Hernia Reduction

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