Strangulated hernia: a tender, irreducible, tense lump with overlying skin change or features of obstruction. This is a surgical emergency: the bowel is ischaemic.
Types
- Inguinal: commonest (indirect more than direct)
- Femoral: narrow neck, below and lateral to the pubic tubercle, high strangulation risk, commoner in women
- Incisional, umbilical and parastomal
Spectrum of severity
- Reducible: lump reduces, no acute concern
- Incarcerated: irreducible but not yet ischaemic
- Obstructed: colicky pain, vomiting, distension
- Strangulated: continuous pain, tenderness, systemic upset, ischaemia
Reducible
- Soft, non-tender, reduces
- Elective repair
- Safety-net advice
Incarcerated
- Irreducible and tender
- Risk of obstruction
- Urgent surgical review
Strangulated
- Severe pain, skin change, unwell
- Bowel ischaemia risk
- Resuscitate and emergency surgery
Management
1
1. Diagnose
Examine standing and lying, check reducibility and a cough impulse. Examine all hernial orifices. USS or CT if uncertain or for obstruction.
Examine standing and lying, check reducibility and a cough impulse. Examine all hernial orifices. USS or CT if uncertain or for obstruction.
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2
2. Reduce or not
Gentle reduction only if early incarceration without peritonism (senior decision). Do not reduce a tender strangulated hernia (risk of returning dead bowel).
Gentle reduction only if early incarceration without peritonism (senior decision). Do not reduce a tender strangulated hernia (risk of returning dead bowel).
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3
3. Resuscitate
Nil by mouth, NG tube and IV fluids if obstructed. Analgesia. Antibiotics and crossmatch if ischaemic bowel is suspected.
Nil by mouth, NG tube and IV fluids if obstructed. Analgesia. Antibiotics and crossmatch if ischaemic bowel is suspected.
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4
4. Operate
Emergency repair with assessment of bowel viability (resect non-viable bowel). Femoral hernias warrant prompt repair even when reducible.
Emergency repair with assessment of bowel viability (resect non-viable bowel). Femoral hernias warrant prompt repair even when reducible.
Watch for
- Femoral hernia presenting as obstruction in an older woman
- Richter hernia: part of the bowel wall strangulated with few obstruction signs
- Skin erythema or discolouration over the lump
Pitfalls
- Forcing reduction of a strangulated hernia
- Missing a femoral hernia (easily overlooked)
- Delaying theatre in bowel ischaemia
- Not examining the groin in a patient with obstruction
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026