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hernias, elective herniorrhaphy should be done shortly after the hernia is
diagnosed.
Hydroceles of the spermatic cord with associated communicating hernias are
sometimes difficult to differentiate from an incarcerated hernia. If an empty
hernia sac can be felt above the hydrocele, the physician can be assured this is an
asymptomatic hernia with an associated hydrocele. However, if there is fullness
above the hydrocele and the mass cannot be reduced, the child should be taken to
the operating room on the assumption that it probably is an incarcerated hernia
that needs to be managed surgically. If there is any uncertainty, US may be useful
to define the hernia. Bowel gas in the hernia sac is not reliably present for
diagnostic reasons.
Management
Fortunately, strangulation of the entrapped loop of bowel in an incarcerated
hernia occurs relatively late so, contrary to adult practice, efforts to reduce the
incarceration without surgery are usually warranted. When a child with an
incarcerated hernia presents in the ED, the child should be given nothing to eat or
drink, given pain medication, and placed in a Trendelenburg position. Often, this
alone will reduce the incarceration. If it does not, bimanual reduction should be
attempted. The fingers and thumb of one hand should compress the internal ring
area, while an effort is made with the other hand “to milk” either gas or fluid out
of the entrapped bowel back into the abdomen. This relieves the pressure and
usually allows the entire loop of bowel to reduce back into the abdominal cavity.
Once the incarcerated hernia is reduced, the child should be admitted or
scheduled for elective surgery at the surgeon’s discretion. Patients who were
vomiting, had guaiac-positive stools, or had significant difficultly reducing
hernias should be admitted for serial abdominal examinations. A day or two
should be allowed to pass to lessen the edema of the area, as well as to allow an
easier and safer elective herniorrhaphy.

Epiploceles (Epigastric Hernias)
If a discrete mass occurs intermittently about one-third of the distance from the

umbilicus to the xiphoid, it is usually the result of a weakness of the linea alba
through which properitoneal fat protrudes. This defect is called epiplocele. Such
defects are fairly common in infants and usually close spontaneously. In older
children, the mass may occasionally be tender. If it becomes excruciatingly
tender, it is a sign that fat has become incarcerated in the hernia. Although there is
no great urgency, these small midline defects should be repaired surgically when
they become symptomatic.