Incarcerated hernia/SBO

Question 1

A 70 year old woman presents with the clinical features of distal small bowel obstruction. She is found to have an irreducible femoral hernia. How would you manage her?

Answer 1

Impression
Incarcerated femoral hernia (given irreducible nature) leading to small bowel obstruction.

Other complications of hernia;
- obstructed
- incarcerated
- perforation/ischaemic

Causes of SBO
- mechanical: adhesions, malignancy, external mass
- functional: paralytic ileus, medications

Question 2

Incarcerated hernia/SBO - History

Answer 2

History
Would conduct primary survey initially to rule out further complications IE shocked/peritonitis etc, otherwise assuming stable move to history.

• sx: pain (SOCRATES), constipation vs obstipation, urinary changes, when noticed inguinal lump, occurred previously? How long for?
• RISKS: previous abdo surgery, excessive coughing, weight lifting, obesity.
• PSHx (abdo surgery), PMHx
• Medications, allergies, SNAP

Question 3

Incarcerated hernia/SBO - Examination

Answer 3

Examination
- vitals
- general appearance
- abdo examination: massess, distension, shifting dullness, peritonitis
- hernia exam: location (above or below inguinal ligament, reducible vs irreducible, cough impulse, etc), bowel sounds over hernia present?
- DRE for ?empty rectum

Question 4

Incarcerated hernia/SBO - Investigations

Answer 4

Investigations
Key
- ultrasound of hernia sac to determine contents
- AXR/CXR upright for ?perf if clinically indicated
- CT abdo with IV contrast for surgical planning

• bedsidE: VBG (As part of A to E if relevant), ECG
• bloods: FBC, UEC, LFT/ CRP/ESR, cultures if septic, G+H, coags
• imaging: as above

Question 5

Incarcerated hernia/SBO - Management

Answer 5

Management
- get early gen surg review as patient will likely require admission and surgical fixation for definitive management in the acute setting, as high risk of strangulation and further complications in femoral hernia.

Supportive
- NBM
- NG tube and gastric decompression to reduce aspiration risk
- analgesia, fluids and electrolytes as indicated
- VTE prophylaxis

Definitive
- Femoral hernia repair +/- resection if bowel necrosis is evident.