Impact of Surgical Delay on Bowel Viability in Internal Hernia: Clinical, Imaging, and Biochemical Predictors of Early Strangulation

Background: Internal hernia–related small bowel obstruction (SBO) is a time-critical condition with a high risk of rapid progression to strangulation and bowel necrosis. Early surgical decision-making is challenging because classical clinical and radiological signs of ischemia are often absent during the reversible phase. Methods:This retrospective cohort study included patients who underwent surgery for internal hernia–related SBO between January 2019 and December 2025. Admission laboratory parameters and preoperative non-enhanced abdominal computed tomography (CT) findings were analyzed. Multivariable logistic regression was used to identify predictors of bowel strangulation and factors associated with delayed surgical intervention. Clinical outcomes were compared between delayed and non-delayed surgery groups. Results: A total of 119 patients were included, of whom 82 (68.9%) had strangulated internal hernia. Lactate (OR = 3.643) and D-dimer (OR = 3.277) were independent predictors of bowel strangulation. In patients with strangulated internal hernia, the absence of peritonitis (OR = 0.021), absence of the whirlpool sign on CT (OR = 0.147), and higher base excess (OR = 1.274) were independently associated with delayed surgical intervention. Patients in the delayed surgery group had significantly higher rates of bowel resection (85.7% vs. 53.2%), bowel necrosis, and longer hospital stays compared with those undergoing timely surgery. Conclusion: Surgical delay in internal hernia–related SBO is frequently driven by deceptively mild clinical and radiological findings during early ischemia. While lactate and D-dimer indicate established strangulation, base excess—together with non-enhanced CT features—may provide earlier warning of mesenteric compromise. An integrated interpretation of laboratory and imaging findings may facilitate earlier surgical intervention, reduce bowel resection, and improve clinical outcomes.