Hernia Reduction

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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]

Hernias may be broadly divided into two main groups, depending on whether they develop in the upper abdomen or in the groin (see the image below), and each group contains multiple types.

Groin hernias include the following:

Abdominal hernias include the following:

Before surgical repair of a hernia, manual reduction can return the tissue to its original compartment. ^[4] Reduction benefits the patient by mitigating associated symptoms, avoiding adverse outcomes such as strangulation, and permitting elective surgical repair, which has lower morbidity than emergency repair. ^{[5, 6]}  The most common hernias amenable to reduction are described in this article.

The presence of a nonstrangulated hernia is an indication for manual reduction. ^[7] 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, ^[8] 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. ^[9] In addition, harmful outcomes to attempted reduction are unlikely in these unrecognized strangulated hernias.

Manual reduction is contraindicated in strangulated hernias. In such cases, nasogastric suction, fluid replacement, and antibiotic therapy can be started.

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 necessitate urgent reduction in the operating room. ^[10]

For the purposes of manual reduction, hernias are best classified into the following three groups ^[11] :

This classification also helps direct treatment.

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. ^[2]  Although reduction helps alleviate patient’s symptoms, elective surgical repair is usually warranted for long-term management.

In some cases, nonoperative treatment may suffice for asymptomatic patients with easily reducible hernias. A large prospective trial suggested that in patients who are minimally symptomatic, nonoperative treatment can produce outcomes similar to those experienced by minimally symptomatic patients who undergo surgical repair. ^[12]

An incarcerated hernia cannot easily be returned to its original compartment. The 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. ^{[9, 13]}

Obstruction is a concern; a hernia is one of the three 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. (See the image below.)

Even with proper sedation and technique, not every hernia can be manually reduced. In such cases, surgical reduction is more urgent to prevent strangulation. ^{[14, 15]}

A strangulated hernia (see the image below) 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 signaled in the 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 distention, and a patient who appears to be toxic, dehydrated, and febrile. Mortality is high, and treatment should be initiated immediately. ^[16]

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Leem JG. Ultrasound-guided Nerve Blocks for Post-hernia Repair Pain. Korean J Pain. 2010 Dec. 23(4):227-9. [Medline].

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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. [Medline].

Narci A, Korkmaz M, Albayrak R, Sozubir S, Guvenc BH, Koken R, et al. Preoperative sonography of nonreducible inguinal masses in girls. J Clin Ultrasound. 2008 Sep. 36(7):409-12. [Medline].

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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. [Medline]. [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. [Medline].

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. [Medline]. [Full Text].

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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.

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.

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.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Gil Z Shlamovitz, MD, FACEP Associate 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, American Medical Informatics Association

Disclosure: Nothing to disclose.

Hernia Reduction

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