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 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.
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.
Ultrasonography as Aid to Reduction
Ultrasonography (US) 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 US to be less useful in children. [22]
US 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 US-assisted reduction (see the video below) includes the following steps:
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Position the patient as previously described (see Patient Preparation)
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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
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Identify the point of maximal aperture of the inguinal canal or fascial defect
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Hold the tissue perpendicular to the plane of maximal aperture, and guide it through
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Compress the tissue from a distal point while guiding the proximal end through the aperture
Laparoscopic Reduction of Internal Hernia
Youn et al reported a case in which laparoscopic reduction of an intersigmoid hernia, a rare form of internal hernia, was carried out in a 32-year-old man who presented with mechanical obstruction. [26] Herniation of small bowel through the intersigmoid recess was observed. The bowel was viable, and laparoscopic reduction of this incarcerated ileum was therefore performed. The patient recovered uneventfully, and the authors recommended that laparoscopic reduction of intersigmoid hernia be considered as an alternative technique for reduction.
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. [27, 28, 29] In such a case, the bowel progresses to obstruction and strangulation despite apparent reduction. [30] 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. [31]
Umbilical hernia has been noted as a consequence of umbilical cord graft repair after hernia reduction in patients with gastroschisis. Taher et al reported the development of umbilical hernia in such patients even after preservation of the rectus fascia (two out of four patients); hence, a high index of suspicion is warranted in this setting. [32]
In a retrospective study that included 1763 cases of laparoscopic indirect inguinal hernia repair, Pan et al used propensity score matching analysis to investigate the effect of complete reduction and transection of the hernia sac on the formation of seromas. [33] They found transection of the hernial sac to be significantly associated with postoperative seroma formation.
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Variations of hernia type and location.
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50-year-old man presents with recurrent umbilical hernia, which is reduced in emergency department.
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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.
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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.
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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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Ice pack is applied to patient with left inguinal hernia in Trendelenburg position.
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Slow constant pressure is applied to patient with left inguinal hernia.
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Emergency department hernia reduction by surgical resident. Sedation with propofol is required after unsuccessful reduction attempt with opioid analgesia.
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Hernia content balloons over external ring when reduction is attempted.
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Hernia can be reduced by medial pressure applied first.
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Inguinal hernia reduction under ultrasonographic guidance. Video courtesy of Ultrasoundpaedia at http://www.ultrasoundpaedia.com.
