Hernia MDM

Hernia MDM
Last reviewed: March 2026

Contents

MDM Templates
Clinical Education
References

MDM Templates

Reducible Hernia

Patient presents with pain and swelling at a known hernia site. Hernia sac is soft and nontender. No signs of intestinal obstruction — no bilious vomiting, no change in stooling pattern, passing flatus. No skin changes overlying the hernia. Hernia successfully reduced with gentle manual pressure.

Plan: Pain improved after reduction. Ice and analgesia.
Disposition: Discharge with outpatient surgical referral for elective hernia repair. Return precautions for inability to reduce the bulge, vomiting, worsening pain, fever, or skin discoloration over the hernia site.

Incarcerated Hernia

Patient presents with painful, irreducible bulge at the *** hernia site. No skin discoloration or signs of strangulation. No peritoneal signs. Bowel sounds present.

If reduction successful:

Patient placed in supine Trendelenburg position with ice applied to the hernia site. After analgesia and relaxation, firm steady pressure applied to the distal hernia and contents successfully reduced through the defect. Post-reduction, abdomen soft and nontender. No signs of bowel ischemia.

Plan: Observation in the ED for 1–2 hours post-reduction to ensure no signs of bowel compromise develop. Tolerating PO.
Disposition: Discharge with urgent surgical follow-up within 1 week for repair. Return immediately for vomiting, abdominal pain, fever, or hernia re-protrusion.

If reduction unsuccessful:

Unable to reduce hernia despite analgesia, positioning, and sustained manual pressure. No signs of strangulation at this time but contents remain incarcerated. Surgery consulted for operative reduction and repair.
Disposition: Admit to surgery.

Strangulated Hernia

Patient presents with a tender, irreducible hernia with overlying skin changes (erythema / discoloration) and signs of bowel obstruction. Concerning for strangulated hernia with compromised bowel.

Manual reduction not attempted due to concern for strangulation — reducing necrotic bowel into the abdomen risks perforation and peritonitis. Surgery consulted emergently. IV antibiotics initiated — cefoxitin 2 g IV. IV fluid resuscitation.
Disposition: Admit to surgery for emergent operative repair.

Clinical Education

Hernia Types

Type	Location	Key Features
Inguinal (indirect)	Through internal inguinal ring, lateral to inferior epigastrics	Most common overall. Can extend into scrotum.
Inguinal (direct)	Through Hesselbach triangle, medial to inferior epigastrics	Older adults. Rarely incarcerates.
Femoral	Below inguinal ligament, medial to femoral vein	More common in women. Highest incarceration risk.
Umbilical	Umbilical ring	Common in children (most close by age 5) and cirrhotics.
Incisional	Prior surgical site	Occurs in up to 20% of laparotomies.

Reduction Technique

Successful reduction of an incarcerated hernia starts with adequate pain control and positioning. Place the patient supine in mild Trendelenburg. Apply an ice pack to the hernia site for 15–20 minutes to reduce edema. Give adequate analgesia ± anxiolysis (consider procedural sedation for large or very painful hernias).^[1]

Reduction technique: Apply firm, constant, circumferential pressure to the most distal portion of the hernia, directing contents back through the fascial defect. The key is sustained pressure — it often takes several minutes. Intermittent pushing is less effective than steady, patient pressure.

Do NOT attempt reduction if strangulation is suspected (skin changes, crepitus, peritoneal signs, signs of sepsis). Reducing necrotic bowel into the peritoneal cavity causes peritonitis and can mask the need for emergent surgery.^[2]

Incarcerated Hernia Pearls

Incarceration ≠ strangulation. Incarceration means the hernia contents cannot be manually returned — the bowel is trapped but may still be viable. Strangulation means the blood supply to the trapped bowel is compromised — this is a surgical emergency. Incarceration can progress to strangulation, which is why incarcerated hernias need timely attention.^[2]

After successful reduction of an incarcerated hernia, observe for signs of bowel ischemia. If the patient develops worsening pain, fever, peritoneal signs, or bloody stool after reduction, the reduced bowel may have been ischemic — this requires imaging and surgical consultation.

Signs of Strangulation

Clinical signs that suggest strangulation: Skin erythema or discoloration over the hernia, severe constant pain (not just with activity), peritoneal signs, fever, tachycardia, leukocytosis, elevated lactate, signs of bowel obstruction (bilious vomiting, absence of flatus). CT may show bowel wall thickening, free fluid, or pneumatosis — but strangulation is ultimately a clinical and operative diagnosis.^[3]

No single lab or imaging finding reliably rules out strangulation. Lactate can be normal early. CT findings may be subtle. If the clinical picture is concerning — irreducible, tender, erythematous hernia in a patient with obstructive symptoms — consult surgery regardless of lab or imaging findings.

Special Hernias

Femoral hernias have the highest incarceration and strangulation rate (~20–45% present as emergencies). They are more common in women and are often misdiagnosed as inguinal hernias or lymphadenopathy. Location: below the inguinal ligament, medial to the femoral pulse. All femoral hernias should be referred for surgical repair regardless of symptoms.^[4]

Richter hernia: Only part of the bowel wall (anti-mesenteric border) herniates through the defect — can strangulate without causing complete obstruction. The patient may not have classic obstructive symptoms, which delays diagnosis. Femoral hernias are the most common location for Richter hernias.^[2]

Umbilical hernias in cirrhotics: Ascites increases intra-abdominal pressure and enlarges the defect. Risk of incarceration, skin breakdown, and spontaneous rupture with ascitic fluid leak. Elective repair should be considered after ascites optimization. Emergent repair is needed for rupture, incarceration, or skin necrosis.

Disposition

Admit if: Strangulated hernia (emergent surgery), irreducible incarcerated hernia (surgery consult), signs of bowel obstruction, or post-reduction concern for bowel viability.

Discharge if: Reducible hernia with elective surgical referral, successfully reduced incarcerated hernia with observation period and reassuring exam, tolerating PO, reliable follow-up for urgent surgical repair.

References

Fitzgibbons RJ, Forse RA. Groin hernias in adults. N Engl J Med. 2015;372(8):756-763. PubMed
Bittner R et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (IEHS). Surg Endosc. 2014;28(1):2-29. PubMed
Stoker J et al. Imaging patients with acute abdominal pain. Radiology. 2009;253(1):31-46. PubMed
Hernandez-Richter T et al. The femoral hernia: an ideal teaching model for clinical reasoning. Hernia. 2001;5(4):193-198.