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An inguinal hernia develops when the processus vaginalis fails to obliterate during late gestation, allowing communication between the abdominal cavity and the inguinal canal to persist. Abdominal contents can then herniate into the inguinal canal. The vast majority of hernias in children are indirect, with contents protruding through the internal inguinal ring into the inguinal canal. 

Inguinal hernias in children generally present in the first year of life as an intermittent, reducible inguinal mass. The diagnosis may be made by history alone, without the presence of a mass on physical examination. Between 14 and 31 percent of cases will be incarcerated at the time of diagnosis. 

The management of inguinal hernia ultimately requires surgical repair. Incarcerated hernias must be emergently reduced:

Children with a compatible history and those with a reducible mass should be referred to a surgeon for evaluation. Because incarceration can occur in children awaiting elective repair, particularly in those less than one year of age, we suggest that repair be performed soon after diagnosis. 

We recommend that manual reduction be attempted for children with an incarceration without signs of peritoneal irritation . Immediate referral to a surgeon is recommended if manual reduction is not successful. Children with an incarcerated hernia should have nothing by mouth, in case emergent surgical reduction is required.

Hernias in females are caused by the persistence of the diverticulum of Nuck and contain the suspensory ligament of the ovary. Because of the significant likelihood that reproductive organs are within the hernial sac, the clinician should attempt a gentle reduction and then obtain an ultrasound (US) if not successful. In patients in whom an incarcerated ovary is suspected, ultrasound first, if available, is an alternative approach. If the US indicates that reproductive organs are not present, then further efforts at reduction are appropriate.

Following successful manual reduction of an incarcerated inguinal hernia, children should be referred to a surgeon. We suggest that definitive hernia repair be performed within five days (within two days for infants born prematurely) of the reduction. 

From Up To Date: Inguinal hernia in children 

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