Hernia Reduction

imagesIncarcerated hernias should have attempted manual reduction


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


CONTRAINDICATIONS



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


RISK/CONSENTS



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


LANDMARKS AND ETIOLOGY



imagesGroin


   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


imagesVentral


   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


imagesPelvic


   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


TECHNIQUE



imagesPreparation


   imagesProvide adequate analgesia and sedation


   imagesIce or cold compress applied to the hernia may assist reduction


imagesPositioning


   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


imagesReduction


   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


COMPLICATIONS



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


SAFETY/QUALITY TIPS




imagesProcedural


   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


imagesCognitive


   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

Only gold members can continue reading. Log In or Register to continue

Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Hernia Reduction
Premium Wordpress Themes by UFO Themes