The decision to perform laparoscopic reduction or open reduction was made by the surgeon after determining whether the patient had undergone laparoscopic surgery in the past, whether the patient presented with poor vital signs in the emergency room, and the statuses of bowel edema and dilation in the abdominal cavity on abdominal CT.

The operation began with an incision at the site of the previous incision, and an additional incision was made if necessary. During the incision, adhesiolysis was carefully performed to prevent injury to organs with adhesions. After the abdominal wall was opened, the viability of the herniated small bowel was determined. If the herniation direction was easy to detect, surgery was performed immediately. However, it was sometimes difficult to determine the correct direction of herniation. In these cases, we performed the following. First, we identified the ileocaecal valve and fully reduced the herniated bowel. After complete reduction, we checked the status of bowel perforation and necrosis. If the bowel was not viable even after reduction, we resected the damaged small bowel segment. We closed Petersen’s space with non-absorbable sutures.

We inserted the first trocar at just inferior to the umbilicus or in the lower abdomen area by an open method with a new incision. Mostly, we performed the reduction using three or four trocars. The intra-abdominal reduction process was the same as that performed in the open method. However, it was difficult to determine the correct direction of herniation with a laparoscope. Therefore, we identified the ileocaecal valve, traced the bowel proximally to identify the herniating segment then reduced it with gentle traction. After complete reduction, we checked the status of bowel perforation and necrosis. If the bowel was not viable even after reduction, we resected the damaged small bowel segment. We closed Petersen’s space with non-absorbable sutures (supplement Video).

The possibility of damage or bleeding in the small intestine is higher during laparoscopic hernia reduction than during open reduction due to forceful pulling of laparoscopic graspers. We recommend open conversion for patients with a poor pneumoperitoneum condition or severely damaged bowel, as reduction is difficult due to severe bowel edema.

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