Incarcerated hernias should have attempted manual reduction
Techniques for reduction are applicable to both the adult and pediatric patient
CONTRAINDICATIONS
Strangulated Hernia
Recognize signs and symptoms, including extreme tenderness, skin discoloration, erythema, peritoneal signs, evidence of bowel obstruction, free air on x-ray, fever, or shock
If a strangulated hernia is missed and manual reduction is attempted, necrotic bowel can be introduced into the abdomen, worsening clinical outcome
RISK/CONSENTS
Mild pain during procedure is common, but should resolve when hernia is reduced
Risk of incomplete reduction or unsuccessful reduction
Medications for procedural sedation may be used and sedation risks should be addressed
Alternative therapy usually is surgical repair of defect
LANDMARKS AND ETIOLOGY
Groin
Indirect inguinal hernia—occurs superior to the inguinal ligament and passes through the inguinal ring into the inguinal canal
Direct inguinal hernia—protrusion through an acquired weakness in Hesselbach triangle formed by the rectus sheath, inferior epigastric vessels, and the inguinal ligament; does not pass through inguinal canal
Femoral hernia—peritoneal contents protrude into the femoral canal inferior to the inguinal ligament; more prevalent in females
Ventral
Incisional hernia—iatrogenic due to breakdown of fascial closure after abdominal surgery
Umbilical hernia—due to failure of closure of the umbilical ring, with a high incidence occurring in children
Spigelian hernia—also known as a lateral ventral hernia, arises when peritoneum protrudes through Spigelian fascia
Pelvic
Perineal hernia—often develops after pelvic surgery or in patients with chronic constipation or atrophy of pelvic floor muscles and can contain fluid, fat, or intestinal contents
TECHNIQUE
Preparation
Provide adequate analgesia and sedation
Ice or cold compress applied to the hernia may assist reduction
Positioning
Place patient in 20-degree Trendelenburg position for groin hernias, or in position such that gravity assists reduction
Supine positioning is adequate for reduction of umbilical, ventral, and incisional hernias
Allow patient to remain in position for up to 30 minutes to allow for spontaneous reduction
Reduction
Position thumb and index finger along the lateral edges of the defect with your nondominant hand
Gently reduce the hernia through the external and internal rings using slow steady pressure, guiding the proximal portion first
Successful reduction is indicated by disappearance of the hernia mass, reduction in pain, and often a gurgling sound
Repeated failed attempts or significant pain should prompt surgical consultation
COMPLICATIONS
Injury to underlying bowel due to excessive force
Reduction of bowel into a preperitoneal location
Development of a Richter hernia in which one side of the bowel wall remains incarcerated in the fascial defect after reduction
Reduction en masse—return of strangulated bowel to the abdomen, leading to further bowel ischemia and necrosis
SAFETY/QUALITY TIPS
Procedural
Start with adequate positioning and analgesia to increase likelihood of success
A period of proper positioning and ice application will increase likelihood of success
Consider ultrasonography to evaluate anatomy and confirm etiology of mass, especially in children or when it is not a clinically obvious hernia
Cognitive
Recognize signs of strangulation and involve surgical services early
Pediatric populations have a high incidence of hernias and can be diagnostically difficult as hernias tend to spontaneously reduce and symptoms may be nonspecific, such as irritability, intermittent vomiting, or abdominal pain
Complications are greater with femoral hernias, advanced age, and female gender
Chronically incarcerated hernias may not be amenable to nonsurgical reduction, and are not usually associated with strangulation or significant pain