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be attempted. The child should be given opioid pain medications, such as
intranasal fentanyl or IV fentanyl, with standard cardiopulmonary monitoring.
The mother should then cuddle the baby until it relaxes and falls asleep. An older
child may be placed in the Trendelenburg position to allow gravity to facilitate
the reduction. Once the child is asleep, gentle manipulation of the incarcerated
mass should be attempted. Mild pressure should be exerted at the internal ring
with one hand, while the other attempts to squeeze gas or fluid out of the
incarcerated bowel back into the abdominal cavity. If the reduction is
unsuccessful, a surgeon should be consulted immediately.
Disposition. After the hernia has been reduced manually, the child may be
admitted for observation but not immediate repair. The hernia sac and spermatic
cord are edematous after a reduction, making the repair difficult. Usually, it is
done 24 hours after admission. If a child has persistent emesis after a manual
reduction of a hernia, consider the possibility that the bowel was incompletely
reduced. Children that develop peritoneal signs after manual reduction should be
evaluated for possible perforation associated with gangrenous bowel. Rarely
should a child be sent home after a manual reduction unless the parents are
properly informed concerning signs of recurrence or intestinal obstruction.

Incarcerated Umbilical Hernia
Incarceration of an umbilical hernia is rare. If present, there is a persistent and
tender bulge in the umbilical hernia sac. If the incarceration is of short duration, a
gentle effort might be made to reduce it manually, but it is often necessary to
prepare the child for urgent surgery. At the time of surgery, the loop of
incarcerated bowel should be inspected, rather than letting it drop back into the
abdominal cavity, to be certain there has been no vascular impairment.

Malrotation of the Bowel With Volvulus
Goals of Treatment
The goals of treatment are simple: early recognition, emergency surgical
consultation, treatment of shock, and immediate operative care to preserve

viability of the bowel.
CLINICAL PEARLS AND PITFALLS