalva maneuver. Large hernias in the groin area may present as a mass near the vessels of the thigh or as a scrotal mass.
Recently trapped hernias may look red, hard, swollen, and are painful to touch. If the trapped bowel is within the hernia defect, fluid movement within the hernia sac may be felt. If the bowel is strangulated, the patient may show signs of localized or generalized inflammation of the abdomen on examination.
Testing for Strangulated Hernia
Hernias are usually identified by a physical check-up. If your doctor is concerned that the hernia might be strangulated, which means that the blood flow to the gut is cut off, they might need to rule out a condition called bowel ischemia, where part of your gut isn’t getting enough blood.
To check for these, your doctor might order for a full blood count and a basic metabolic panel. These tests look for high white blood cell count (known as leukocytosis) and other abnormalities that indicate strains to your body’s functions. Sometimes, a lactate test might be used, as it helps to identify if there is damage to your body’s tissues. However, this test might show normal results in the earliest stages of a strangulated small bowel, as it can take up to 8 hours for the lack of blood supply to affect the results.
An ultrasound test is usually the first step when trying to identify a hernia, especially if the pain seems to be associated with the testicles. A CT scan, which is a special kind of X-ray, of your abdomen and pelvis can help to show up the exact location of the hernia and whether the gut has been strangulated. MRI scans, which use strong magnetic fields to create pictures of your body’s internal structures, are more detailed than CT scans and are particularly good at showing up hernias that aren’t obvious (occult hernias). They can also show up other injuries to the muscles and skeleton. However, they aren’t usually the first choice in an emergency situation.
Diagnostic laparoscopy, a procedure where the doctor uses a special instrument to view the inside of the abdomen and pelvis, can also be used to identify occult hernias, but this isn’t generally needed.
Treatment Options for Strangulated Hernia
Patients with hernias that aren’t trapped (non-incarcerated hernias) might be given the option of an elective surgical repair depending on their symptoms. If patients have moderate to severe symptoms and are in good health, surgery could be a suitable solution. On the other hand, older patients with several other health conditions that have a largely symptom-free hernia may best be served by monitoring the situation closely (watchful waiting), as the risk of the hernia trapping tissue (strangulation) is low.
For a hernia that has become suddenly trapped but doesn’t contain any bowel, manual reduction, or pushing the hernia back into place, can be tried. This might require sedation if it’s too painful for the patient. The patient should lie flat on their back, and lifting the patient’s legs and lower body may help reduce hernias in the groin (Trendelenburg position). Applying gentle pressure evenly to the hernia can help move it back into the abdomen. Applying ice can help reduce any inflammation of the hernia sack. If the patient has a hernia that is suddenly trapped and may contain trapped tissue (strangulation), immediate surgery is needed.
Femoral hernias, or hernias in the groin, have a higher risk of becoming trapped and should be repaired soon after discovery to prevent future complications. If a hernia is suspected to be strangulated, an immediate surgical consultation should be sought. In the presence of a bowel obstruction, a tube might be placed in the nose and guided to the stomach (nasogastric tube) in order to relieve pressure, and it must be ensured that the patient is properly hydrated. If there is a possibility that the bowel is dying (necrosis) or has busted (perforation), the patient should be given a wide range of antibiotics.
For a strangulated hernia, the surgical repair method will depend on the surgeon’s skills and experience. Both laparoscopic (via small incisions) or robotic techniques have been used successfully for examining trapped tissue (strangulated bowel). Surgeons who are adept at these techniques may also perform bowel resection, the removal of a part of the bowel. If a surgeon doesn’t have much experience with these techniques, open surgeries can work just as well. Before closing the hernia, it is important to check that the bowel is healthy. While studies have shown that synthetic mesh can be safely placed during the acute phase of hernia repair, many surgeons tend to avoid it to minimize the risk of infection, especially during a bowel resection.
For hernias that have become trapped but are not strangulated, placing a synthetic mesh has been proven safe and is the best way to prevent the hernia from reoccurring. When closing the hernia, an option is to use a technique that uses the patient’s own tissues or a non-synthetic option like a biologic acellular dermal matrix. Both are well-recognized options for immediate treatment.
What else can Strangulated Hernia be?
Here’s how you might be experiencing discomfort in your groin:
For groin masses, possible causes could be:
- Lymph node swelling (lymphadenopathy)
- A pocket of pus (abscess)
- A testicle that hasn’t moved into the sac (undescended testicle)
- A bulge in a blood vessel (vascular aneurysm)
- A fatty lump under the skin (lipoma)
For scrotal masses, the causes may include:
- Fluid-filled sac around a testicle (hydrocele)
- A growth in the testicle (testicular tumor)
- An enlargement of the veins within the loose bag of skin that holds the testicles (varicocele)
- Twisting of the testicle (testicular torsion)
For groin pain, possible reasons may be:
- Injury to the muscles or skeleton (musculoskeletal injury)
- A common type of sports injury (athletic pubalgia, also known as sports hernia)
- Inflammation of the tube at the back of the testicle (epididymitis)
Here’s a respond to your query about some medical terms:
- Abscess: a pocket of pus
- Athletic pubalgia: a common type of sports injury
- Epididymitis: inflammation of the tube at the back of the testicle
- Hydrocele: a fluid-filled sac around a testicle
- Lipoma: a fatty lump under the skin
- Lymphadenopathy: lymph node swelling
- Musculoskeletal injury: injury to the muscles or skeleton
- Testicular torsion: twisting of the testicle
- Testicular tumor: a growth in the testicle
- Varicocele: an enlargement of the veins within the loose bag of skin that holds the testicles
- Vascular aneurysm: a bulge in a blood vessel
- Undescended testicle: a testicle that hasn’t moved into the sac
What to expect with Strangulated Hernia
How well a patient recovers and their risk of death after groin hernia surgery can depend on whether the surgery was planned or done as an emergency. Planned, or ‘elective’, groin hernia surgeries have a very low risk of mortality, at just 0.1%.
However, the risk of mortality increases to as high as 3% when the surgery is done as an emergency to treat a “strangulated bowel”, which is when part of the intestine gets caught in the hernia and its blood supply gets cut off. This risk is particularly high when a part of the bowel needs to be removed.
Possible Complications When Diagnosed with Strangulated Hernia
Emergencies and past abdominal surgeries or hernia repairs often lead to higher rates of complications. Larger hernias can change the normal arrangement of the body and increase the risk of damaging internal body parts during surgery. People who are undergoing emergency surgery and have other existing health conditions or are older typically experience more complications related to hernia surgery.
Common complications:
- Infection at the site of surgery
- Large bruises forming at the site of surgery
- Wound splitting open after surgery
- Long-term pain
- Leakage from the site where the bowel was sewn back together (if the bowel was removed as part of the surgery)
- Death of bowel tissue
- Death of testicular tissue
- Damage to nerves
- Damage to blood vessels
Recovery from Strangulated Hernia
For patients with bowel obstructions, continuous support and treatment is essential. A nasogastric tube, inserted through the nose to help drain the stomach, should be left in until the bowel starts to work normally again, or the amount of drained material has substantially reduced. Once the bowel starts to work properly, the patient can go home. Patients should refrain from heavy lifting for about 6 to 8 weeks to allow for complete recovery.
Preventing Strangulated Hernia
The most frequent reason for a blockage in the small intestine is a trapped hernia. Whenever a patient experiences a bowel blockage, it’s important to check for any hernias. Any noticeable changes on the skin accompanied by a hernia could indicate a severely trapped hernia. In such a case, it’s crucial to promptly get a surgeon’s advice before trying to treat the severely trapped hernia on your own.
