Surgical Treatment of Incarcerated Ventral Hernias

What is an incarcerated ventral hernia?

In incarceration, the hernia contents cannot return to the abdominal cavity on their own and are compressed at the abdominal wall defect.

The hernia sac may contain:

• loops of the small intestine
• the large intestine
• the omentum
• other intra-abdominal structures

Impaired blood supply to the trapped organ can quickly lead to irreversible changes.

When is urgent surgery needed?

Surgery is indicated for:

• an irreducible and painful hernia
• suspected incarceration
• signs of bowel obstruction
• worsening pain
• signs of ischemia of the hernia contents
• suspected bowel necrosis
• peritonitis
• deterioration of the patient's general condition

An incarcerated ventral hernia is an emergency.

How is the operation performed?

The operation is performed under general anesthesia.

The main stages of the procedure are:

• access to the hernia defect
• opening and exploration of the hernia sac
• release of the trapped organ
• assessment of its viability
• reduction of viable hernia contents
• if necessary, resection of a non-viable segment of bowel
• restoration of bowel continuity when indicated
• cleansing of the abdominal cavity if it is contaminated
• closure of the hernia defect
• reconstruction and reinforcement of the abdominal wall

The extent of the operation is determined during the procedure, depending on the condition of the hernia contents and local tissues.

Assessing bowel viability

One of the most important stages of the operation is determining the viability of the trapped bowel loop.

The following are assessed:

• the color of the bowel wall
• pulsation of the mesenteric vessels
• blood filling
• peristalsis
• other signs that the blood supply has been restored

If the bowel remains non-viable after the incarceration is relieved, *the affected segment is resected*.

Whenever possible, bowel continuity is restored by creating an anastomosis.

Repair of the hernia defect

After the incarceration is relieved and the condition of the bowel is assessed, the optimal method of abdominal wall reconstruction is chosen.

The following may be used:

• suture closure of the hernia defect with the patient's own tissues
• repair with a mesh implant
• retromuscular reconstruction
• other reconstructive techniques

The choice of method depends on:

• the condition of the surgical field
• the presence of infection or contamination
• the need for bowel resection
• the size of the defect
• the condition of the tissues
• previous operations
• the presence of a previous mesh implant

Can a mesh be used for an incarcerated hernia?

Not in every situation.

If the tissues remain viable after the hernia contents are reduced and the surgical field is not significantly contaminated, a mesh repair may be performed in suitable cases.

With bowel necrosis, perforation, peritonitis, or significant contamination of the surgical field, the decision on using a mesh is made with particular caution.

In such cases, the priority is controlling infection and safely completing the emergency operation.

Is laparoscopic surgery possible?

In selected patients, the laparoscopic approach can be used to diagnose and treat an incarcerated ventral hernia.

Whether a laparoscopic approach is possible depends on:

• how long the hernia has been incarcerated
• the condition of the bowel
• the presence of peritonitis
• the size of the defect
• previous operations
• the extent of adhesions
• the need for bowel resection

If the patient is in serious condition or there are severe complications, an open approach may be necessary.

Incarcerated recurrent ventral hernia

Incarceration of a recurrent hernia after previous hernia repair is especially complex.

These patients may have:

• extensive adhesions
• altered abdominal wall anatomy
• a previous mesh implant
• multiple defects
• a shortage of their own tissue

The strategy is determined individually. After the acute complication has been treated, reconstruction of the front abdominal wall may be needed.

Advantages of timely surgical treatment

• Relief of the incarceration
• Restoration of blood supply to viable bowel
• Prevention of necrosis and perforation
• Treatment of bowel obstruction
• Removal of non-viable tissue if necessary
• Restoration of the integrity of the abdominal wall
• Lower risk of severe intra-abdominal complications

The earlier incarceration is diagnosed and treated, the better the chances of avoiding irreversible damage to the hernia contents.

Recovery after surgery

The length of recovery depends on the complexity of the operation.

After a simple repair of an incarcerated hernia, recovery may be faster.

If bowel resection, cleansing of the abdominal cavity, or complex reconstruction of the front abdominal wall was performed, the treatment and recovery period will be longer.

After surgery, the following are provided:

• early mobilization
• pain control
• a return to eating
• monitoring of bowel function
• prevention of thromboembolic complications
• monitoring of the surgical wound
• a gradual return to physical activity

Whenever possible, the principles of *ERAS (Enhanced Recovery After Surgery)* are applied.

Frequently Asked Questions