Is it okay to push an inguinal (lower abdominal) hernia back in?

Manual Reduction of Inguinal Hernias

Manual reduction of a reducible inguinal hernia is acceptable as a temporizing measure, but only when there are no signs of strangulation or incarceration, and the hernia contents slide back smoothly without resistance. 1

When Manual Reduction is Appropriate

Manual reduction can be attempted when ALL of the following conditions are met:

• The hernia is soft and compressible (not firm or tender) 1
• No skin changes are present over the hernia (no erythema, warmth, or discoloration) 1
• No peritoneal signs are present on abdominal examination 1
• The contents slide back smoothly into the abdominal cavity without resistance 1
• The patient has no systemic symptoms such as fever, tachycardia, or signs of bowel obstruction 1

Absolute Contraindications to Manual Reduction

Do NOT attempt manual reduction if any of the following are present:

• Firm, tender, irreducible mass that does not compress 1
• Skin changes including erythema, warmth, or discoloration over the hernia 1
• Peritoneal signs on examination (guarding, rigidity, rebound tenderness) 1
• Systemic inflammatory response syndrome (SIRS) criteria present 1, 2
• Elevated laboratory markers including lactate ≥2.0 mmol/L, elevated CPK, or D-dimer levels 2
• Symptoms lasting >8 hours, which significantly increases morbidity risk 1

Critical Management After Successful Reduction

Even if manual reduction is successful, this does NOT eliminate the need for further evaluation. 1

• Diagnostic laparoscopy or hernioscopy should be strongly considered to evaluate bowel viability and rule out occult ischemia, as bowel may have been compromised even if reduction was achieved 1
• Hernioscopy after spontaneous or manual reduction can decrease hospital stay and prevent unnecessary laparotomies in high-risk patients 1
• All successfully reduced hernias still require definitive surgical repair on an urgent basis (within 1-2 weeks) to prevent recurrence of incarceration 1, 3

Emergency Situations Requiring Immediate Surgery

Immediate surgical intervention is mandatory (not manual reduction) when:

• Intestinal strangulation is suspected, as delayed treatment >24 hours is associated with significantly higher mortality rates 1, 3
• Bowel obstruction is present with systemic symptoms 1
• Any signs of bowel compromise are evident on examination or imaging 1

Common Pitfalls to Avoid

• Never force reduction if there is any resistance, as this can cause bowel perforation or worsen ischemia 1
• Do not assume successful reduction means the hernia is "safe" - occult bowel ischemia may still be present and requires evaluation 1
• Delaying definitive surgical repair after successful reduction increases the risk of recurrent incarceration and strangulation 1, 3
• Missing femoral hernias, which have an 8-fold higher risk of requiring bowel resection and should never be manually reduced 3

Definitive Treatment

All inguinal hernias require surgical repair as the definitive treatment, with mesh repair being the recommended approach in clean surgical fields due to significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 3