A patient presents with pain in his ventral hernia. You wonder whether it could be strangulated. Does the bedside examination help? Sure. Check for tenderness, localized peritoneal signs, assess appetite, ability to eat and drink, bowel habits. Does this answer the question as to whether there is strangulation? Probably not.
There is no question that strangulated hernias need immediate surgery. And there is no question that reducible hernias, if there is no concern for infarction, do not need admission to the hospital. But it seems that there is some debate over incarcerated hernias. Many surgeons, at least in southern California, want to send patients with “incarcerated but non-strangulated hernias” home. They will tell the emergency physician over the phone that there is no strangulation.
The problem is that there is no way to reliably identify this category of patient. The gold standard for diagnosis of strangulation is the surgeon’s eye and hands on the bowel. This means looking at the bowel for color, signs of venous congestion, and peristalsis. Some choose to do this laparoscopically through the hernia site (Ferzli Surg Endosc 2004). A study of 147 patients with incarcerated hernia found at operation that 61 were strangulated and 85 were merely incarcerated (Alvarez Hernia 2004). 41% of these patients experienced complications after surgery. There are no studies I found that say physical diagnosis can reliably discriminate strangulation from mere incarceration.
Incarceration and acute pain suggests venous obstruction. Even if one could be assured there is no strangulation, untreated venous congestion disrupts the health of the bowel and puts the patient at risk for local adhesions (Kingsnorth A Fundamentals of Surgical Practice 2011). Surgeons, before telling emergency physicians to send patients home with incarcerated hernias, need to cite evidence for why this is safe. A search today on pubmed for “outpatient incarcerated hernia” reveals that outpatient management of incarcerated hernias never been studied.
If you are the emergency physician what can you do? Reduce the reducible hernias. Give good analgesia, try to pull traction on the hernia and then compress it to evacuate the extra venous blood. If it still doesn’t reduce, then this is a case where you call the surgeon and request surgery, or at least admission for observation.
Take home points:
Using physical diagnosis to decide strangulation is usually not possible
Using physical diagnosis to decide incarceration is easy
Patients with incarcerated hernias need surgical evaluation