Equipment

Equipment used in hernia reduction includes the following:

Means of anesthesia or sedation
Cold compress
Gurney capable of Trendelenburg positioning

Anesthesia

Anesthesia is generally not required for most reductions. Procedural sedation is recommended if the patient is a young child. Procedural sedation can also be used in adults if a difficult reduction is expected or if initial attempts without sedation are unsuccessful. Epidural anesthesia has also been successfully used and might be an alternative for infants.^[17]Ilioinguinal nerve blocks have been used as an adjunct for pain control for inguinal hernias.^{[18, 19]}

Positioning

For reduction of an inguinal hernia, the patient should be placed in a 20° Trendelenburg position (see the image below). Gravity pulls the bowel contents inward from the site of herniation and facilitates reduction. A supine position is appropriate for a hernia of the upper abdomen.

40-year-old man presents with left inguinal pain, swelling, and erythema consistent with left inguinal hernia. He is placed in Trendelenburg position to aid in reduction.

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Technique

Read RC. Recent advances in the repair of groin herniation. Curr Probl Surg. 2003 Jan. 40 (1):13-79. [QxMD MEDLINE Link].
Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg. 1998 Sep. 68 (9):650-4. [QxMD MEDLINE Link].
Chirdan LB, Uba AF, Kidmas AT. Incarcerated umbilical hernia in children. Eur J Pediatr Surg. 2006 Feb. 16 (1):45-8. [QxMD MEDLINE Link].
Fitch MT, Manthey DE. Abdominal hernia reduction. Roberts JR, Custalow CB, Thomsen TW, Chanmugam AS, Chudnofsky CR, DeBlieux PMC, et al, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine. 7th ed. Philadelphia: Elsevier; 2019. 897-903.
Nilsson H, Stylianidis G, Haapamäki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg. 2007 Apr. 245 (4):656-60. [QxMD MEDLINE Link].
Alvarez JA, Baldonedo RF, Bear IG, Solís JA, Alvarez P, Jorge JI. Incarcerated groin hernias in adults: presentation and outcome. Hernia. 2004 May. 8 (2):121-6. [QxMD MEDLINE Link].
Smith G, Wright JE. Reduction of gangrenous small bowel by taxis on an inguinal hernia. Pediatr Surg Int. 1996 Oct. 11 (8):582-3. [QxMD MEDLINE Link].
Askew G, Williams GT, Brown SC. Delay in presentation and misdiagnosis of strangulated hernia: prospective study. J R Coll Surg Edinb. 1992 Feb. 37 (1):37-8. [QxMD MEDLINE Link].
Kauffman HM Jr, O'Brien DP. Selective reduction of incarcerated inguinal hernia. Am J Surg. 1970 Jun. 119 (6):660-73. [QxMD MEDLINE Link].
Fitzgibbons RJ Jr, Quinn TH, Krishnamurty DM. Abdominal wall hernias. Mulholland MW, Lillemoe KD, Doherty GM, Upchurch GR Jr, Alam H, Pawlik TM, eds. Greenfield's Surgery: Scientific Principles and Practice. 6th ed. Philadelphia: Wolters Kluwer; 2017. Chap 72.
Perrott CA. Inguinal hernias: room for a better understanding. Am J Emerg Med. 2004 Jan. 22 (1):48-50. [QxMD MEDLINE Link].
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006 Jan 18. 295 (3):285-92. [QxMD MEDLINE Link].
Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg. 1993 Apr. 28 (4):582-3. [QxMD MEDLINE Link].
Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991 Oct. 78 (10):1171-3. [QxMD MEDLINE Link].
Hair A, Paterson C, Wright D, Baxter JN, O'Dwyer PJ. What effect does the duration of an inguinal hernia have on patient symptoms?. J Am Coll Surg. 2001 Aug. 193 (2):125-9. [QxMD MEDLINE Link].
Andrews NJ. Presentation and outcome of strangulated external hernia in a district general hospital. Br J Surg. 1981 May. 68 (5):329-32. [QxMD MEDLINE Link].
Brindley N, Taylor R, Brown S. Reduction of incarcerated inguinal hernia in infants using caudal epidural anaesthesia. Pediatr Surg Int. 2005 Sep. 21 (9):715-7. [QxMD MEDLINE Link].
Millat B, Borie F, Fingerhut A. Patient's preference and randomization: new paradigm of evidence-based clinical research. World J Surg. 2005 May. 29 (5):596-600. [QxMD MEDLINE Link].
Leem JG. Ultrasound-guided Nerve Blocks for Post-hernia Repair Pain. Korean J Pain. 2010 Dec. 23 (4):227-9. [QxMD MEDLINE Link].
Sinha R, Rajiah P, Tiwary P. Abdominal hernias: imaging review and historical perspectives. Curr Probl Diagn Radiol. 2007 Jan-Feb. 36 (1):30-42. [QxMD MEDLINE Link].
den Hartog D, Dur AH, Kamphuis AG, Tuinebreijer WE, Kreis RW. Comparison of ultrasonography with computed tomography in the diagnosis of incisional hernias. Hernia. 2009 Feb. 13 (1):45-8. [QxMD MEDLINE Link].
Narci A, Korkmaz M, Albayrak R, Sözübir S, Güvenç BH, Köken R, et al. Preoperative sonography of nonreducible inguinal masses in girls. J Clin Ultrasound. 2008 Sep. 36 (7):409-12. [QxMD MEDLINE Link].
Torzilli G, Del Fabbro D, Felisi R, Leoni P, Gnocchi P, Lumachi V, et al. Ultrasound-guided reduction of an incarcerated Spigelian hernia. Ultrasound Med Biol. 2001 Aug. 27 (8):1133-5. [QxMD MEDLINE Link].
Chen SC, Lee CC, Liu YP, Yen ZS, Wang HP, Huei-Ming Ma M, et al. Ultrasound may decrease the emergency surgery rate of incarcerated inguinal hernia. Scand J Gastroenterol. 2005 Jun. 40 (6):721-4. [QxMD MEDLINE Link].
Mariani PJ. Ultrasonographic diagnosis and facilitated reduction of an abdominal wall hernia. Acad Emerg Med. 2008 Jul. 15 (7):691-2. [QxMD MEDLINE Link].
Youn SI, Kim DW, Jee YS. Laparoscopic reduction of intersigmoid hernia: early surgical intervention for a rare form of internal hernia. J Surg Case Rep. 2022 Feb. 2022 (2):rjac003. [QxMD MEDLINE Link]. [Full Text].
Wright RN, Arensman RM, Coughlin TR, Nyhus LM. Hernia reduction en masse. Am Surg. 1977 Sep. 43 (9):627-30. [QxMD MEDLINE Link].
Maupoey Ibáñez J, Carreño Sáenz O, Beltrán Herrera H, Moya Sanz A, Carbonell Tatay F. En masse reduction of an incarcerated inguinal hernia. Emergency laparoscopic management. Cir Esp. 2015 Nov. 93 (9):603-5. [QxMD MEDLINE Link]. [Full Text].
Hoshiai S, Mori K, Shiigai M, Uchikawa Y, Watanebe A, Shiotani S, et al. Reduction en masse of inguinal hernia: MDCT findings of two cases. Hernia. 2015 Dec. 19 (6):999-1003. [QxMD MEDLINE Link].
Watanobe I, Yoshida N, Watanabe S, Maruyama T, Ihara A, Kojima K. Late-Onset Bowel Strangulation due to Reduction En Masse of Inguinal Hernia. Case Rep Surg. 2014. 2014:295686. [QxMD MEDLINE Link]. [Full Text].
Xu X, Hong T, Li B, Liu W, Zheng C, He X. Retroperitoneal hematoma after manual reduction of indirect inguinal hernia. Am J Emerg Med. 2013 Jul. 31 (7):1151.e1-2. [QxMD MEDLINE Link].
Taher H, Khalil H, Ahmed S, Gad M, Elezaby B, Magdy A, et al. Umbilical hernia repair post umbilical cord graft closure of gastroschisis: A cohort study. Int J Surg Case Rep. 2022 Jun. 95:107175. [QxMD MEDLINE Link]. [Full Text].
Pan C, Xu X, Si X, Yu J. Effect of complete reduction of hernia sac and transection of hernia sac during laparoscopic indirect inguinal hernia repair on seroma. BMC Surg. 2022 Apr 25. 22 (1):149. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Variations of hernia type and location.
50-year-old man presents with recurrent umbilical hernia, which is reduced in emergency department.
64-year-old woman presents with vague abdominal pain of 2 days' duration. Physical examination reveals tender palpable mass in left lower quadrant. CT reveals incarcerated ventral hernia.
Erythematous edematous left scrotum in 2-month-old boy with history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
40-year-old man presents with left inguinal pain, swelling, and erythema consistent with left inguinal hernia. He is placed in Trendelenburg position to aid in reduction.
Ice pack is applied to patient with left inguinal hernia in Trendelenburg position.
Slow constant pressure is applied to patient with left inguinal hernia.
Emergency department hernia reduction by surgical resident. Sedation with propofol is required after unsuccessful reduction attempt with opioid analgesia.
Hernia content balloons over external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied first.
Inguinal hernia reduction under ultrasonographic guidance. Video courtesy of Ultrasoundpaedia at http://www.ultrasoundpaedia.com.

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Author

Ajita R Shah, MD Resident Physician, Department of Emergency Medicine, University of Texas Health Science Center at Houston, Memorial Hermann Hospital

Ajita R Shah, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Anil Samoilenko Menon, MD, MS, MPH Assistant Professor, University of Texas Medical Branch School of Medicine

Anil Samoilenko Menon, MD, MS, MPH is a member of the following medical societies: Aerospace Medical Association, Society of United States Air Force Flight Surgeons, Wilderness Medical Society

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS Dean (Academic) and Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Fellow of the Faculty of Surgical Trainers (RCSEd), Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Gil Z Shlamovitz, MD, FACEP Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

The Chief Editor would like to acknowledge the assistance of Dr Gurushankari Balakrishnan, Surgical Oncology Resident, Cancer Institute (WIA), Adyar, Chennai, India, in updating the review of this article.

Hernia Reduction Periprocedural Care

Equipment

Patient Preparation

Anesthesia

Positioning

References

Tables

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