Small bowel obstruction in strangulated inguinal hernia - A surgical emergency. Re: Strangulated Hernia in Old People
We read with interest the case reports of successful surgical operation for strangulated hernia in old people and sincerely appreciated the report on an apparently healthy 81 year old patient who successfully underwent surgical operation after he reported to emergency ward with complaints of irreducible oblique inguinal hernia. (1) Early recognition of intestinal strangulation in patients with small bowel obstruction (SBO) is essential to allow safe non-operative management of selected elderly patients. (2) However, preoperative diagnosis of strangulation cannot be made or excluded reliably by any known clinical parameter, combination of parameters, or by experienced clinical judgement.
Usually small gut strangulation remains unrecognised preoperatively, and early surgery is therefore indicated in most cases as soon as intestinal obstruction is diagnosed clinically or with radiologic evidence.(2) Small intestinal obstruction remains “a frequently encountered problem in abdominal surgery”. Although modern day surgical management continues to focus appropriately on avoiding operative delay whenever surgery is indicated, not every patient is always best served by immediate operation.(3) For medically unfit elderly patients, non-operative conservative management of intestinal obstruction is undertaken at a calculated risk of delaying definitive treatment for intestinal ischaemia.
Moreover, postoperative adhesions and neoplastic-associated SBO, particularly in patients with numerous previous abdominal procedures, concomitant medical problems, or incomplete or partial obstruction, often justifiably benefit from a trial of non-operative management. (4)
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.(5)
At the same time, we suggest that surgeons should continue their aggressive attitude towards elective repair of any and all abdominal hernias, which continue to account for close to 15 per cent of all cases of small intestinal obstruction and still remain the most common cause of strangulation.(3)
Dr. Azzard Comrie, Senior Medical officer, Hargreaves Hospital
Prof. Dr. Jogenananda Pramanik, Executive Dean, Careers Abroad Institute School of Medicine, #32, Hargreaves Avenue, Mandeville, Manchester, Jamaica, WI.
1. T.B. Curling. Strangulated Hernia in Old People: Lond J Med 1850; s2-2 doi: https://doi.org/10.1136/bmj.s2-2.18.507 (Published 03 June 1850)
2. Sarr MG, Bulkley GB, Zuidema GD. Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability. Am J Surg. 1983 Jan; 145(1):176-82.
3. Mucha P Jr. Small intestinal obstruction. Surg Clin North Am. 1987 Jun; 67 (3):597-620.
4. Otamiri T, Sjödahl R, Ihse I. Intestinal obstruction with strangulation of the small bowel. Acta Chir Scand. 1987 Apr; 153 (4):307-10.
5. Comrie A, Pramanik J. Strangulated hernia causing sudden unexpected death-A major concern. Re: Inguinal hernias. https://www.bmj.com/content/336/7638/269/rr.
Competing interests: No competing interests