The importance of predictive markers in incarcerated abdominal wall hernia

Emergency abdominal wall hernia repairs play a significant role in general surgical emergencies. In such cases, the time taken to decide on surgery is crucial, as the situation may progress to necrosis, perforation, and organ resection due to strangulation following incarceration. To facilitate the early detection of this condition, studies have been conducted on various predictive markers, most of which are related to similar markers used in acute mesenteric ischemia. This study aims to assess the predictive significance of preoperative laboratory and imaging findings in incarcerated abdominal wall hernia with strangulation.

Retrospectively, 122 patients who underwent emergency surgery for incarcerated abdominal wall hernias with a preoperative diagnosis between January 1, 2018, and September 1, 2023, at the General Surgery Clinic of Samsun University Education and Research Hospital were included in the study. According to the examination of the operation notes, Group I was designated for patients who underwent bowel resection, Group II for those who underwent omental resection, and Group III for those without resection. The study investigated the association between patients 'age, gender, hernia type and side, preoperative laboratory parameters (pH, Base Excess (BE), Lactate, White Blood Cell Count (WBC), Neutrophil (N), Lymphocyte (L), Monocyte (M), Platelet (P), C-Reactive Protein (CRP), and pH/BE, pH/Lactate, Lactate/BE, N/L, N/M, L/M, N/CRP, M/P, P/CRP ratios), physical examination (PE), and imaging findings among the resection groups.

Out of the 122 patients operated with a preliminary diagnosis of acute incarcerated abdominal wall hernia, 68 were female, 34 were male, and the median age was found to be 67.16 (30-99). In the conducted statistical analysis, mean values of Lactate (p = 0.007), WBC (White Blood Cell) (p = 0.001), Neutrophil (p < 0.001), and NLR (Neutrophil-to-Lymphocyte Ratio) (p = 0.003) were significantly different based on resection groups. Subsequent pairwise comparisons indicated that these differences were attributed to variations in mean values of Lactate, WBC, Neutrophil, and NLR between the Bowel Resection and Resectionless groups. Mean values of Monocytes were also significantly different among resection groups (p = 0.049), and pairwise comparisons revealed that this difference was due to variations in mean values of Monocytes between the Omental Resection and Resectionless groups. The cut-off values were determined as follows in the ROC analysis: 1.2 mmol/L for Lactate, 18.5 (10^9/L) for WBC, 8.1 (10^9/L) for Neutrophil and 10 mg/L for CRP concerning bowel resection.

In cases of abdominal wall hernia operations due to incarceration, bowel and/or intra-abdominal organ resections related to strangulation can lead to significant morbidity and mortality. Beyond the imaging methods available for preoperative assessment, high levels of laboratory parameters, including Lactate, WBC, Neutrophil, and NLR ratio, may primarily indicate the need for bowel resection, considering that omental resection is associated with lower morbidity and mortality compared to bowel resection, elevated levels of monocytes may primarily indicate the requirement for omental resection in emergency abdominal wall hernia surgery. We recommend that this be prioritized in emergency surgery to prevent complications such as bowel perforation and sepsis and improve clinical outcomes. The surgeon is advised to keep this in mind.