Strangulated inguinal hernia - nietoeditores.com.mx

* Departamento de Cirugía General, Hospital General Gaudencio 

González Garza, Centro Médico la Raza, Instituto Mexicano del 

Seguro Social, Mexico, D.F., Mexico 

Correspondence: 

Ernesto Manuel Góngora-Gómez 

Querétaro 144-412, Col. Roma, Deleg. Cuauhtémoc 

CP 06700, Mexico, D.F., Mexico 

Tel: (0155) 10844747 Ext. 7401 

E-mail: herniagongora@gmail.com 

Received for publication: 9-14-2011 

Accepted for publication: 3-28-2012 

abstract 

Cir Cir 2012;80:331-341 

Strangulated inguinal hernia 

Ernesto Manuel Góngora-Gómez 

Background: Strangulated inguinal hernia (SIH) has an overall prevalence of 1.3% in adults, affecting mainly senile 

patients, with a high incidence of morbidity and mortality. There are more than 13 different surgical techniques for treatment, 

but none has proven to be more effective than the others. 

methods: The present observational, longitudinal and prospective study carried out at Hospital General, Centro Medico 

La Raza in Mexico City proposes a new surgical technique to treat SIH. Between December 2000 and August 2010, 

43 adult patients with SIH were consecutively subjected to preperitoneal mesh repair and exploratory laparotomy (PPMR 

and ELAP), a personal modification by the author to the Stoppa-Rives technique. Several variables were studied. 

results: There was zero mortality. There were no cases of inguinal recurrence or reintervention. One patient developed 

a granuloma at the surgical site. There were three cases of superficial wound infection, six cases of inguinoscrotal seroma, 

and one case of incisional hernia. 

discussion: There is no international consensus on the treatment of SIH although it is interesting to analyze the studies 

published during the last two decades and to observe the results. Studies that propose a preperitoneal approach with 

mesh demonstrate the best results by reducing morbidity and mortality. 

Conclusions: Preperitoneal mesh repair and exploratory laparotomy reduce the rate of morbidity and mortality in the 

treatment of SIH. Inguinal hernias must be repaired at the time of diagnosis to avoid strangulation. 

Key words: strangulated inguinal hernia, preperitoneal mesh repair, exploratory laparotomy 

introduction 

The worldwide prevalence of strangulated inguinal hernia 

(SIH) is 0.3–2.9% of all inguinal hernias in adults. 1-3 

Primary hernias strangulate more than recurrent and small 

hernias more than large hernias at a ratio of 5:1. 4 The risk 

of hernia strangulation is greatest during the first 3 months 

of its appearance 5 and occurs at an average age of 69 years 

with no difference between genders. The right side is most 

affected (2:1). Indirect hernias become strangulated more 

than direct and femoral hernias; the latter are more frequent 

in females. 6 

Before the use of mesh in inguinal hernia surgery there 

were no reports on morbidity of SIH because there was 

practically no short- or long-term follow-up on management 

of these cases. However, there were reports on mortality 

as follows: in 1959, Rogers 7 reported 26%, in 1960 

Nyhus et al. 8 reported 33%, in 1975 Read 9 reported 25%, 

in 1994 Pans and Jacquet 10 reported 17%, in 2000 Steinke 

and Zellweger 11 reported 25% and Harouna et al. 12 reported 

40%. After the advent of mesh, the mortality index has been 

reduced to 1–3%, whereas the reported incidence of recurrence 

is 0–4%, surgical wound infection 5–21%, and seroma 

3–15%. 13-15 

Some femoral, and mainly the obturator, hernias become 

chronically sporadically trapped (especially in females). 

Isolated reports exist on the morbidity and mortality index 

of the latter when they cause acute episodes of occlusion 

and constitute a surgical emergency. 

From the time that plastic prostheses began to be used in 

the management of abdominal wall hernia, mainly inguinal, 

a revolution in surgical techniques began and thereby its 

terminology, coining new concepts such as “with tension” 

to refer to the traditional techniques by Bassinni, McVay, 

Halsted, and Shouldice and “tension free” to refer to the 

Volume 80, No. 4, July-August 2012 331

new techniques that used prosthetic mesh such as Lichtenstein, 

Stoppa, Mesh-Plug, PHS, etc. With the advent of the 

mesh, a revolution in the management of hernias began, 

mainly in the groin. Prior to these changes there were at 

least nine procedures with “tension” suggested for management 

of SIH. After the onset of mesh prostheses, new 

“tension free” techniques have been incorporated, with application 

of the mesh anteriorly, preperitoneally, 21-23 or with 

laparoscopic techniques. 24-28 Currently, there are more than 

13 procedures recommended for management of SIH. 

This study once again proposes the preperitoneal repair 

with mesh and exploratory laparotomy, confirming its advantages 

and favorable results because it resolves the hernia 

as well as the damage caused by the ensuing strangulation 

by achieving the following: 

a) Access to both inguinal regions by the Cheatle-Henry 

technique 

b) Reduction of the sac and its contents 

c) Application of the prosthetic material and of a drainage 

system in the preperitoneal region 

d) Wide approach of the abdominal cavity that allows assessment 

of the damage, observation of the existence 

of unsuspected concomitant hernias, identification of 

the number and degree of lesions in the internal organs, 

facilitation of intestinal decompression, performance 

of the pertinent enterostomy and anastomosis or bowel 

rest if required and, finally, for washing and draining 

the cavity in case of intestinal leak and generalized 

peritonitis 

e) One sole repair technique for all types of inguinal hernias 

by the application of mesh in the preperitoneal 

space, which allows for correction of all hernia defects 

in the inguinocrural region, eliminating the need to apply 

a different technique for each hernia type 

f) No specialized training necessary because all surgeons 

can perform the procedure and the use of sophisticated 

equipment is not required (such as the laparoscope) or 

a long learning curve 

g) The only option for advanced cases (gangrene of the 

soft tissues or great intestinal dilation) that require 

debridement, orchiectomy, bowel decompression, and 

relaxing incisions to enlarge the orifice and free the 

trapped organ 

Early diagnosis, overall evaluation of the patient’s status 

and timely treatment are the keys for prognosis as well as 

intensive fluid replacement, adequate antibiotic use, nasogastric 

decompression of the abdomen, kidney monitoring 

and correction of coagulation parameters and other existing 

health issues due to the multipathological nature of these 

patients. These objectives must be met promptly, during the 

first 2–4 h prior to the surgical event. 

Góngora-Gómez EM 

Details of the surgical technique: preperitoneal mesh repair 

and exploratory laparotomy (Figure 1) 

A midline infraumbilical incision was made close to the 

symphysis pubis and after dissection by planes the preperitoneal 

space was entered without opening the peritoneum. 

Ipsilateral traction was carried out over the muscular wall to 

expose by blunt dissection the posterior wall of the affected 

groin (the surgeon has the option to primarily explore the 

contralateral groin in search of suspected or unidentified 

concomitant hernias) 29 and the site of hernia strangulation 

was located to manually reduce it with traction and internal 

and external gentle countertraction. If such a reduction is 

not possible, relaxing incisions should be made to widen the 

neck of the hernia. In case of indirect hernia, the epigastric 

vessels should be cut and ligated, protecting the sac and its 

contents so as to not open it. A cut is made in the internal 

ring between 11 and 12 o’clock in an oblique superomedial 

direction, resecting the fibers of the ligament of Hesselbach 

and the conjoined tendon (Figure 2). In the direct hernia 

the cut is made between 10 and 11 o’clock and over the 

posterior fascia of the union of the rectus and transverse 

muscles (posterior face of the conjoined tendon or ligament 

of Henle) (Figure 3). 

If the hernia is femoral, the cut will be oblique in the 

iliopubic tract at its insertion at the ligament of Cooper 

(Gimbernat ligament) medially. It should be noted that the 

femoral vessels are found adjacent in the external lateral 

sense and in the lateral superior direction the epigastrics 

emerge. Exposure and cutting maneuvers should be done 

gently and precisely (Figure 4). 

If an obturator hernia is found, the cut should be made in 

the endopelvic fascia below the ligament of Cooper medially 

and inferior to avoid the obturator vessels and nerves 

(Figure 5). 

Once the sac and its contents are freed, it is retracted 

towards the abdomen without opening it, in order to avoid 

contamination. If reduction of the sac is impossible (because 

it is intimately adhered) it can be ligated and cut at 

the level of the neck avoiding as much as possible escape of 

the contents to the preperitoneal space, leaving the inguinoscrotal 

remnant of the sac attached. This will be exhaustively 

washed and will allow exteriorization of one of the 

drainage tubes closed to suction (in case a perforated sac 

is found, with evident contamination due to the presence 

of an abscess and/or intestinal leak, a mesh should not be 

applied and Nyhus type fascial repair will be done). A piece 

of polypropylene mesh not less than 10 × 12 cm should be 

placed before parietalization of the spermatic cord, suturing 

it with nonabsorbable monofilament material to the pubic 

tubercle, Cooper’s ligament, iliopsoas fascia and conjoined 

332 Cirugía y Cirujanos


Midline incision 

Perforated sac 

Abscess and intestinal leak 

in inguinal region. Do not 

apply 

Fascial type Nyhus repair 

Contralateral 

preperitoneal exploration 

Preperitoneal exploration 

Groin pathology 

Reduction of sac 

Not opened 

Integral sac 

Apply polypropylene mesh 

parietalization of the cord 

Installation of closed 

drainage 

Approach abdominal cavity 

according to midline,not 

Exploration and evaluation 

of damage 

Resection and intestinal 

anastomosis, closed technique 

Solution for other damages 

¿lavage?/cavity drainage? 

Closure of wall with 

aseptic technique 

Presence of hernia 

Absence of hernia 

figure 1. Algorithm of surgical technique: preperitoneal repair with mesh and exploratory laparotomy. 

Unilateral 

prosthesis 

Adherence of sac 

section at the level of the 

neck; avoid leaks 

Leave residual sac in situ 


figure 2. Incision in ligament of Hesselbach. 

tendon. A closed drain is then installed, which is exteriorized 

from below and inside the anterior superior iliac spine 

(the surgeon decides on the exit site according to the type 

of case). This type of drainage has decreased the number 

of hematomas reported in other studies. We now proceed 

(but not earlier) to opening the peritoneum via the midline 

to complete the approach by means of a laparotomy. Using 

this route, the cavity is explored to evaluate the damage and 

its repair. Resection of the affected organs is performed and 

anastomosis, if the damage is intestinal. This exposure will 

allow washing of the cavity and draining, if necessary. In 

some cases decompression of the dilated intestine is obligatory 

because if not done it imposes closure under tension of 

the cavity. The surgeon will manually decompress in retrograde 

manner or aspiration through enterotomy. The wall 

closure should be completed using aseptic technique. Also, 

the skin edges and epidermis will be left open in case of 

peritonitis and according to the surgeon’s judgment. 

Emphasis is given to proceed with careful handling of 

tissues, judicious use of cautery and suture materials, shorter 

operative times, removal of devitalized tissue, use of efficient 

drainage and aseptic closure of the cavity. General 

figure 3. Incision in ligament of Henle. 


anesthesia is ideal for this surgery because it provides adequate 

intraoperative relaxation. 

Patients and methods 

From December 1, 2000 to August 31, 2010, 43 adult patients 

with SIH underwent emergency surgery consecutively 

with preperitoneal repair with mesh and exploratory 

laparotomy. Patients were all seen in the Emergency Department 

of the General Hospital Medical Center La Raza 

in Mexico City. All patients underwent routine screening 

studies: blood count, blood chemistry, serum electrolytes, 

blood amylase, prothrombin time, partial thromboplastin 

time, abdominal x-rays standing and supine and chest xray. 

All patients were assessed primarily by an emergency 

physician who initiated rehydration therapy, analgesia and 

antibiotics. The Department of General Surgery was then 

contacted for interconsultation. 



figure 4. Incision in ligament of Gimbernat. 

results 

Average age of the patients was 71 years (range: 26–92 

years). There were 18 females and 25 males. There were 33 

patients with comorbidities with the following being predominant: 

hypertension (19 patients), obesity (16 patients), 

type 2 diabetes mellitus (8 patients), prostatism (6 patients), 

lung disease (6 patients), heart disease (5 patients), and renal 

disease (3 patients). There were 33 cases of primary hernia 

and 10 cases of recurrent hernia (three with more than 

two recurrences). Small hernias (8 cm (9 cases). The right side 

was most affected (24 cases) than the left (19 cases). The 

time of evolution since the first symptoms appeared until 

the time of surgery was 46.2 h (9–90 h); 39 patients had 

signs of intestinal obstruction and 24 patients had signs of 

peritoneal irritation. There were 19 cases of dehydration. 

Leukocytosis >10,000 was demonstrated in 28 patients and 

bandemia in 12 patients. Dermoepidermal changes were 

present in five cases (one with scrotal gangrene). X-rays of 

the abdomen showed air fluid levels in 36 patients, bowel 

loop dilation in 39 patients, free fluid in the cavity in eight 

patients, and intestinal wall edema in 28 cases. All patients 

were subjected to preperitoneal surgical repair with mesh 

figure 5. Incision in the endopelvic fascia below Cooper’s ligament. 

and exploratory laparotomy. We chose the Gilbert-Rutkow 

classification (because it was the most practical and complete 

in our estimation) to group the hernias of our patients: 

type II (8 cases); type III (14 cases); type IV (6 cases), type 

V (1 case), type VI (5 cases) and type VII [9 cases (female 

predominance with 7 cases and 2 cases of males)]. There 

were also concomitant hernias found: six contralateral, one 

ipsilateral, two umbilical and two postincisional. There 

were four Richter hernias identified and one Amyand. 30 

Resection was carried out on 34 patients due to necrosis, 

although in some cases there was compromise of more than 

one organ: small intestine in 18 cases (all with involvement 

of some segment of the ileum and that was resolved with 

end-to-end anastomosis in two planes), hernia lipoma in 13 

cases, hernia sac in 19 cases, omentum in eight cases, epiploic 

appendix in four cases, testicle in three cases, colon in 

two cases (the cecum in one case that required an ileostomy 

and sigmoid in the second case that required colostomy of 


the descending colon); the cecal appendix of the Amyand 

case was excised despite vascular recuperation. There were 

nine cases without resection because the trapped organs recovered 

their viability. There was also more than one organ 

found trapped: small intestine 6, colon 5 (two of the cecum 

and three of sigmoid), and omentum 5 (Table 1). 

Peritonitis due to intestinal leakage occurred in four cases, 

all of which were managed with scrupulous washing of the 

cavity, application of Saratoga-type drains in both parietocolic 

gutters and management with double or triple antibiotic. 

One case of intestinal leak was due to cecal perforation 

(the case that required ileostomy) and the other three were 

leaks from the small intestine. After segmental bowel resection, 

anastomosis with aseptic technique was performed 

in two planes. A preperitoneal inguinal drain was placed 

in 24 patients and intraabdominal in ten patients (four of 

these patients experienced intestinal leak). A relaxing incision 

was done in the constricting hernia ring because it was 

impossible to free up the hernia sac and its contents with 

simple maneuvers in 18 cases: ten indirect hernias, four indirect 

hernias and four femoral hernias. The characteristics 

of the mesh installed were Dacron 2, polypropylene (PPL) 

37, light mesh 3, and composite (polypropylene + Teflon) 

1. General anesthesia was administered in all cases because 

of the requirement of adequate intraabdominal relaxation. 

Average surgical time was 142 min (75–260 min) (Table 2). 

Antibiotic therapy was administered with one or more 

drugs: two cases without antibiotics, monotherapy in 21 

cases, two antibiotics in 15 cases, and three antibiotics in 

five cases. Average hospital stay was 7.1 days (2–25 days). 

Follow-up of 1–118 months was reported in 21 patients; 

13 patients died during the course of the study due to non- 

table 1. Resection due to necrosis or vascular repair 

Resection for necrosis* 34 Small intestine 18 

Hernia sac 19 

Hernia lipoma 13 

Omentum 8 

Epiploic appendix 4 

Testicle 3 

Colon 2 

Without resection for 9 Small intestine 6 

vascular recuperation ** Colon 5 

Omentum 5 

Cecal appendix 1 

* Various cases with more than one necrosed organ. 

** Various cases with more than one incarcerated organ. 


table 2. Surgical findings for SIH 

Peritonitis* 4 

Drainage Inguinal** 24 

Abdominal 10 

Relaxing incision Indirect opening 10 

(18) 

Direct opening 4 

Femoral opening 4 

Type of mesh Polypropylene 37 

Light 3 

Dacron 2 

Bilayer 1 

Type of anesthesia General 43 

Surgical Time (min) 142’ 

*Intestinal leak due to perforation. 

**Closed drainage. SIH, strangulated inguinal hernia. 

surgical-related causes. Nine patients were lost to followup. 

No deaths occurred during surgical management or during 

the postoperative period. Deaths occurred during a 10year 

period due to various diseases unrelated to the surgery. 

There were zero recurrences during the follow-up period. 

There were no re-operations. No case had to be reoperated 

during the immediate postoperative period. There was 

an infected granuloma in one patient; 2 months after surgery 

an area of swelling was demonstrated in the interior 

commissure of the scar that finally revealed three knots of 

suture material and remained oozing until we opened to 3 

cm and washed the area intensively for 12 days until control 

was obtained. Closure was done by secondary intent 

without requiring re-exploration or removal of the mesh. 

Incisional hernia was done in one patient detected 1 month 

after surgery in the mid-third portion of the scar. The patient 

underwent conventional open herniorraphy during the 

second month without incident. Infection occurred in three 

patients. The wound was left open due to development of 

peritonitis and the infection was controlled with exhaustive 

lavage, without mesh infection. In two patients we reapproximated 

the wound margins with sutures, and in the 

third patient closure was done by secondary intent. There 

were six cases of seroma, four were noted among the first 

10 cases reported. We did not leave a preperitoneal drain as 

routinely done and the other two occurred with cases of giant 

inguinoscrotal hernias. All resolved with one and three 

evacuation punctures performed aseptically during office 

consultation (Figure 6). 



7 

6 

5 

4 

3 

2 

1 

0 

Results 

Seroma Surgical Incisional 

wound 

infection 

hernia 

figure 6. Results of morbidity with the surgical technique for 

strangulated inguinal hernia. 

discussion 

Granuloma 

Management of the complicated inguinal hernia requires 

a precise diagnosis. It is important to define the degree of 

involvement of its contents. In the case of SIH, all intervening 

aggravating factors should be analyzed. Selection 

of the operative technique is still controversial; however, 

each day there is further proof of the benefits derived from 

wide abdominal cavity exploration and hernia repair with 

preperitoneal prosthesis during the same surgical event. Another 

reason for the controversy is the use of mesh in areas 

potentially contaminated; however, various reports confirm 

that its use in such situations is not contraindicated. 31-34 

Approaching a strangulated inguinal hernia via an inguinal 

incision without exploration of the abdominal cavity 

carries distinct risks: 

• Missing inadvertent unsuspected concomitant hernias 

• Totally missing intraabdominal lesions that cannot 

be identified through a limited hernia orifice such as 

perforation and intestinal leak, severe ischemia and/or 

necrosis of the small or large intestine, of the omentum, 

epiploic appendix or cecal appendix, bladder or 

the testicle 

• Not identifying chronic constrictions in the intestine 

when strangulated, provoked by the tight neck of the 

hernia that in the future will stenose and cause difficult 

to diagnose intestinal occlusions 35 

• Ignoring the presence of unsuspected purulent or intestinal 

blood collections that warrant drainage 

• High degree of difficulty for intestinal resection and 

anastomosis as well as placing the surgical procedure 

at risk when performing a contaminated procedure in 

the inguinal region 

Postponing the surgery for a second surgical time gives 

priority to the resection, maintaining the latent risk of a second 

strangulation in the short term. 

In the past decade, various types of light mesh prostheses 

associated with polyglactine or polyglecaprone to reduce 

regional inflammatory reaction of index of seroma began to 

be used. We used three types of these mesh prostheses and 

no cases of seroma were presented. However, it should be 

mentioned that this complication may be due to a number of 

associated factors such as the size of the hernia and, therefore, 

the extension of the regional surgical dissection, size 

and characteristics of the prosthesis (heavy or light), resection 

or not of the hernia sac, use of a delayed surgery and 

installation of a good closed drainage. In other reports on 

seromas, minor complications have been reported after use 

of heavy Dacron or polypropylene mesh, but these reports 

did not mention if drains were used. In our series the largest 

number of seromas occurred when a closed drain was not 

installed. We also point out that the closed drain decreases 

the possibility of exterior contamination as may occur with 

open drains. 

Since 1994, various studies reporting the use of mesh for 

management of SIH have been published with good short- 

and long-term results; however, some of these studies do not 

distinguish, with certainty, incarcerated from SIH and both 

concepts were managed in an indistinct manner. Some are 

reports of individual cases and other report on larger series. 

Up to now there have been no comparative and randomized 

studies that individually confront the different techniques. 

The studies that report the use of open techniques with 

mesh and those that use laparoscopic techniques report a 

substantial decrease in morbidity and mortality. 

In 1994, Henry and Randriamanantsoa 22 proposed the 

use of prostheses in surgical emergencies. They applied 

15 mesh plugs, 32 Mersiline meshes and 7 Vicryl meshes, 

mainly through an inguinal approach. Resection was carried 

out in five cases, reporting only one wall abscess as a 

complication. 

In 1996, Gavioli et al. 32 presented their work with 31 

cases subjected to the application of a polypropylene mesh 

(29 cases) and Dacron (2 cases) preperitoneally or retromuscularly. 

They performed intestinal resection in three 

patients and omentum in 13 due to necrosis. There were no 

infections or recurrences. These authors proposed the use of 

mesh in SIH, excluding the case with severe infection due 

to gangrenous intestine, perforation and peritonitis as well 

as in those in whom colonic resection is performed. 

In 1997 Pans et al. 21 published a retrospective study suggesting 

the use of a preperitoneal prosthesis using a midline 

abdominal approach. They presented a series of 35 cases in 

which 13 resections were performed, although the degree of 

vascular involvement in the unresected cases was not speci- 


fied. Complications included two infections of the surgical 

wound that did not require mesh removal, six hematomas, 

one seroma, one recurrence 46 months later and a death unrelated 

to the surgery. No drains were left. Follow-up was 

4.2 years. 

In 2000, Mauch et al. 23 studied 44 patients: 32 with incarcerated 

inguinal hernia and 12 with SIH. These authors 

proposed a midline posterior approach and repair with mesh 

in all cases. Resection was done in 12 cases and the results 

included eight cases of wound infection, two recurrences 

and no deaths. 

The first reports of transabdominal preperitoneal laparoscopic 

management management (TAPP) combined with 

assisted intestinal resection were published by Tschudi et 

al. 16 and Watson et al. 24 in 1993 (report of isolated cases). 

Since then, other reports have been published such as the 

one from Leibl et al. 28 in 2001 that consisted of a retrospective 

study of 194 cases of incarcerated inguinal hernias. 

These authors introduced the terms “chronic incarcerated” 

and “acute incarcerated,” and performed resection in only 

six cases, reporting a morbidity of 6.6% without deaths or 

recurrences during a 26-month follow-up. 

In 2004, Ferzli et al. 27 proposed the total extraperitoneal 

(TEP) laparoscopic approach in a retrospective study of 16 

patients, of whom five were managed via a conventional 

anterior approach (type of technique was unspecified) because 

of intestinal gangrene and inflammation of the inguinal 

wall. Eleven patients began with TEP and three patients 

were converted to an open procedure, but the technique 

was not specified. A morbidity of 25% was reported and 

included a mesh infection resolved with local hygiene and a 

wound infection. These authors introduced the term “acutely 

incarcerated.” 

In 2005, Gongora 4 reported on a comparative study presenting 

38 cases of SIH divided into two groups: group A 

with 20 cases operated with different open techniques and 

group B with 18 cases operated with preperitoneal repair 

with mesh and exploratory laparotomy. Eighteen cases in 

group A required resection of some intraabdominal organ 

and 16 cases in group B. Results on morbidity and mortality 

show important differences between groups. In group A 

there were three deaths, five recurrences, five wound infections, 

two granulomas, and four re-operations. In group B 

there were no cases of recurrences, death or re-operation. 

There were two wound infections, one granuloma, one seroma 

and one case of incisional hernia. It is notable that 

the index of recurrence has statistical significance (p


anesthetic contraindications or due to the large size of the 

hernias.) Two cases required resection and one case had 

postincisional herniorrhaphy performed without recurrence 

after an 18-month follow-up. They concluded that TAPP 

can be proposed for management of SIH allowing the correction 

of the hernia and the resolution of the damage as 

well as visual control of the type of vascular injury of the 

trapped organ and its possible recovery. 

In 2009, Deeba et al. 38 presented a review paper on seven 

references captured from Medline, Ovid, Cochrane, Embase 

and Google on the laparoscopic management of SIH. They 

analyzed 328 cases reporting six conversions, 17 bowel resections 

resolved laparoscopically or by minilaparotomy 

and 34 complications (25 classified as minor). No mention 

was made of recurrence or mortality. Table 3 provides a review 

of all the authors mentioned above, emphasizing that 

there is statistical significance with p 12 h of evolution 

• intestinal occlusive syndrome with gastrointestinal 

vomiting, bloating and diffuse colic 

• systemic inflammatory response syndrome (tachycardia, 

dehydration, leukocytosis, etc.) 

• signs of peritoneal irritation 

• radiological changes with bowel loop distention, air 

fluid levels, free fluid and/or intra-abdominal collections, 

etc. 

Given these signs and symptoms, we may ascertain that 

it is possible to establish the definitive diagnosis of SIH 

Years of 

follow-up 

1994 Henry22 Inguinal approach 54 5 9 - 

1996 Gavioli32 Preperitoneal mesh 31 16 51 - 

1997 Pans21 Preperitoneal mesh 35 13 37 4.2 

2000 Mauch23 Preperitoneal mesh 44 12 27 2 

2001 Leibl28 Tapp** 194 6 3 2 

2005 

Papaziogas34 Lichtenstein 33 4 12 9 

Bassini 42 10 23 9 

2006 Rebuffat6 Tapp 28 9 32 1 

2006 Wisocky14 Lichtenstein 56 8 14 3 

Bassini 21 5 23 3 

2007 Bessa15 Lichtenstein 25 4 16 1 

2008 Dieng36 Bassini-McVay 228 16 7 3.5 

2008 Legnani37 Tapp 9 2 22 1.5 

2009 Deeba38 * Tapp-Tep*** 328 17 5 - 

2010 Góngora20 RPPM and LAPE**** 43 34 79 10 

*Review articles from 1989–2008: COCHRANE, OVID, MEDLINE, EMBASE, GOOGLE (seven articles chosen 

among 43). 

**Intraabdominal preperitoneal technique. 

***Total extraperitoneal technique. 

****Preperitoneal repair with mesh and exploratory laparotomy. 


from the preoperative period. Therefore, that this set of syndromes 

should be considered as inclusion criteria to qualify 

specific cases of SIH and to clearly differentiate incarcerated 

inguinal hernias or reduced hernias. The latter do not 

suffer vascular damage and, therefore, constitute a bias by 

their imprecise inclusion in the case series. After emphasis 

on vascular damage and its impact from SIH, treatment 

should be considered mandatory, whereas an elective procedure 

may be used for reduced or incarcerated hernias. 

In conclusion: 

• The operative technique of preperitoneal mesh repair 

and exploratory laparotomy has reduced morbidity and 

mortality in the management of SIH. 

• Proceeding with preperitoneal mesh repair and exploratory 

laparotomy would allow for resolution of all cases 

of SIH, regardless of the complications that arise and 

type of existing hernia, including more advanced cases. 

• Preperitoneal mesh repair and exploratory laparotomy 

is accessible to any surgeon because it requires no additional 

technology than what is available in any operating 

room. 

• The use of mesh in hernias and/or in potentially contaminated 

areas should not be considered a contraindication. 

• All inguinal hernias must undergo a tension-free plasty 

in the shortest time possible, especially in the case of 

patients >60 years of age. 

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