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infant showing pneumatosis intestinalis and branching radiolucencies (arrowheads ) within the
liver representing air within the portovenous system. D: US of another infant with perforation
following necrotizing enterocolitis shows free intraperitoneal fluid (F) containing echogenic
debris and punctated areas of high echogenicity within the intestinal wall (arrows ), consistent
with pneumatosis intestinalis. E: Left lateral decubitus radiograph shows free intraperitoneal air
(arrow ) indicating perforation in an infant with necrotizing enterocolitis. (Reprinted with
permission from Brant WE, Helms C. Fundamentals of Diagnostic Radiology . Philadelphia,
PA: Lippincott Williams & Wilkins; 2012.)

CLINICAL PEARLS AND PITFALLS
Reduction of an incarcerated hernia may require sedation to facilitate
adequate muscle relaxation; sedation in the neonate requires additional
post-sedation monitoring.
Patients with abdominal wall defects, connective tissue disorders, or
chronically increased intra-abdominal pressure (ascites, dialysis,
ventriculoperitoneal shunting, etc.) are at increased risk for umbilical or
inguinal hernias.
In females, inguinal hernias may contain the ovary and may present
with labial swelling.
Inguinal Hernia
Inguinal hernias result when abdominal contents pass through the inguinal canal.
The overall incidence is between 1% and 4% but can be as high as 30% in
preterm infants. Similarly, the rates of incarceration increase with decreasing
gestational age. Hernias often will present with an intermittent bulge in the groin,
or swelling of the testes (boys) or labia (girls) that can be exacerbated during
crying or Valsalva maneuvers. While most inguinal hernias are painless, an
incarcerated hernia will present with a bulge that does not reduce spontaneously
and may be associated with irritability, pain, and/or vomiting. The differential
diagnosis of an inguinal mass includes hydrocele, testicular torsion, or
lymphadenopathy. Distinguishing between inguinal hernias and hydroceles may
be difficult at this age, and transillumination of the scrotal sac may not be a

reliable test. In general, hydroceles rarely cause pain and typically do not fully
reduce. In testicular torsion the testes is palpable and hard, and may or may not
be tender on examination. While most hernias, hydroceles, and torsions can be
differentiated on examination, US can be a helpful adjuvant.
Given the high rate of incarceration, surgical repair is recommended once an
inguinal hernia is identified, and can be done as an elective outpatient procedure.
If the hernia was difficult to reduce, surgical intervention should be performed