Prepare for USMLE Step 2 with our QOTD on limited hip abduction, Developmental Dysplasia of the Hip, & Barlow maneuver. Strengthen your exam knowledge.
A 58-year-old man presents to the primary care office for evaluation of a painful abdominal lump for the last six months. He states the lump becomes painful when he lifts heavy objects. He has not had fevers, nausea, or vomiting, and his bowel movements are regular. Past medical history is significant for type II diabetes and his last HbA1c was 9.1%. He travels for work and often forgets to bring his medications. Temperature is 37.0°C (98.6°F), pulse is 80/min, respiratory rate is 16/min, and blood pressure is 124/80 mmHg. Exam reveals a 3.1 cm soft, non-tender hernia over the lower midline of the abdominal wall which cannot be reduced. There are no skin changes over the affected area. Which of the following is the best next step in management?
A. Elective surgical repair following hyperglycemic control
B. Elective surgical repair within one week
C. Urgent surgical repair within 12 hours
D. Referral to the emergency department for surgical consultation
E. Watchful waiting and surgical repair only if signs of strangulation occur
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 CK Question is…
A. Elective surgical repair following hyperglycemic control
Before we get to the Main Explanation, let’s see why the answer wasn’t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today’s incorrect answers are…
B. Elective surgical repair within one week
Incorrect: This patient should be medically optimized prior to elective surgery given the chronic nature of the hernia and absence of strangulation. Undergoing surgery while his diabetes is poorly controlled would place him at an increased risk for surgical complications, therefore time and care should be taken to get his diabetes under control.
C. Urgent surgical repair within 12 hours
Incorrect: Given the chronic nature of the hernia and the fact that there are no signs or symptoms of strangulation, an elective repair is appropriate after medical optimization.
D. Referral to the emergency department for surgical consultation
Incorrect: Emergency department evaluation with same-day surgical consultation would be indicated for an acute incarcerated hernia or if signs of strangulation were present. This patient has reported mild symptoms for six months and signs of strangulation are absent. Elective repair following medical optimization is appropriate.
E. Watchful waiting and surgical repair only if signs of strangulation occur
Incorrect: An incarcerated hernia requires surgical repair. This patient’s hyperglycemia can be treated which will place him at a lower surgical risk.
Main Explanation
This patient presents with six months of symptoms and a non-reducible bulge in the abdominal wall, consistent with a chronically incarcerated ventral hernia. Elective surgical repair is appropriate once medical optimization of modifiable risk factors (i.e. poorly controlled diabetes) has been achieved.
Most ventral hernias require surgical repair due to the high lifetime risk of complications when left untreated. Elective repair is appropriate for symptomatic reducible hernias and for hernias that have been chronically incarcerated over weeks, months, or years. Due to the elective nature of these repairs, modifiable risk factors such as smoking, poorly controlled diabetes, alcohol use, severe obesity, and CHF should be optimized prior to surgery to reduce the risk of complications.
Small, asymptomatic hernias may be managed with watchful waiting in patients who wish to avoid surgery. It is reasonable to attempt to reduce an acutely incarcerated hernia which has been present for only a few hours; however, the likelihood of success is low and given the risk of strangulation, urgent surgical consultation should be pursued if reduction fails. Emergent surgical consultation is essential when a strangulated hernia is suspected, as patients with necrotic bowel may become septic.
Major takeaway
Elective surgical repair is indicated for chronically incarcerated ventral hernias once modifiable risk factors have been optimized to prevent surgical complications.
References
Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011 Jan 19;2(1):5. doi: 10.1258/shorts.2010.010071. PMID: 21286228; PMCID: PMC3031184. ––––––––––––
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