Hernia Reduction

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July 13, 2017 by dailybolusoflr

by: Shaughn Keating


Types of Hernias:

Groin Hernias (75% of all hernias)

  • Indirect inguinal hernia – most common
  • Direct inguinal hernia – minimal risk incarceration
  • Femoral hernia – high risk incarceration

 

Abdominal Hernias

  • Inicisional hernias – up to 20% all abdominal wall hernias
  • Umbilical hernias- often seen in infants, usually resolves by age 5.
  • Epigastric hernia
  • Spigelian hernia – rare, through semilunar line at edge of linea alba

Classes of Herniations:

“Asymptomatic”/Reducible hernia
  • Swelling, greater with valsalva
  • Aching, but no tenderness
  • Easily return to abdominal compartment

 

Incarcerated hernia: trapping of contents within hernia sac
  • Venous/lymphatic obstruction; this leads to surrounding edema
  • Cannot be manipulated back into abdomen
  • May have obstructive symptoms
  • Classic teaching that smaller aperture of herniation more likely to incarcerate, but there is little evidence to support this

 

Strangulated hernia
  • Progression of edema which leads to eventual arterial flow limitation and thus ischemia and necrosis
  • Severe pain/tenderness, obstructive symptoms, nausea, vomiting
  • Cytokine release with SIRS and edema/erythema around site
  • Localized pain unless spontaneously reduces
  • Up to half of patients needing emergent repair may not have been previously identified as having a hernia

Hernia Reduction:

DO NOT reduce hernias when concerned for strangulation. This is a predominantly CLINICAL decision. If any of the following, start antibiotics and consult surgery
  1. Non-toxic appearance
  2. Overlying erythema/inflammation
  3. Evidence of end-organ perfusion deficits
  4. Peritonitis

 

Overall, we are good at picking out who can be reduced: Study of 1557 hernia patients, 162 attempted reductions, 129 of which were successful – no harm from attempts and no attempts to reduce nonviable bowel.

Reduction of even “asymptomatic” hernia decreases risk of incarceration and improves symptoms

Technique:

  • Cold compress – decrease edema a swelling, leave on for at least several minutes prior to attempt
  • For groin hernias, place bed in Trendelenburg to help shift intraabdominal contents away. Supine position for ventral hernias
  • Analgesia vs procedural sedation. If patient needs procedural sedation, have surgeon/consultant at bedside so they can guide attempt as well (rather than sedating twice). At this point, some hernias may self reduce.
  • Avoid excess distal pressure – causes hernia to balloon out around aperture
  • Guide medial edge of hernia into body cavity while GENTLY and STEADILY applying distal pressure
  • This can take up to 15 minutes

 

If unable to reduce, call surgery for emergent evaluation and reduction versus operative repair. Repeated attempts increase swelling and decreased likelihood of surgeon’s bedside reduction.


References:

  1. Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Chapter 44, 873-879.e1
  2. Kauffman HM Jr, O’Brien DP. Selective reduction of incarcerated inguinal hernia. American Journal of Surgery. 1970 June. 119(6):660-73

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