Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Stomac and duodenum
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Surgical Treatment of Strangulated Groin Hernia

Provide immediate treatment to patients with a strangulated groin hernia to relieve the obstruction. Begin an intravenous infusion with an electrolyte solution, hydrate the patient, insert a nasogastric tube and aspirate the stomach. If your patient has been vomiting, establish baseline serum electrolyte levels and correct any abnormalities.

Surgical repair

:: Open the skin, subcutaneous tissue and external oblique, as previously described (see Figures 8.1, 8.2 and 8.3). The internal ring may have to be divided to relieve the obstruction in indirect hernia and the inguinal ligament in femoral hernia. In both cases, divide the ring on the superior aspect to avoid underlying blood vessels.
Figure 8.1
Figure 8.1

Figure 8.2
Figure 8.2

Figure 8.3
Figure 8.3

:: Open the sac, being careful to prevent gut from returning to the abdomen, then carefully inspect it for viability. Give particular attention to constriction rings. If bowel falls back into the abdomen prior to assessment of its viability, perform a laparotomy.
:: Apply warm, wet packs to the gut for a few minutes. Gangrenous or nonviable gut will be black or deep blue without peristalsis. The mesenteric veins of the loop will appear thrombosed. There may be no arterial pulsation and the serosa will have lost its shiny appearance.
:: Resect any gangrenous loop of bowel and make an end-to-end anastomosis (see pages 6–10 to 6–11). If the resection of gangrenous bowel can be performed easily and well through the groin incision, continue with that approach. Otherwise, make a lower midline abdominal incision and do the resection using an abdominal approach. Excise the hernial sac and complete the repair as appropriate.

Operation for incarceration can be difficult in children, in patients with recurrent hernias, and in those with large, inguinoscrotal hernias. In these cases, consider non-operative reduction when patients present early with no signs of inflammation in the region of the hernia. To achieve non-operative reduction, place the patient in the Trendelenburg position, support both sides of the neck of the hernia with one hand and apply gentle, firm and continuous pressure to the sac with the opposite hand. Narcotic analgesia may be helpful.

Failure of reduction within 4 hours is an indication for operation. Observe the patient for at least 12 hours after a successful non-operative reduction.

Simple division of the obstructing ring

If non-operative reduction is unsuccessful in children, it may sometimes be prudent simply to divide the obstructing hernial ring. The obstructing ring in children is often the external inguinal ring, while in adults it is usually the internal ring. If such temporizing treatment is used, referral to a surgeon is required for definitive treatment.

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  Kep Points  
In strangulated inguinal hernia, extend the inferior end of the skin incision over the hernia mass

This incision gives good access to the incarcerated mass

Always consider strangulated inguinal or femoral hernia as a cause of small bowel obstruction.