Surgical management of incarcerated and strangulated inguinal hernias requiring urgent surgical intervention: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma

Author

Farrell, Michael S. MD, MS; Zhang, Zugui PhD, FAHA; Kirsch, Jordan MD; Bower, Katie MD; Bower, Curtis MD; Gelbard, Rondi MD; Kent, Alistair J. MD, MPH; Khariton, Konstantin DO, FACS; Perez, Arielle MD; Menzo, Emanuele Lo MD; Rabinowitz, Judy B. MLIS; Ratnasekera, Asanthi DO, FACS

Background

Patients with acutely incarcerated or strangulated inguinal hernias require urgent surgical evaluation. Most literature on inguinal hernia management focuses on elective repairs. We aimed to provide evidence-based guidelines for managing inguinal hernias requiring urgent surgical intervention.

Methods

An evidence-based systematic review was performed. Clinically relevant questions regarding defined Population(s), Intervention(s), Comparison(s), and Outcome(s) were selected. These questions centered around the timing of intervention, the use of mesh, the surgical approach, and the use of antibiotics in patients who presented with incarcerated or strangulated inguinal hernias requiring urgent surgical interventions. A comprehensive literature search was completed from 1946 through March 11, 2024. The Grading of Recommendations Assessment, Development and Evaluation methodology was used in the creation of the recommendations. Consensus was achieved for all final recommendations.

Results

Of 7,038 articles reviewed, 34 met the inclusion criteria. Early intervention (<6 hours from symptom onset) was associated with a lower incidence of bowel resection (odds ratio [OR], 0.1 [0.05, 0.29]; p < 0.0001). Hernia repair with mesh was associated with decreased incidence of recurrence (OR, 0.34 [0.13, 0.87]; p = 0.02) and mixed results for surgical site infections. Laparoscopic repairs decreased recurrence rates (OR, 0.75 [0.58, 0.99]; p = 0.03) and had shorter hospital length of stay (mean difference, −3.00 [−5.54, −0.47]; p < 0.01) compared with open repairs. There were not enough studies to address the routine use of postoperative antibiotics. Quality was deemed very low with much of the literature being retrospective studies.

Conclusion

We conditionally recommend early surgical intervention for adult patients presenting with acutely incarcerated or strangulated inguinal hernias who are deemed to require surgery. We conditionally recommend mesh repairs over primary tissue repairs and laparoscopic approaches over open approaches for this population. No recommendations can be made regarding the routine use of antibiotics.

Level Of Evidence

Systematic Review/Meta-analysis; Level III.