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Case 65: Incarcerated hernia

You are performing an emergency laparotomy on a 47 year old diabetic man who presented with a painful, incarcertaed incisional hernia. The picture below shows the important operative findings.

1. What does the photo show?

There is a segment of small bowel that is obviously non-viable and will require resection. It appears well demarcated. The proximal bowel is mildly dilated. The distal extent is not well seen. There is a long length of normal bowel visible.

2. How would you manage the hernia defect which measures 8cm in diameter?

In the elective setting a hernia of 8 cm would usually be managed with a mesh as it is unlikely to be closed with simple suturing without significant tension. In this setting where the small bowel requires resection and anastomosis there is an increased risk of mesh infection. It must be remembered that the primary aim of this operation is to save the patient from a potentially lethal problem. A residual hernia could be managed at a subsequent operation.

The decision of whether to use mesh or not will depend on assessment of the risk of infection and the patients ability to tolerate a mesh infection. This diabetic patient has an additional risk factor for wound infection. With modern meshes the risk of infection is high Also modern antibiotics often allow mesh infection to be managed without removal of the mesh. Therefore if the bowel has not perofrated it is reasonable to use mesh to repair this hernia.