Incarcerated (Strangulated) Hernia

An incarcerated hernia occurs when herniated tissue becomes trapped and cannot be pushed back into the abdomen. If blood supply is cut off, it progresses to a strangulated hernia, which is a surgical emergency requiring immediate intervention to prevent tissue death and severe complications.

Symptoms of an incarcerated hernia include persistent pain, swelling, and tenderness at the hernia site. Strangulation adds alarming signs such as fever, nausea, vomiting, and skin discoloration. These manifestations indicate ischemia and necrosis, demanding urgent evaluation and surgical management.

Risk factors for incarceration and strangulation involve large hernia defects, delayed treatment, and increased abdominal pressure. Patients with chronic constipation, heavy physical activity, or prior abdominal surgeries are at higher risk. Awareness of these triggers helps reduce complication rates.

Surgical repair remains the only curative option for strangulated hernia. Emergency surgery involves resection of necrotic tissue if present, followed by hernia defect closure, often with mesh support. Early diagnosis and rapid surgical intervention significantly lower morbidity and mortality rates.

What Exactly Is a Strangulated Hernia?

A strangulated hernia is a critical medical condition in which the piece of tissue or organ that has entered the hernia sac (usually intestine or intra-abdominal fat) becomes trapped and, because of this entrapment, its blood supply is completely cut off. Imagine there is a weakness or tear in your abdominal wall, and tissue is pushing outward through it. If that tissue becomes stuck in the opening and cannot return, we first call this “hernia incarceration.” At this stage the tissue is still viable but trapped. If the entrapment becomes so severe that the vessels supplying the tissue are compressed, blood flow stops and “strangulation” occurs—this is the strangulated hernia in question. Lack of blood flow deprives the tissue of oxygen and nutrients (ischemia). Unless corrected quickly, the tissue begins to die (necrosis). Dead tissue can turn gangrenous and lead to dangerous infections (sepsis) throughout the body. Therefore, a strangulated hernia is a life-threatening emergency requiring urgent surgery. Any type of hernia can strangulate, though the risk is higher in some forms. It is vital to know that a hernia can first incarcerate and then, by loss of blood flow, strangulate—showing why early diagnosis and treatment of hernias are so important.

What Causes a Strangulated Hernia?

A strangulated hernia usually develops when a pre-existing hernia becomes incarcerated. If the opening in the abdominal wall is narrow, especially when a large amount of tissue tries to protrude, the risk of strangulation rises. Once tissue passes through this tight opening, it may not pass back and becomes trapped. Over time the entrapment worsens, blocking the blood vessels that supply the tissue. Conditions that suddenly raise intra-abdominal pressure can promote entrapment and strangulation—lifting a heavy object, intense and prolonged coughing, straining during defecation, and similar events. Sometimes the exact trigger is unclear, but the basic mechanism is overfilling and trapping of contents in the hernia sac. Certain hernia types, such as femoral hernias, carry higher risk because they exit through inherently narrower canals. The relation between the size of the hernia opening and the amount of tissue protruding is a key factor: squeezing a large piece of tissue through a small defect increases the chance of entrapment and impaired blood flow, whereas very wide defects may have a lower strangulation risk (though they can cause other problems).

Who Is at Risk for a Strangulated Hernia?

The fundamental risk factor for developing a strangulated hernia is already having a hernia, because strangulation is a complication of an existing hernia. If you have a hernia, you potentially carry the risk of strangulation. Femoral hernias, in particular, are more prone to strangulation. Additionally, any condition or activity that raises intra-abdominal pressure increases the risk:

• Pregnancy: As the uterus enlarges, intra-abdominal pressure naturally rises.
• Chronic cough: Persistent coughing due to smoking or COPD strains the abdominal muscles and raises pressure.
• Chronic constipation: Repeated straining is a significant factor.
• Heavy lifting: Especially frequent lifting with poor technique or strenuous work.
• Obesity: Excess weight places constant pressure on the abdominal wall.

Conditions that weaken body tissues can also raise risk—for example, connective tissue disorders. Previous abdominal surgeries (including cesarean section) create weak spots at incision sites, predisposing to hernia formation and thus strangulation. Advancing age weakens muscles naturally, increasing hernia and complication risk. Remember that strangulation usually follows incarceration; therefore, factors promoting incarceration indirectly heighten strangulation risk.

What Are the Symptoms of a Strangulated Hernia?

• Sudden and Severe Pain: Sharp, constant, rapidly worsening pain at the hernia site—far stronger than previous hernia discomfort.
• Nausea and Vomiting: Common, especially if intestine is involved, due to bowel obstruction or ischemia.
• Fever: Body reaction to infection or tissue damage.
• Skin Discoloration: Redness, bluish-purple, or dark discoloration over the hernia bulge—sign of inadequate blood supply.
• Inability to Pass Gas or Stool: If intestine is trapped, bowel movement may cease (bowel obstruction).
• Tenderness and Hardness: The bulge becomes extremely tender, firm, and cannot be reduced (pushed back in).
• General Weakness and Rapid Heartbeat: Systemic response to this emergency.

What Is the Difference Between a Strangulated Hernia and an Ordinary Hernia?

• Blood Flow: In an ordinary hernia blood circulation continues; in a strangulated hernia, vessels are compressed and flow stops—leading to tissue death.
• Pain: Ordinary hernias are often painless or cause mild, activity-related discomfort. Strangulated hernias cause sudden, severe, constant pain.
• Reducibility: Ordinary hernias can often be gently pushed back (especially when lying down). Incarcerated or strangulated hernias cannot; they are fixed and hard.
• Appearance and Touch: Ordinary bulges are soft with normal skin color; strangulated bulges are firm, extremely tender, with skin color changes.
• Systemic Symptoms: Ordinary hernias rarely cause fever, nausea, or vomiting; strangulated hernias often do.
• Urgency: Ordinary hernias require planned medical follow-up; strangulated hernias are absolute surgical emergencies.

How Is a Strangulated Hernia Diagnosed?

Diagnosis starts with patient history and physical examination, then is confirmed with imaging.

The physician listens to your complaints (pain onset, severity, other symptoms) and carefully examines the hernia site—checking for hardness, extreme tenderness, irreducibility, and skin discoloration.

Imaging tests:

• Ultrasonography (US): Common first choice—shows sac contents, possible bowel obstruction, and, with Doppler, presence or absence of blood flow.
• Computed Tomography (CT): Provides detailed information about hernia location, contents, bowel wall condition, and complications—frequently preferred if US is inconclusive or suspicion is high.
• MRI: Very sensitive but less practical in emergencies; not usually first choice.
• Laboratory Tests: CBC may show elevated white blood cells; lactate level may hint at ischemia.

What Should Be Done Immediately If a Strangulated Hernia Is Suspected?

The only correct and life-saving action is to go to the nearest emergency department without delay. Trying to push the hernia back yourself is not recommended and can be dangerous—especially if skin discoloration is present. In an emergency room, doctors rapidly assess, perform necessary tests, and, if diagnosis is confirmed, prepare for urgent surgery. Intravenous fluids and broad-spectrum antibiotics are started beforehand. Remember: seeking professional medical help immediately is crucial; waiting greatly increases complications and mortality risk.

Which Surgical Methods Are Used to Treat a Strangulated Hernia?

The sole definitive treatment is emergency surgery. Goals: release trapped tissue, restore blood flow, assess tissue viability, and repair the hernia defect.

• Open Surgery: Usually preferred. A single larger incision over the hernia provides direct access. The surgeon first relieves the constriction, then checks viability. If tissue is healthy, it is returned; if necrotic, the dead part (e.g., bowel segment) is resected and healthy ends are joined (anastomosis). Finally, the abdominal wall defect is closed—often with sutures plus a synthetic mesh. If bowel resection or infection is present, synthetic mesh may be avoided or a biological mesh used.
• Laparoscopic/Robotic Approaches: In selected cases and with experienced surgeons, minimally invasive methods may be used, but in many emergencies—especially when bowel resection is likely—open surgery remains the safer option.

What Happens If a Strangulated Hernia Is Not Treated?

Untreated strangulated hernias have extremely serious and fatal consequences. Ischemic tissue starts dying within hours (gangrene). Dead tissue releases toxins, causing severe pain and rapid deterioration. Bacteria and toxins enter the blood, leading to sepsis, which triggers organ failure and shock. If intestine is involved, obstruction develops, and the necrotic bowel wall may perforate, spilling contents into the abdomen and causing peritonitis. All can be fatal without urgent surgery.

What Awaits Patients in the Long Term After Strangulated Hernia Surgery?

With timely and appropriate surgery, long-term outcomes are generally good. Recovery depends on pre-operative health, age, duration of strangulation, and whether bowel resection was necessary. Simple repair heals faster; resection extends recovery to six weeks or more. Hospital stays are longer than for elective hernia repairs. Possible postoperative issues include chronic pain, infection, bleeding, nerve injury, and recurrence. Strict adherence to postoperative instructions (wound care, pain control, activity limits) minimizes risks. Regular follow-up and compliance with recommendations are vital for long-term health.

Frequently Asked Questions

What are the symptoms of a strangulated hernia?

A strangulated hernia presents with sudden symptoms such as severe abdominal pain, swelling, nausea, and vomiting. The hernia area becomes hard and painful to touch. This condition requires emergency surgery.

What is the difference between an incarcerated hernia and a strangulated hernia?

An incarcerated hernia occurs when the intestine or tissue is trapped inside the hernia sac. A strangulated hernia develops when the blood supply to the trapped tissue is compromised. Strangulation carries the risk of tissue death and is more dangerous.

Why is a strangulated hernia life-threatening?

When blood supply to the intestine is cut off, the tissue quickly dies, which can lead to bowel perforation and peritonitis. This increases the risk of sepsis. If untreated, it can become life-threatening in a short time.

Who is at higher risk of developing a strangulated hernia?

People with long-standing hernias, those doing heavy physical work, or those with chronic cough or constipation are at increased risk. Older age and obesity also make strangulation more likely.

How does a strangulated hernia progress during pregnancy?

In pregnancy, increased intra-abdominal pressure facilitates hernia formation. If strangulation occurs, it poses serious risks for both mother and baby. Emergency surgery may be required, and the process should be managed in a multidisciplinary way.

What imaging methods are used in the diagnosis of a strangulated hernia?

Physical examination is usually sufficient for diagnosis. However, in uncertain cases, ultrasound and CT scan are preferred to evaluate the hernia contents and check for strangulation.

How is surgery for a strangulated hernia performed?

During surgery, the trapped tissue is released and its blood supply is assessed. Viable tissue is preserved, while necrotic parts are removed. The hernia is then repaired. Surgery is generally performed under emergency conditions.

What happens if bowel resection is necessary after a strangulated hernia?

If intestinal tissue has died, the affected segment is surgically removed. The remaining healthy ends are then reconnected. This may temporarily affect bowel function but is life-saving.

What is the recovery process after strangulated hernia surgery?

Patients usually get up within a few days, but if bowel resection was performed, recovery takes longer. Nutrition is gradually reintroduced, and full recovery may take several weeks. Regular follow-up is important.

Can a strangulated hernia recur?

With modern surgical repair techniques, the risk of recurrence is low. However, factors such as obesity, heavy lifting, and chronic coughing may still increase the chance of a new hernia developing.

Dr. Ahmet Bekin

Op. Dr. Ahmet Bekin was born in Istanbul in 1983. He graduated from the Faculty of Medicine at Kocaeli University in 2006 and completed his specialty training in the Department of General Surgery at Istanbul University Çapa Faculty of Medicine in 2011. After his specialization, he worked in the fields of hernia surgery, reflux surgery, obesity surgery, advanced laparoscopic surgery, and robotic surgery. In addition, he received training in endocrine surgery, oncological surgery, and minimally invasive surgery. He is currently accepting patients from Turkey as well as from countries such as Germany and France at his private clinic located in Istanbul.