• 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.
• 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.
• 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.
• Lymphadenopathy.
• 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 do not require an operation until after this time.
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