Strangulated & Incarcerated Hernias: Junior Doctor Guide & Clerking Template

Q: What are the red flags for an acute hernia?

Tender, tense, irreducible lump — think strangulation; Red, hot skin over the lump — think strangulation; Vomiting, distension, no flatus — think obstructed hernia; Fever, tachycardia, raised lactate — think ischaemic bowel; Lump below and lateral to the pubic tubercle — think femoral hernia — high risk; Obstruction with no visible lump — think Richter's / femoral / internal hernia

Q: What is the initial management of an acute hernia?

Analgesia (—); IV access, bloods (FBC, U&E, CRP, lactate, G&S); Nil by mouth (if obstructed or strangulated); NG tube (if vomiting/obstructed); Surgical review (urgent if irreducible or tender); CT if unclear (obstruction, ischaemia, occult hernia)

Q: What diagnoses must you not miss in an acute hernia?

Strangulated hernia (emergency surgery); Obstructed hernia (SBO); Testicular torsion (mimic) (groin/scrotal pain)

Q: What investigations should a junior doctor order for an acute hernia?

Bloods: FBC, U&E, CRP, lactate, G&S.; Imaging: Obstruction, ischaemia, occult (obturator, femoral, internal) hernias.

Q: Admit or discharge: how is the plan decided for an acute hernia?

Home: Reducible, non-tender hernia: elective surgical referral; femoral → urgent referral. Safety-net for irreducibility, pain, vomiting.; Theatre: Strangulated or obstructed hernia.

Settle them, and check the basics

strangulated?

Red flags — what each should make you think

Tender, tense, irreducible lumpstrangulation Red, hot skin over the lumpstrangulation Vomiting, distension, no flatusobstructed hernia Fever, tachycardia, raised lactateischaemic bowel Lump below and lateral to the pubic tuberclefemoral hernia — high risk Obstruction with no visible lumpRichter's / femoral / internal hernia

🩺

Pearl

Femoral hernias are small, easy to miss (especially in older women with lots of subcutaneous fat), and the most likely to strangulate. Always palpate below the inguinal ligament in a patient with bowel obstruction.

First actions

💊Analgesia
IVIV access, bloods
NBMNil by mouth
NGNG tube
☎Surgical review
CTCT if unclear

Understand the hernia

type · state

States

Reducible — goes back; elective repair
Incarcerated — irreducible but no obstruction or ischaemia
Obstructed — bowel inside is obstructed (vomiting, distension)
Strangulated — blood supply compromised: severe constant pain, tenderness, skin changes, systemic upset — emergency

Types

Inguinal (most common) — above and medial to the pubic tubercle; indirect (through deep ring, into scrotum) or direct (Hesselbach's triangle)
Femoral — below and lateral to the pubic tubercle; women, elderly; high strangulation risk → repair urgently even if not symptomatic
Umbilical / paraumbilical, incisional, epigastric, spigelian, obturator (elderly thin women, pain down the inner thigh)
Richter's — only part of the bowel wall trapped: can strangulate without obstruction

Reduction?

Gentle reduction of an incarcerated hernia may be attempted by a senior if there are no signs of strangulation, with analgesia and the patient positioned comfortably
Don't force it: risk of reducing dead bowel or "reduction en masse"
After reduction, observe for peritonitis and arrange repair

Work A–E — assess and act as you go

AAirway. Vomiting.NG tube

BBreathing. ——

CCirculation. HR, BP, dehydration.fluids

DDisability. ——

EExposure. All hernial orifices (inguinal, femoral, umbilical, incisional), scrotum, skin over the lump, abdomen.—

The diagnoses you must not miss

tap to open each

What points toward it, what would rule it in, and how to manage it.

points toward it

Tense, tender, irreducible lump, overlying skin changes, constant pain, systemic upset.

rule in

Clinical ± CT.

manage it

Resuscitate, IV antibiotics if ischaemia suspected, emergency repair ± bowel resection.

Source: WSES guidelines — complicated abdominal wall hernias

points toward it

Small bowel obstruction with an irreducible hernia.

rule in

CT.

manage it

Drip and suck, urgent surgery. See the bowel obstruction page.

Source: Bowel obstruction page

points toward it

Sudden scrotal pain, high-riding testis.

rule in

Clinical.

manage it

See the testicular torsion page.

Source: Testicular torsion page

Investigate — what to order, when, and what it tells you

test with a question in mind

Bloods

Routine

FBC, U&E, CRP, lactate, G&S.

Imaging

Obstruction, ischaemia, occult (obturator, femoral, internal) hernias.

USS

Groin lumps when uncertain (non-urgent).

How the plan comes together

disposition · handover

home

Reducible, non-tender hernia: elective surgical referral; femoral → urgent referral. Safety-net for irreducibility, pain, vomiting.

theatre

Strangulated or obstructed hernia.

Hand over: type, state, duration irreducible, bloods, CT.

🩺

Pearl

Examine every orifice, especially the femoral canal, and treat a tender, irreducible lump as strangulated. Don't force a reduction. Nicely done getting here.

✎

Clerking template

copy or download

Hernias — documentation structure

A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.

HERNIAS — CLERKING TEMPLATE PRESENTING COMPLAINT: HISTORY OF PRESENTING COMPLAINT Lump — site / duration / reducible before? / when became irreducible: Pain — constant / colicky: Vomiting / bowels / flatus: Previous surgery at that site: RED FLAGS ASKED (record present or absent) [ ] Tender, tense, irreducible lump -> strangulation [ ] Red, hot skin over the lump -> strangulation [ ] Vomiting, distension, no flatus -> obstructed hernia [ ] Fever, tachycardia, raised lactate -> ischaemic bowel [ ] Lump below and lateral to the pubic tubercle -> femoral hernia — high risk [ ] Obstruction with no visible lump -> Richter's / femoral / internal hernia SCORES / KEY CHECKS Hernia type: State: reducible / incarcerated / obstructed / strangulated Skin changes / tenderness: Lactate: Surgical review (time): PAST MEDICAL HISTORY: DRUG HISTORY: ALLERGIES: SOCIAL HISTORY (smoking / alcohol / function / who's at home): FAMILY HISTORY: OBSERVATIONS: RR SpO2 ( % O2) HR BP Temp GCS NEWS2 EXAMINATION A - B - C - D - (GCS pupils glucose ) E - INVESTIGATIONS ORDERED: IMPRESSION: DIFFERENTIALS CONSIDERED: [ ] Strangulated hernia [ ] Obstructed hernia [ ] Testicular torsion (mimic) [ ] Lymph node [ ] Hydrocele / varicocele [ ] Lipoma [ ] Saphena varix [ ] Femoral aneurysm PLAN: 1. 2. 3. ESCALATION / SENIOR DISCUSSION: Discussed with: Time: Advice: SAFETY NET / IF DETERIORATES: Documented by: Grade: Date/Time:

Test yourself

active recall

Cover the answer, say it out loud, then reveal. Retrieval beats re-reading.

0 / 9 known

Red flag

Tender, tense, irreducible lump — what should it make you think?

strangulation

Red flag

Red, hot skin over the lump — what should it make you think?

strangulation

Red flag

Vomiting, distension, no flatus — what should it make you think?

obstructed hernia

Red flag

Fever, tachycardia, raised lactate — what should it make you think?

ischaemic bowel

Red flag

Lump below and lateral to the pubic tubercle — what should it make you think?

femoral hernia — high risk

Red flag

Obstruction with no visible lump — what should it make you think?

Richter's / femoral / internal hernia

Must not miss

How do you rule in strangulated hernia?

Clinical ± CT.

Must not miss

How do you rule in obstructed hernia?

CT.

Must not miss

How do you rule in testicular torsion (mimic)?

Clinical.

Frequently asked questions

quick answers

What are the red flags for an acute hernia?

Tender, tense, irreducible lump — think strangulation
Red, hot skin over the lump — think strangulation
Vomiting, distension, no flatus — think obstructed hernia
Fever, tachycardia, raised lactate — think ischaemic bowel
Lump below and lateral to the pubic tubercle — think femoral hernia — high risk
Obstruction with no visible lump — think Richter's / femoral / internal hernia

What is the initial management of an acute hernia?

Analgesia — —
IV access, bloods — FBC, U&E, CRP, lactate, G&S
Nil by mouth — if obstructed or strangulated
NG tube — if vomiting/obstructed
Surgical review — urgent if irreducible or tender
CT if unclear — obstruction, ischaemia, occult hernia

Always alongside senior support and your local guideline.

What diagnoses must you not miss in an acute hernia?

Strangulated hernia — emergency surgery
Obstructed hernia — SBO
Testicular torsion (mimic) — groin/scrotal pain

Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.

What investigations should a junior doctor order for an acute hernia?

Bloods — FBC, U&E, CRP, lactate, G&S.
Imaging — Obstruction, ischaemia, occult (obturator, femoral, internal) hernias.

Admit or discharge: how is the plan decided for an acute hernia?

Home — Reducible, non-tender hernia: elective surgical referral; femoral → urgent referral. Safety-net for irreducibility, pain, vomiting.
Theatre — Strangulated or obstructed hernia.

Is there a clerking template for an acute hernia?

Yes — there is a clerking template for an acute hernia on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.

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