Manual reduction of incarcerated hernia
-
Once incarceration of an inguinal hernia has been confidently diagnosed, the parents must be informed that reduction of the hernia will be attempted. The patient is placed in the supine position and his or her pelvis is grasped gently but firmly by an assistant to prevent any lateral movement of the buttocks. Depending on the side of the hernia, the ipsilateral leg is then externally rotated and completely flexed into the frog position. This position causes the external ring to ascend so that it more nearly, but not completely, overrides the internal inguinal ring.
-
Once both of these conditions have been established, the first 2 fingers of the guiding hand are placed over the hernial bulge and overriding the upper margin of the external inguinal ring in such a fashion as to prevent the hernia subluxating upwards and over the margin of the ring. Next, the apex of the hernia is grasped between the first 2 fingers and thumb of the reducing hand, and prolonged, steady, firm pressure is applied.
-
This last point is crucial; the reducing hand must not be withdrawn after only a few seconds. One indication of the correct application of this technique is the onset of stiffness in the first 2 fingers and an ache in the thenar eminence. After a given interval that may take minutes, a sudden reduction of the hernia occurs with an almost audible thud, accompanied by complete relief in the patient. Using this method of reduction, open operation of incarcerated inguinal hernia is a rare event. By successfully reducing an incarcerated inguinal hernia, the open operation can be accomplished electively and with decreased morbidity.
-
Typical appearance of an infant with a large right indirect inguinal hernia. The right scrotal sac is enlarged and contains palpable loops of bowel and fluid.
-
A premature baby boy with bilateral giant inguinoscrotal hernias. Because of the large size of the hernias, operative repair typically requires repair of the inguinal floor in addition to the high ligation of the indirect hernia sac.
-
Illustration of the technique for intraoperative diagnostic laparoscopy to evaluate for the presence of an asymptomatic contralateral inguinal hernia at the time of elective repair of an indirect inguinal hernia.
-
Laparoscopic view of a left indirect inguinal hernia at the time of surgery for laparoscopic needle-assisted repair.
-
Laparoscopic needle-assisted repair of a left indirect inguinal hernia. Note the passage of a Prolene suture through a small 22G spinal needle; this is used for creation of the purse-string suture that closes the open inguinal ring.
-
Laparoscopic view of the repaired left indirect inguinal hernia with the closed Prolene purse-string suture around the internal inguinal ring.
