Intended for healthcare professionals

Clinical Review

Inguinal hernias

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39450.428275.AD (Published 31 January 2008) Cite this as: BMJ 2008;336:269

Strangulated hernia causing sudden unexpected death-A major concern. Re: Inguinal hernias

Strangulated hernia causing sudden unexpected death-A major concern.
Dr. Azzard Comrie, Senior Medical officer, Hargreaves Memorial Hospital, Mandeville, Manchester, Jamaica, WI (www.hargreaveshospital.com) and Prof. Dr.Jogenananda Pramanik, Executive Dean, Career Abroad Institute School of Medicine, 32, Hargreaves Avenue, Mandeville, Manchester, Jamaica, WI.(www.caisom.org)

We read the clinical review on Inguinal Hernias by Jenkins and O’Dwyer,
and sincerely applauded their insightful recommendation that all medically fit patients with an inguinal hernia should have it repaired (1) Inguinal hernias account for 75% of abdominal wall hernias, with a lifetime risk of 27% in men and 3% in women.(1)

An inguinal hernia isn't necessarily dangerous always. However, if it doesn't improve on its own, or if patients aren't able to push the hernia in, the contents of the hernia can be trapped (incarcerated) in the abdominal wall. An incarcerated hernia can become strangulated, which cuts off the blood flow to the tissue that's trapped and can lead to life-threatening complications.
Excruciating pain due to ischaemic changes in entrapped gastrointestinal tissue may endanger life causing neurogenic shock. If surgical interventions are delayed, toxic materials from strangulated gut may spread and cause further deterioration of the patient’s overall general condition. Such irreversible complications may often ensue sudden unexpected death in elderly patients.

Less expensive watchful waiting under periodic evaluation, may be a popular endeavour among young patients with inguinal hernia to postpone surgical interventions and also to differ certain uncomfortable postoperative events like sexual dysfunction. (2, 6)

However, repair of inguinal hernia is one of the most common operations in general surgery, with rates ranging from 10 per 100 000 of the population in the United Kingdom to 28 per 100 000 in the United States (1).

Ironically, there is no definite sign for early detection of strangulation of herniated tissue in inguinal hernia and therefore, it seems difficult for patients or their relatives to ascertain when to terminate “watchful waiting period” and decide to seek surgical procedures for remote rural area patients in particular. (3) A third of patients scheduled for surgery have no pain, and severe pain is uncommon (1.5% at rest and 10.2% on movement) (1)

Moreover, there are reports about postoperative death of strangulated inguinal hernia patients who most commonly report for lifesaving surgical intervention late. (4) Postoperative mortality after elective and emergency surgery for inguinal hernia has also been reported (5).

Sudden unwitnessed, unexpected deaths when the bodies are found in public places require a complete and meticulous medico-legal autopsy to ascertain the cause and manner of death to avoid further unnecessary investigations by the legal authorities (7, 8).

References:

1. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ 2008; 336:269-272.

2. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P.
Observation or operation for patients with an asymptomatic inguinal
hernia. Ann Surg 2006; 244:167-73.

3.Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomised clinical trial.JAMA2006;295:285-92.
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4.Haapaniemi S, Sandblom G, Nilsson E. Mortality after elective and emergency surgery for inguinal and femoral hernia. Hernia1999;4:205-8.
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5. McGugan E, Burton H, Nixon SJ, Thompson AM. Deaths following hernia surgery: room for improvement. J R Coll Surg Edinb2000;45:183-6.
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6. Kehlet H. Chronic pain after groin repair. Br J Surg 2008;
95:135-6.

7. T.B.Curling: Strangulated Hernia in Old People; Lond J Med 1850; s2-2:507 doi: https://doi.org/10.1136/bmj.s2-2.18.507

8. Menezes RG et al. Sudden unexpected death due to strangulated inguinal hernia. Med Leg J. 2016 Jun;84(2):101-4. doi: 10.1177/0025817216629848. Epub 2016 Feb 2.

Competing interests: No competing interests

08 April 2018
Jogenananda Pramanik
Professor
Dr. Azzard Comrie Senior Medical officer, Hargreaves Memorial Hospital, Mandeville,Manchester, Jamaica,WI
Careers Abroad Institute School of Medicine
#32,Hargreaves Avenue, Mandeville,Manchester,Jamaica,WI