kings county hospital department of surgeryhernia reduction • place first 2 fingers of...
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Kings County Hospital Department of Surgery
Morbidity & Mortality ConferenceCase Presentation
Baiju C. Gohil, M.D.March 12, 2004
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MANAGEMENT OF INCARCERATED
HERNIAS
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INTRODUCTION
• Abdominal wall hernias among the most common of all surgical problems
• Leading cause of work loss and disability• Hernias themselves usually harmless• Nearly all have risk of incarceration and
strangulation• Surgical emergency
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TYPES
• Inguinal Hernia– 75% of abdominal wall hernias occurring up
to 25X more in men – Both direct and indirect forms appear as
bulge in inguinal crease• Femoral Hernia
– Femoral canal contains artery, vein, and nerve leaving abd cavity to enter thigh
– Normally tight space, enlarges to allow abdcontents (ie. intestine) into canal medial to femoral vein 2o weak transversalis fascia
– Bulge below inguinal crease; usually occurs in women and prone to incarceration and strangulation because of narrow neck
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TYPES
• Umbilical Hernia– Often noted at birth as umbilical protrusion 20
failure of closure of umbilical ring – Rare in adults; prediposing factors include multiple
pregnancies, ascites, obesity, and large intra-abdominal tumors
• Obturator Hernia– Rare, most commonly occurring in women– Protrusion from pelvic cavity through obturator
foramen– Will not show bulge but can cause bowel obstruction– Howship-Romberg sign is pain in medial aspect of
thigh relieved by flexion of thigh
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CAUSES
• Any condition that increases the pressure of the abdominal cavity may contribute to formation or worsening of a hernia– Obesity– Heavy lifting– Coughing (smokers)– Straining during bowel movement or
urination– Chronic lung disease (COPD)– Kyphoscoliosis– Fluid in the abdominal cavity
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S & S OF INCARCERATION
• Signs and symptoms of a hernia range from a painless lump to an irreducible, painful, tender, swollen protrusion
• Incarceration is associated with– Painful enlargement of previous hernia which has
become irreducible– Some may be chronically incarcerated without pain– May present as bowel obstruction (N/V, abd dist)– Can lead to strangulation; bowel may become
gangrenous in 5 hours• Incarceration occurs in 6-10% of indirect
inguinal hernias in adults and 14 to 56% of femoral hernias
Roberts: Clinical Procedures in Emergency Medicine, 3rd ed., Copyright © 1998
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HERNIA REDUCTION
• Immediate reduction of an acutely incarcerated hernia prevents strangulation
• IV analgesics and sedation PRN • 20-degree Trendelenburg position with pillow
to support buttocks for groin hernias (Trendelenburg position not necessary for umbilical hernias)
• Padded ice bag to hernia diminishes blood flow while analgesics take effect
• After 30 min, hernia may spont reduce; if not, manual reduction is attempted
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HERNIA REDUCTION
• Pelvis firmly grasped by assistant to prevent lateral movement of the hips
• Ipsilateral leg externally rotated, completely flexed, placed in frog position; this allows external inguinal ring to override internal inguinal ring
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HERNIA REDUCTION
• Place first 2 fingers of "guiding" hand over hernial bulge, overriding the external inguinal ring in such a manner as to prevent the hernialsac from subluxating over margin of ring
• Apex of hernia then grasped between first 2 fingers of "reducing" hand, and prolonged, firm, steady pressure is applied
• Reducing hand should stay in place as long as possible; these maneuvers, if successful, often result in a gurgle signifying successful reduction
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HERNIA REDUCTION
• If hernia cannot be reduced immediate surgical repair is warranted
• If reduction is successful, elective repair in 24-48 hrs should be performed because of possibility of residual Richter’s hernia or reduction en masse where there is ongoing strangulation
• Contraindications to reduction include fever, leukocytosis, and other signs of toxicity indicating strangulated bowel
• Incarcerated femoral hernias not amenable to manual reduction because of small neck and large amount of overlying tissue
Emergency Medicine Clinics of North AmericaVolume 14 • Number 4 • November 1996
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REVIEW OF LITERATURE
• “Presentation and Outcome of Incarcerated External Hernias in Adults”
• Bahadir Kulah, M.D., et al.• American Journal of Surgery
Volume 181 • Number 2 • February 2001• 385 consecutive pts undergoing emegency
surgery for incarcerated external hernia between 1996-1999, ages between 15-100
• Concluded that higher mortality rate after emergency repair is associated with advanced age (>60), severe coexisting diseases, and delayed presentation (>24 hrs after onset of symptoms)
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REVIEW OF LITERATURE• “Emergency Hernia Repairs in Elderly Patients”• Perez JA, Baldonedo RF, et al.• Int Surg. 2003 Oct-Dec;88(4):231-7• 143 pts >65 years old underwent emergency surgery for
incarcerated external hernias between 1992-2001• 35% of pts presented 48 hrs after onset of symptoms• Coexisting diseases found in 77.7% • Bowel resection was required in 17.5% • Mortality 4.9%• Longer duration of symptoms, delayed hospitalization,
concomitant illness were linked with unfavorable outcome.
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INTRODUCTION
• Abdominal wall hernias among the most common of all surgical problems
• Leading cause of work loss and disability• Hernias themselves usually harmless• Nearly all have risk of incarceration and
strangulation• Surgical emergency
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