Hernias Treatment & Management

  • Author: Bret A Nicks, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Jan 25, 2010
 

Emergency Department Care

  • Reduction of a hernia[2, 9, 15]
    • Provide adequate sedation and analgesia to prevent straining or pain. The patient should be relaxed enough to not increase intra-abdominal pressure or to tighten the involved musculature.
    • Place the patient supine with a pillow under his or her knees.
    • Place the patient in a Trendelenburg position of approximately 15-20° for inguinal hernias.
    • Apply a padded cold pack to the area to reduce swelling and blood flow while establishing appropriate analgesia.
    • Place the ipsilateral leg in an externally rotated and flexed position resembling a unilateral frog leg position.
    • Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding over the ring during reduction attempts.
    • Firm, steady pressure should be applied to the side of the hernia contents close to the hernia opening, guiding it back through the defect.
    • Applying pressure at the apex, or first point, that is felt may cause the herniated bowel to "mushroom" out over the hernia opening instead of advancing through it.
    • Consult with a surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use repeated forceful attempts.
    • The spontaneous reduction technique requires adequate sedation/analgesia, Trendelenburg positioning, and padded cold packs applied to the hernia for a duration of 20-30 minutes. This can be attempted prior to manual reduction attempts.
    • Also see Hernia Reduction.
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Consultations

Consult a surgeon for the following reasons:[1, 16, 3]

  • Inability to reduce the hernia
  • Concern for a strangulated bowel and a patient with a toxic appearance
  • Patients with comorbid risks for sedation should have a surgeon present for the initial reduction attempt
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Contributor Information and Disclosures
Author

Bret A Nicks, MD  Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Wake Forest University Health Sciences

Bret A Nicks, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Christian Medical & Dental Society, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Kim Askew, MD  Assistant Professor, Department of Emergency Medicine, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard Lavely, MD, JD, MS, MPH  Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine

Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  2. Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann. Dec 2001;30(12):729-35. [Medline].

  3. Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med. May-Jun 1999;17(3):515-6. [Medline].

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  7. Wants GE. Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994.

  8. Mensching JJ, Musielewicz AJ. Abdominal wall hernias. Emerg Med Clin North Am. Nov 1996;14(4):739-56. [Medline].

  9. Manthey DE. Abdominal hernia reduction. In: Clinical Procedures in Emergency Medicine. 2003.

  10. Brandt ML. Pediatric hernias. Surg Clin North Am. Feb 2008;88(1):27-43, vii-viii. [Medline].

  11. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. Jun 1993;73(3):413-26. [Medline].

  12. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am. Dec 1998;78(6):941-51, v-vi. [Medline].

  13. Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. Aug 1998;45(4):773-89. [Medline].

  14. Akbulut S, Cakabay B, Sezgin A. A familial tendency for developing inguinal hernias: study of a single family. Hernia. Aug 29 2009;[Medline].

  15. Smith S. Inguinal hernia reduction. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:840-847/87.

  16. Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med. Feb 2006;30(2):155-7. [Medline].

 
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Anatomic locations for various hernias.
 
 
 
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