Background

Hernia reduction involves pushing protruding tissue back into normal position during treatment.

Hernia happens when organ or tissue pushes through weak muscle and connective spot

Hernia repair is a common surgery type. It frequently occurs in abdomen, groin, and near incisions.

Hernias are divided into two main groups as:

Groin hernias

Abdominal hernias

These are further sub-divided as:

Inguinal Hernia: In the groin area

Femoral Hernia: Located just below the inguinal ligament

Umbilical Hernia: It involves part of the intestine

Spigelian hernia: Located at the lateral edge of the rectus abdominis

Manual reduction of a hernia before surgery relieves symptoms and prevent complications. Patient should relax their abdominal muscles, while physician applies pressure to encourage tissue/organ to return properly.

This process may relieve symptoms temporarily but is not a permanent solution.

Indications

Reducible Hernia:

A hernia that is soft and can be pushed back into the abdomen without surgical intervention.

Incarcerated Hernia:

If the hernia remains incarcerated or if manual reduction is not possible then surgery is indicated to prevent complications.

Strangulated Hernia:

When a hernia becomes strangulated i.e., the blood supply to the herniated tissue is cut off completely. This can lead to tissue necrosis.

Post-Injury or Sudden Onset Hernias:

Hernias that occur suddenly after trauma or heavy lifting may require immediate reduction to prevent further damage.

Contraindications

Absolute Contraindication for Manual Reduction:

Strangulation Occurs When the Blood Supply is Cut Off

Risk of Compromising Blood Flow

Signs of Peritonitis or Systemic Infection

Peritonitis

High Risk of Bowel Perforation

Severe Pain with Attempted Reduction

Long-Standing, Irreducible Hernia

Fibrosis or Adhesions

Large Hernias with Suspected Organ Entrapment

Patient Unstable for Surgery

Outcomes

Manual reduction for reducible hernias provides temporary relief from discomfort and bulging.

Manual reduction of hernia does not fix the root cause. Surgery is needed to prevent recurrent hernias.

Nonoperative approach adequate for asymptomatic patients with reducible hernias. Prospective trial shows good outcomes for minimally symptomatic.

An irreducible hernia presents normal skin, non-tense contents, and possible audible bowel sounds.

Obstructed hernias present with more tension and visible bowel shadows on diagnostic imaging compared to non-obstructed hernias.

Equipment required

Cold compress

Scalpel & Forceps

Needle Holders

Surgical Sutures

Anesthesia Equipment

Wound Closure and Dressing

Laparoscopic Instruments

Laparoscope

Trocar and Cannulas

Laparoscopic Suturing Devices

Patient Preparation

For hernia present in the intestine, bowel preparation may be required to reduce the risk of infection during surgery.

Patients are instructed to fast for 6 to 8 hours prior to surgery.

Informed Consent

Patients should understand procedure, benefits, risks, and alternatives for consent.

Patient Positioning

Place the patient in a Trendelenburg position. (i.e., head down & legs up)

In cases of an inguinal hernia, the patient should be in a supine position.

For Manual Hernia Reduction

Step 1: Relax abdominal muscles:

Motivate patients to relax their abdominal wall with gentle pressure and ask them to breathe deep.

Step 2: Application of Gentle Pressure

Slow and steadily apply pressure with your fingers or the palm of hand over the herniated bulge. This should gently guide the contents back through the defect in the abdominal wall.

For Surgical Hernia Reduction

A. Open Hernia Repair:

Step 1: Anesthesia

General/local anesthesia is administered.

Step 2: Incision

Surgeons will make incisions directly at the site of the hernia.

Step 3: Reduction of Hernia

The surgeon carefully identifies the herniated tissue and gently reduces it back into the abdominal cavity.

Step 4: Hernia Repair

For small hernia cases, the defect may be closed with sutures alone by stitching the edges of the healthy tissue together.

For larger hernia cases, a synthetic mesh is placed over or under the defect to reinforce the weakened area.

Step 5: Closure

The surgical wound is closed in layers. The deeper muscle and fascia are sutured first.

Fig 1. Open Hernia Repair

B. Laparoscopic Hernia Repair:

Step 1: Anesthesia

General anesthesia is administered.

Step 2: Incision and Access

Small incisions are made in the abdominal wall to insert the laparoscope.

The abdomen is inflated with CO2 gas to create space for visualization and manipulation of the herniated tissue.

Step 3: Reduction of Hernia

The herniated contents are observed with the laparoscope and then surgeon gently manipulates the herniated tissue back into the abdominal cavity.

Step 4: Placement of mesh

Synthetic mesh is placed over the hernia and fixed in place with sutures.

Step 5: Closure

The small incisions are closed with sutures.

Fig 2. Laparoscopic Hernia Repair

Complications:

Complications of Manual Hernia Reduction are:

Incomplete Reduction

Injury to Herniated Contents

Missed Strangulation

Hematoma or Seroma Formation

Complications of Surgical Hernia Reduction are:

Infection

Bleeding or Hematoma

Seroma

Hernia Recurrence

Bowel Injury or Perforation

Bowel Obstruction

Ischemia or Necrosis of Herniated Tissue

References

References