General Surgery · Year 3 · from General Surgery
Case 1: Incarcerated Inguinal Hernia
Patient Demographics
- Age: 67 years
- Sex: Male
- Occupation: Retired truck driver
Chief Complaint
"I have a painful bulge in my groin that won't go back in."
History of Present Illness
The patient presents to the emergency department with an 8-hour history of a painful right groin mass. He reports having a reducible right inguinal hernia for approximately 5 years that he has been able to push back in when it protrudes. Earlier today while lifting boxes in his garage, he felt the hernia come out and has been unable to reduce it since. The bulge has become increasingly painful and tender. He reports nausea with one episode of vomiting but no abdominal distension. He has passed flatus earlier today but has not had a bowel movement.
Past Medical History
- Right inguinal hernia (diagnosed 5 years ago, declined surgery)
- COPD
- Benign prostatic hyperplasia
- Obesity (BMI 32)
Medications
- Albuterol inhaler as needed
- Tamsulosin 0.4 mg daily
Social History
- Former smoker (quit 3 years ago, 40 pack-year history)
- No alcohol use
Physical Examination
- Vitals: BP 156/94 mmHg, HR 96 bpm, RR 18/min, Temp 37.6°C, SpO2 95% on room air
- General: Overweight male in moderate distress
- Abdomen: Soft, mildly distended, mild diffuse tenderness, no peritoneal signs
- Groin examination:
- Right: 6 cm firm, tender mass in the right inguinal region extending into the scrotum
- Mass does not transilluminate
- Overlying skin erythematous
- Unable to reduce with gentle pressure
- No cough impulse palpable
- Left: No hernia palpable
Laboratory Results
- WBC: 13,400/μL
- Hemoglobin: 14.8 g/dL
- Lactate: 1.8 mmol/L
- Creatinine: 1.1 mg/dL
- Urinalysis: Normal
Imaging
CT Abdomen/Pelvis:
- Right inguinoscrotal hernia containing loops of small bowel
- Bowel wall thickening noted
- No evidence of bowel obstruction proximally
- Small amount of fluid within the hernia sac
- No free air
Clinical Assessment
Incarcerated right indirect inguinal hernia with concerning features for early strangulation (tenderness, erythema, elevated WBC).
Management Decision
Given inability to reduce the hernia, duration >6 hours, and concerning clinical features, emergent surgical exploration is indicated.
Attempted Reduction
After IV sedation and Trendelenburg positioning, a gentle attempt at manual reduction was made in the ED without success. Decision made to proceed to OR.
Operative Course
- Open right inguinal exploration via inguinal incision
- Large indirect inguinal hernia sac identified containing two loops of small bowel
- Hernia sac opened; small bowel appeared dusky but viable
- After release of constricting ring and warm saline application, bowel color improved with peristalsis
- Bowel returned to abdominal cavity
- High ligation of hernia sac performed
- Lichtenstein tension-free mesh repair
Postoperative Course
- Monitored closely for 24 hours for signs of bowel ischemia
- No fever, abdominal pain resolved
- Bowel function returned POD 1
- Discharged POD 2 with activity restrictions
- Follow-up in 2 weeks
Teaching Points
- Incarcerated hernias that cannot be reduced require urgent surgical exploration
- Time is critical - longer duration increases risk of strangulation
- Signs of strangulation: fever, leukocytosis, erythema, severe tenderness
- Bowel viability must be assessed intraoperatively
- Mesh repair can be safely performed in clean-contaminated cases if bowel is viable
Clinical Image
Image Description: Anatomical illustration demonstrating the relationship of direct and indirect inguinal hernias to the inferior epigastric vessels and the structures of the inguinal canal. Indirect hernias pass through the deep inguinal ring lateral to the vessels, while direct hernias protrude through Hesselbach's triangle medially.
Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Inguinal_hernia