Hernia Reduction

imagesIncarcerated hernias should have attempted manual reduction

imagesTechniques for reduction are applicable to both the adult and pediatric patient


imagesStrangulated Hernia

   imagesRecognize signs and symptoms, including extreme tenderness, skin discoloration, erythema, peritoneal signs, evidence of bowel obstruction, free air on x-ray, fever, or shock

   imagesIf a strangulated hernia is missed and manual reduction is attempted, necrotic bowel can be introduced into the abdomen, worsening clinical outcome


imagesMild pain during procedure is common, but should resolve when hernia is reduced

imagesRisk of incomplete reduction or unsuccessful reduction

imagesMedications for procedural sedation may be used and sedation risks should be addressed

imagesAlternative therapy usually is surgical repair of defect



   imagesIndirect inguinal hernia—occurs superior to the inguinal ligament and passes through the inguinal ring into the inguinal canal

   imagesDirect 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

   imagesFemoral hernia—peritoneal contents protrude into the femoral canal inferior to the inguinal ligament; more prevalent in females


   imagesIncisional hernia—iatrogenic due to breakdown of fascial closure after abdominal surgery

   imagesUmbilical hernia—due to failure of closure of the umbilical ring, with a high incidence occurring in children

   imagesSpigelian hernia—also known as a lateral ventral hernia, arises when peritoneum protrudes through Spigelian fascia


   imagesPerineal 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



   imagesProvide adequate analgesia and sedation

   imagesIce or cold compress applied to the hernia may assist reduction


   imagesPlace patient in 20-degree Trendelenburg position for groin hernias, or in position such that gravity assists reduction

   imagesSupine positioning is adequate for reduction of umbilical, ventral, and incisional hernias

   imagesAllow patient to remain in position for up to 30 minutes to allow for spontaneous reduction


   imagesPosition thumb and index finger along the lateral edges of the defect with your nondominant hand

   imagesGently reduce the hernia through the external and internal rings using slow steady pressure, guiding the proximal portion first

   imagesSuccessful reduction is indicated by disappearance of the hernia mass, reduction in pain, and often a gurgling sound

   imagesRepeated failed attempts or significant pain should prompt surgical consultation


imagesInjury to underlying bowel due to excessive force

imagesReduction of bowel into a preperitoneal location

imagesDevelopment of a Richter hernia in which one side of the bowel wall remains incarcerated in the fascial defect after reduction

imagesReduction en masse—return of strangulated bowel to the abdomen, leading to further bowel ischemia and necrosis



   imagesStart with adequate positioning and analgesia to increase likelihood of success

   imagesA period of proper positioning and ice application will increase likelihood of success

   imagesConsider ultrasonography to evaluate anatomy and confirm etiology of mass, especially in children or when it is not a clinically obvious hernia


   imagesRecognize signs of strangulation and involve surgical services early

   imagesPediatric 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

   imagesComplications are greater with femoral hernias, advanced age, and female gender

   imagesChronically incarcerated hernias may not be amenable to nonsurgical reduction, and are not usually associated with strangulation or significant pain

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Hernia Reduction
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