83-year-old man with:
* Painful swelling in the right groin
* No fever
* Nausea but no vomiting, difficulty passing stools
* Swelling not reducible
What do you see? Is it an incarcerated inguinal hernia?
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Imaging findings
* Right-sided inguinal hernia with intestines inside
* Mechanical small bowel obstruction proximal of hernia
* Normal enhancement of the bowel wall
No signs of ischemia.
Differential diagnosis
Mechanical small bowel obstruction: Adhesions/bands–volvulus–internal hernia–obstructing tumour/tumoural implants–other hernia’s–congenital or acquired stenosis
Groin swelling: Adenopathy–femoral hernia–psoas abscess–retracted testicle
Management
If no signs of ischemia are present:
* Careful manual reduction attempt
* If not successful: emergency surgery (risk of strangulation)
If signs of ischemia are present:
* Emergency surgery
Key points
Incarceration only means the hernia is not reducible and does not say anything about the content. An incarcerated inguinal hernia can also contain abdominal fat without bowel loops
Incarcerated hernia can turn into strangulated hernia and lead to small bowel obstruction
Carefully inspect the enhancement of the implicated loop of small bowel
Lack of enhancement is an early sign of ischemia (strangulation) and an indication for urgent surgery
