II. Indications

III. Contraindications (Risk of peritonitis and other complications)

  1. Toxic appearance or signs of peritonitis
  2. Bowel Obstruction
  3. Necrotic or gangrenous tissue
  4. Strangulated Hernia
  5. Undescended Testicle or ovary within Hernia

IV. Technique

  1. Positioning
    1. Abdominal Hernia
      1. Patient supine
    2. Groin Hernia (Inguinal Hernia or Femoral Hernia)
      1. Adult: Patient in 20 degrees Trandelenburg position
      2. Child: Unilateral frog leg position
  2. Ice packs applied to Hernia (reduce edema)
  3. Decrease pain (with decreased abdominal guarding and intraabdominal pressure)
    1. Procedural Sedation (as needed)
      1. Consider surgeon assistance if available, and using Procedural Sedation
    2. Opioid Analgesics
    3. Anxiolysis
  4. Re-examine after 15-20 minutes
    1. Positioning, ice and Analgesics alone may reduce Hernia
  5. Bimanual Reduction
    1. Guide proximal Hernia through fascial defect with one hand
    2. Apply gentle pressure to distal aspect of Hernia (directed toward Hernia neck) with the other hand
      1. Avoid excessive pressure due to risk of edema and more difficult reduction
      2. Slow manual pressure over 5-15 minutes

V. Complications

  1. Failed reduction
    1. Repeated attempts may result in swelling, preventing further successful acute reduction
  2. Bowel perforation (higher risk with ischemic bowel)

VI. Disposition

  1. Surgical Consultation
    1. Immediate if unsuccessful reduction of Incarcerated Hernia or if reduction contraindicated (see above)
    2. Outpatient surgical evaluation within 1-2 weeks if successful Hernia Reduction (for elective repair)

VII. References

  1. Stevens (2013) Crit Dec Emerg Med 27(9): 2
  2. Warrington (2021) Crit Dec Emerg Med 35(7):25

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