Chapter 29

• • A hernia is a benign process unless the contents within the hernia sac become incarcerated.

• Incarceration is the inability of the hernia’s contents to be reduced.

• The risk of incarceration is highest during infancy with a 28–31% incarceration rate before 3 months of age and 15–24% by 6 months of age.

• Although the risk of incarceration gradually decreases with age, the severity of its consequences mandates immediate manual reduction when possible, followed by prompt operative repair.

### Absolute

• • Reduction should not be attempted if there has been bowel compromise or when the patient appears toxic.

• Concern for toxicity should arise when the patient has any of the following:

• • Severe tachycardia.

• Increased leukocyte count.

• Bloody stool or positive result on modified guaiac test.

• Severe pain with palpation.

• Erythema of the hernia sac.

### Relative

• • Some surgeons do not advocate manual reduction if the patient has any signs or symptoms of intestinal obstruction.

• • Gloves.

### Risks

• • There are few risks with manual reduction.

• • However, parents should be informed that once a hernia has been incarcerated, it has a high probability of recurring.

• A hernia will not resolve on its own and operative management will be required in the near future.

• If sedation is used during the reduction, a parent is required to sign a consent form and be made aware of the risks and benefits that accompany sedation.

• In addition, a parent should be instructed not to feed the child should the hernia become strangulated or is not reducible and the patient requires emergent operative intervention.

• • The most common differential diagnosis for a bulge in the groin consists of the following:

• • Hernia.

• Hydrocele.

• Abscess.

• Undescended testis.

• A testicle in the groin may resemble a hernia; thus, it is imperative to confirm the presence of the testis in the scrotum during initial evaluation.

• A hydrocele is usually present at birth and can also be bilateral in nature. It is generally described by the parents as a rapid swelling of the scrotum that may cause the child discomfort if tense.

• With a communicating hydrocele, the swelling is most prominent at the end of the day and reduces over night.

• On examination, a hydrocele is a soft, bluish, cystic swelling within the scrotal sac that cannot be reduced.

• With a hydrocele, the spermatic cord should be able to be felt at its upper limits unlike a hernia, whose upper margin is not clearly defined and continues into the internal ring.

• Transillumination may help differentiate a hernia from a hydrocele.

• • Hernias do not transilluminate as brightly as hydroceles.

• However, hernias can transilluminate if they are filled with an air-filled loop.

• Simple hydroceles generally resolve by the age of 1 year and ...

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