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Clinical Procedures > Gastrointestinal Procedures
Hernia Reduction
Article Last Updated: Apr 8, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Anil Samoilenko Menon, MD, BA, MS, Resident, Stanford-Kaiser Emergency Medicine Program
Anil Samoilenko Menon is a member of the following medical societies: Aerospace Medical Association, American Academy of Emergency Medicine, Emergency Medicine Residents Association, and Wilderness Medical Society
Coauthor(s):
Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Editors: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Memorial Community Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
manual hernia reduction, taxis, incarceration, strangulation, obstruction, irreducible, reduction en masse, femoral hernia, inguinal hernia, hernia reduction, incarcerated hernia, reducible hernia
A hernia is a protrusion of tissue through a defect in its encapsulating walls. This defect occurs frequently; hernia repair is the most common operation in general surgery.1 Prior to surgical repair, manual reduction can return the tissue to its original compartment. Reduction benefits the patient by mitigating associated symptoms, avoiding adverse outcomes such as strangulation, and permitting elective surgical repair, which has lower morbidity than emergent repair.2, 3 The most common hernias amenable to reduction are described in this article.
Common Hernia Subtypes
Variations of hernia type and location.
Groin
- Indirect inguinal: Bounded by the inguinal (Hesselbach's) triangle, an indirect inguinal hernia passes through the internal inguinal ring. It is the most common hernia subtype and is more commonly seen in males.
- Direct inguinal: This type of hernia is similarly bounded by the inguinal triangle, but it passes directly through the muscular and fascial wall of the abdomen. It carries a minimal risk of incarceration.
- Femoral: Originating below the inguinal ligament, a femoral hernia passes through the transversalis fascia and through the femoral canal. It presents a high risk of incarceration.4
Anterior - Umbilical: This type of hernia is seen traversing the fibromuscular ring at the umbilicus. Commonly seen in infants, it usually resolves by the age of 5 years. Repair is indicated when an umbilical hernia is seen in older children or adults, is larger than 2 cm, or is incarcerated.5
A 50-year-old man presents with recurrent umbilical hernia, which was reduced in the emergency department. - Epigastric: An epigastric hernia is a midline hernia that passes through the linea alba.
- Spigelian: This rare type of hernia is located at the lateral edge of the rectus abdominis and passes through the semilunar line.
Manual Reduction ClassificationFor the purposes of manual reduction, hernias are best classified into 3 groups: those that are (1) easily reducible, (2) incarcerated, or (3) strangulated.6 This classification also helps direct treatment. Easily reducible
If a hernia is easily reducible, the abdominal contents can easily be returned to their original compartment. Reduction not only allows symptomatic relief for patients but also reduces the risk of future incarceration.4 - Asymptomatic: A recent large prospective trial suggests that in patients who are minimally symptomatic, nonoperative treatment can produce outcomes similar to those experienced by minimally symptomatic patients who undergo surgical repair.7
- Symptomatic: Reduction helps to alleviate symptoms, but elective surgical repair is usually warranted for long-term management.
Incarcerated
An incarcerated hernia cannot easily be returned to its original compartment. Overlying skin should appear to be normal, the contents should not be tense, and bowel sounds can sometimes be heard. The incarcerated tissue may be bowel, omentum, or other abdominal contents. A smaller aperture of herniation and adhesions can precipitate incarceration. An incarcerated hernia can often be reduced manually, especially with sufficient anesthesia.8, 9
- Obstructing: A hernia is one of the 3 most common causes of obstruction. In addition to causing signs of obstruction, an obstructed hernia has a more tense appearance than a nonobstructed hernia, and radiographs may show bowel shadows at the site of herniation.
CT scan of a 64-year-old woman with vague abdominal pain of 2 days' duration. Physical examination revealed a tender palpable mass in the left lower quadrant. CT scan reveals an incarcerated ventral hernia. - Not reducible: Even with proper sedation and technique, not every hernia can be manually reduced. In this case, surgical reduction is more urgent to prevent strangulation.10, 11
Strangulated
A strangulated hernia is a surgical emergency in which the blood supply to the herniated tissue is compromised. Strangulation stems from herniated bowel contents passing through a restrictive opening that eventually reduces venous return and leads to increased tissue edema, which further compromises circulation and stops the arterial supply. Such a hernia may be recognized in early stages by severe pain and by tenderness, induration, and erythema over the herniation site. As tissue necrosis ensues, findings may include leukocytosis, decreased bowel sounds, abdominal distension, and a patient who appears to be toxic, dehydrated, and febrile. Mortality is high and treatment should be initiated immediately.12
Erythematous edematous left scrotum in a 2-month-old boy with a history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
- The presence of a nonstrangulated hernia is an indication for manual reduction.13
- Although an incarcerated hernia can be strangulated without the usual signs and symptoms of strangulation, reduction should be performed for most incarcerated hernias when clinical evidence of strangulation is not present.
- Although strangulation can be missed,14 one prospective study showed that clinicians are usually correct in deciding when to reduce an incarcerated hernia and when to defer reduction of a strangulated hernia.8
- In addition, harmful outcomes to attempted reduction are unlikely in these unrecognized strangulated hernias.
- Manual reduction is contraindicated in strangulated hernias.
- Nasogastric suction, fluid replacement, and antibiotics can be started in the case of strangulation.
- If the diagnosis of strangulated hernia is missed and manual reduction is performed, necrotic bowel may be introduced into the abdomen. This could result in clinical deterioration and could require urgent reduction in the operating room.15
- Anesthesia is generally not required for most reductions.
- Procedural sedation is recommended if the patient is a young child. (Click here for a Medscape CME activity on pediatric procedural sedation.)
- Procedural sedation can also be used in adults, if a difficult reduction is expected or if initial attempts without sedation are unsuccessful. For more information, see Procedural Sedation.
- Epidural anesthesia has also been successfully used and might be an alternative for infants.16
- Means of anesthesia or sedation
- Cold compress
- Gurney capable of Trendelenburg positioning
- Place the patient in a 20° Trendelenburg position.
- Gravity pulls the bowel contents inward from the site of herniation and aids in reduction.
The 40-year-old man in this photo presented with left inguinal pain, swelling, and erythema consistent with a left inguinal hernia. He was placed in the Trendelenburg position to aid in reduction.
- Apply ice or cold compress to the hernia for several minutes to reduce swelling and allow for an easier reduction.
Ice pack applied to patient with left inguinal hernia in the Trendelenburg position. - To reduce an abdominal hernia, lay the patient supine. To reduce a groin hernia, place the patient in a 20º Trendelenburg position (this position allows gravity to help retract the herniated tissue into the abdomen or pelvis).
- Use sufficient sedation and analgesia if necessary to reduce pain during the procedure. A reduction in pain also aids in reducing guarding and abdominal muscular constriction, thereby decreasing the intra-abdominal pressure and permitting easier reduction.
- Wait 2-30 minutes. Some hernias self-reduce because of the application of cold compresses to reduce edema, the force of gravity, and relaxation of the muscles surrounding the hernia from sedation and analgesia.
- Slowly apply pressure distal to the hernia while guiding the proximal portion through the fascial defect. Use 2 hands to allow guidance through the fascial defect and simultaneous gentle pressure. This part of the reduction can take 5-15 minutes. Too much distal pressure causes the hernia to balloon around the fascial opening, making reduction more difficult.
Slow constant pressure applied to patient with left inguinal hernia.
Hernia content balloons over the external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied first.
Emergency department hernia reduction by surgical resident that required sedation with propofol after unsuccessful reduction attempt with opioid analgesia. - Though some references recommend a truss to temporarily close the fascial defect after successful hernia reduction, efficacy has not been proven.
- Guidance of the proximal hernia into the abdomen is the key to successfully moving the tissue through the fascial defect.
- Early sedation is an important aid to reduction and patient comfort.
- In children, a unilateral frog leg position has been shown to align the inguinal rings for better reduction.17
- Manual reduction can be complicated by worsened pain secondary to pressure and manipulation.
- A reduction en masse, by which the existing peritoneal sac and constricting neck are reduced into the abdomen without relieving the constriction is a serious complication.18 In such a case, the bowel progresses to obstruction and strangulation despite apparent reduction. The occult nature of reduction en masse may lead to delayed or missed diagnosis.
- If strangulation is not recognized, gangrenous bowel can be reduced, which leads to peritonitis and sepsis.13
Ultrasonography is certainly valuable in the diagnosis of a hernia and can be used to determine the contents of a hernia.19 In addition, ultrasonography is currently being advanced as an aid to reduction.20, 21 In this manner, the ultrasound probe can help locate the fascial defect as well as the tissue to be reduced and can give the operator a better grasp on the forces needed for reduction. Suggested technique for ultrasound-assisted reduction includes the following: - Identify the point of maximal aperture of the inguinal canal or fascial defect.
- Hold the tissue perpendicular to the plane of maximal aperture and guide it through.
- Compress the tissue from a distal point while guiding the proximal end through the aperture.
Clinical Procedures in Emergency Medicine: Abdominal Wall Hernias17
Greenfield's Surgery: Abdominal Wall Hernias15
Sabiston Textbook of Surgery: Hernias22
| Media file 2:
A 50-year-old man presents with recurrent umbilical hernia, which was reduced in the emergency department. |
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| Media file 3:
CT scan of a 64-year-old woman with vague abdominal pain of 2 days' duration. Physical examination revealed a tender palpable mass in the left lower quadrant. CT scan reveals an incarcerated ventral hernia. |
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Media type: CT
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| Media file 4:
Erythematous edematous left scrotum in a 2-month-old boy with a history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts. |
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Media type: Photo
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| Media file 5:
The 40-year-old man in this photo presented with left inguinal pain, swelling, and erythema consistent with a left inguinal hernia. He was placed in the Trendelenburg position to aid in reduction. |
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Media type: Photo
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| Media file 6:
Ice pack applied to patient with left inguinal hernia in the Trendelenburg position. |
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Media type: Photo
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| Media file 7:
Slow constant pressure applied to patient with left inguinal hernia. |
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Media type: Photo
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| Media file 8:
Emergency department hernia reduction by surgical resident that required sedation with propofol after unsuccessful reduction attempt with opioid analgesia. |
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Media type: Video
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| Media file 9:
Hernia content balloons over the external ring when reduction is attempted. |
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Media type: Illustration
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| Media file 10:
Hernia can be reduced by medial pressure applied first. |
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Media type: Illustration
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Hernia Reduction excerpt Article Last Updated: Apr 8, 2008
Topic originally published: Apr 8, 2008
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