This is a detailed lecture about different complications of Hernia and their management. Including; Irreducible, obstructed, strangulated, incarcerated hernia.

1. Approach to
complicated Hernia
Dr. Jwan Ali AlSofi

2. Complications of Hernia:-
1) Irreducible: if contents cannot be returned to the abdomen,
and there is no other complications.
2) Obstructed: if bowel in the hernia has a good blood supply but
is obstructed (by stool for example).
3) Strangulated: if blood supply of bowel is obstructed.
4) Infarcted – when contents of the hernia have become
gangrenous, high mortality
5) Inflamed: if contents of the sac became inflamed.
6) Incarcerated: includes all of the above, a broad term which is
not commonly used.

4. UNCOMPLICATED HERNIA
• No skin changes:- No redness, No
ulceration.
• Impulse on coughing/straining
• Reducible
• Extent
• Bubonocele - within inguinal canal
• Funicular - exited superficial ring
• Complete inguinoscrotal - into
scrotal sac
 Incarcerated
• Irreducible
• Relatively well
• No features of obstruction/strangulation
 Obstructed
• Features of intestinal obstruction
• Irreducible
 Strangulated
• Irreducible
• Tender, indurated, erythematous skin
• Sepsis
• Features of intestinal obstruction •
 Recurrent
• Evidence of prior repair
COMPLICATED HERNIA
CLINICAL PRESENTATION

5. Complicated
hernia
UnComplicated
hernia

6. Reducible & Irreducible hernias
Reducible Hernia Irreducible Hernia
1. The hernia either reduces itself when the
patient lies down .
2. Can be reduced by the patient or the
surgeon.
3. A reducible hernia imparts an
expansile impulse on coughing.
4. The intestine usually gurgles on
reduction . The first portion is more
difficult to reduce than the last.
5. Omentum, in contrast, is described as
doughy and the last portion is more
difficult to reduce than the first.
1. The contents cannot be returned to the
abdomen
2. It is usually due to adhesions between
the sac and its contents or overcrowding
within the sac.
3. Irreducibility without other symptoms is
almost diagnostic of an omentocele,
especially in femoral and umbilical
hernias.
4. Note that any degree of irreducibility
predisposes to strangulation .
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8. Obstructed & Incarcerated Hernia
Obstructed Hernia Incarcerated Hernia
1. This is an irreducible hernia containing
intestine that is obstructed from without or
within, but there is no interference to the
blood supply to the bowel.
2. The symptoms:- colicky abdominal pain and
tenderness over the hernia site .
3. Symptoms are less severe and the onset more
gradual than in strangulated hernias,
4. Usually there is no clear distinction clinically
between obstruction and strangulation .
5. The safe course is to assume that
strangulation is imminent and treat
accordingly.
1. This term is correctly employed only
when it is considered that portion of the
colon occupying a hernial sac is blocked
with faeces.
2. The contents of the bowel should be
capable of being indented with the
finger, like putty.
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10. Differential diagnosis of
irreducible Hernia:-
1. a lymph node
2. groin mass
3. an abdominal mass.
• Such cases require urgent investigation by
either ultrasound or CT scan
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12. Strangulated hernia
1. A hernia becomes strangulated when the blood
supply of its contents is seriously impaired .
2. Gangrene may occur as early as 5–6 hours
after the onset of the first symptoms.
3. Femoral hernia is more likely to strangulate
because of the narrowness of the neck and its
rigid surrounding .
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13. • Strangulation of an inguinal hernia occurs at any time during life
and in both sexes.
• Indirect inguinal hernias strangulate more commonly.
• The direct variety not so often because of the wide neck of the sac.
• Sometimes a hernia strangulates on the first occasion that it
descends; more often strangulation occurs in patients who have
worn a truss for a long time and in those with a partially reducible
or an irreducible hernia.
• In order of frequency, the constricting agent is:
1. the neck of the sac;
2. the external inguinal ring in children;
3. Adhesions within the sac (rarely).
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14. Contents
• In order of frequency:-
1. Usually the small intestine is involved in the strangulation
2. the next most frequent being the omentum;
3. sometimes both are involved.
4. It is rare for the large intestine to become strangulated in an
inguinal hernia, even when the hernia is of the sliding variety.
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15. Strangulation during infancy:-
• The incidence of strangulation in infancy is 4% .
• The ratio of girls to boys is 5:1.
• More frequently, the hernia is irreducible but not strangulated.
• In most cases of strangulated inguinal hernia occurring in female
infants, the content of the sac is an ovary or an ovary plus its
fallopian tube.
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17. Pathology of Strangulated Hernia
1. Initially, only the venous return is impeded .
2. The wall of the intestine becomes congested and bright red with the transudation of serous fluid
into the sac.
3. The intestinal pressure increases, distending the intestinal loop and impairing venous return
further.
4. As venous stasis increases, the arterial supply becomes more and more impaired.
5. Blood is extravasated under the serosa and is effused into the lumen .
6. At this stage the walls of the intestine have lost their tone and become friable.
7. Bacterial transudation occurs secondary and the sac fluid becomes infected.
8. Gangrene appears at the rings of constriction .
9. The colour varying from black to green depending on the decomposition of blood in the subserosa.
10. The mesentery involved by the strangulation also becomes gangrenous.
11. Perforation of the wall of the intestine occurs, either at the convexity of the loop or at the seat of
constriction.
12. Peritonitis spreads from the sac to the peritoneal cavity.
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19. Symptoms of strangulated hernia
1. Sudden pain, situated over the hernia .
2. Generalised abdominal pain, colicky in character
and often located mainly at the umbilicus.
3. Nausea and subsequently vomiting ensue.
4. The patient may complain of an increase in hernia
size.
5. Spontaneous cessation of pain must be
viewed with caution, as this may be a sign
of perforation
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20. Signs of Strangulated Hernia
• On examination the hernia is
tense.
• Extremely tender and
irreducible .
• There is no expansile cough
impulse.
• The spasms of pain continue
until peristaltic contractions
cease with the onset of
ischaemia.
• Paralytic ileus , peritonitis ,
and septicaemia develop.
• Spontaneous cessation of pain
may be a sign of perforation .
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21. Richter’s hernia
1. Is a hernia in which the sac
contains only a portion of
the circumference of the
intestine (usually small
intestine).
2. It usually complicates
femoral hernia .
3. Rarely, obturator hernias.
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22. Types of Strangulated Hernia
1. Strangulated Richter’s hernia .
2. Strangulated omentocele .
3. Inflamed hernia .
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23. Inflamed Hernia
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24. Investigations of complicated Hernia:-
• FBC - leukocytosis
• BUSEC - electrolyte derangements, AKI
• ABG - acid-base imbalance
• PT/PTT - sepsis with coagulopathy
• Blood C+S - sepsis
• GSH
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25. Treatment of strangulated inguinal hernia:-
• The treatment of strangulated hernia is by emergency operation.
• Non-operative treatment of hernias  Only indicated in
children.
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26. Preoperative treatment of complicated inguinal
hernias:-
1. Resuscitate with adequate fluids
2. Empty stomach with nasogastric tube
3. Give antibiotics to contain infection
4. Catheterise to monitor haemodynamic state
** operation should not be unduly delayed in moribund patients
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27. Non-operative treatment of complicated hernias:-
• These are indicated only in infants.
• The child is given analgesics
• The child is Placed in gallow’s traction (the judgement of Solomon
position). In 75% of cases reduction is effected and there appears
to be no danger of gangrenous intestine being reduced (Irvine
Smith).
• Taxis manoeuvre (forcible reduction) – is contraindicated in
strangulated hernia.
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29. • Note that vigorous manipulation (taxis) has no place in modern
surgery and is mentioned only to be condemned. Its dangers
include:
1. contusion or rupture of the intestinal wall
2. reduction-en-masse: ‘The sac together with its contents is pushed
forcibly back into the abdomen; as the bowel will still be
strangulated by the neck of the sac, the symptoms are in no way
relieved’.
3. reduction into the a loculus of the sac
4. the sac may rupture at its neck and the contents are reduced, not
into the peritoneal cavity but extraperitoneally.
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31. THE END