Hernia Reduction Technique

Updated: Feb 28, 2017
  • Author: Ajita R Shah, MD; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Reduction of Hernia

Apply ice or cold compress to the hernia for several minutes to reduce swelling and allow an easier reduction (see the image below).

Ice pack is applied to patient with left inguinal Ice pack is applied to patient with left inguinal hernia in Trendelenburg position.

To reduce an abdominal hernia, lay the patient supine. [4] 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). In children, a unilateral frog leg position has been shown to align the inguinal rings for better reduction.

Use sufficient early sedation and analgesia if necessary to reduce pain during the procedure. A reduction in pain also helps decrease guarding and abdominal muscular constriction, thereby lowering 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 into the abdomen through the fascial defect (see the images and the video below). Use two hands to facilitate 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 is applied to patient with Slow constant pressure is applied to patient with left inguinal hernia.
Hernia content balloons over external ring when re Hernia content balloons over external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied f Hernia can be reduced by medial pressure applied first.
Emergency department hernia reduction by surgical resident. Sedation with propofol is required after unsuccessful reduction attempt with opioid analgesia.

Although some references recommend a truss for temporary closure of the fascial defect after successful hernia reduction, the efficacy of this measure has not been proved.

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Ultrasonography as Aid to Reduction

Ultrasonography is certainly valuable in the diagnosis of a hernia and can be used to determine the contents of a hernia. [20]  One study that used computed tomography (CT) as the criterion standard showed a moderate sensitivity and high specificity for ultrasonographic diagnosis of incisional hernias. [21]  A smaller case review found ultrasonography less useful in children. [22]

Ultrasonography has been advanced as an aid to hernia reduction. [23, 24, 25]  By assisting in reduction, it may reduce the rate of emergency repair for incarcerated hernias. [24]  The reasoning is that the ultrasound probe should be able to help locate the fascial defect, as well as the tissue to be reduced, and may give the operator a better grasp on the forces needed for reduction.

The suggested technique for ultrasound-assisted reduction (see the video below) includes the following steps:

  • Position the patient as previously described (see Patient Preparation)
  • Choose the high-frequency linear probe in two-dimensional mode; color Doppler may be applied if a distinction between strangulation and incarceration has not yet been established
  • 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
Inguinal hernia reduction under ultrasonographic guidance. Video courtesy of Ultrasoundpaedia at http://www.ultrasoundpaedia.com.
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Complications

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. [26, 27, 28]  In such a case, the bowel progresses to obstruction and strangulation despite apparent reduction. [29]  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. [7]

Retroperitoneal hematoma resulting from manual reduction of an indirect inguinal hernia has been reported. [30]

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