usually involves the ovary rather than the intestine Often, the patient or family has no previous knowledge of the presence of a congenital hernia Incarceration does not necessarily mean that the nonreducible portion of intestine is compromised or gangrenous However, strangulation can occur within 24 hours of a nonreduced incarcerated hernia because of progressive edema of the bowel caused by venous and lymphatic obstruction This obstruction then leads to occlusion of the arterial supply with resulting necrosis of the bowel and perhaps perforation Clinical Considerations Triage Considerations Children presenting with an inguinal mass should be assessed for bowel obstruction or strangulation If the child is vomiting, has significant pain, or the hernia is discolored, the patient should be seen immediately to determine whether emergent surgical consultation is required even prior to imaging or attempts at reduction Initial Assessment The clinical presentation of a child with an incarcerated hernia is irritability due to pain, vomiting, and occasionally abdominal distension A firm, discrete mass can be palpated at the internal ring that may or may not extend into the scrotum Occasionally, the testicle may appear dark blue because of venous congestion, and in a prolonged incarceration, the testicle may be infarcted Intestinal obstruction may develop quickly, and an abdominal radiograph exhibits signs of small bowel obstruction and possibly gas-filled loops of intestine in the scrotum Lack of air in the inguinal region cannot be used to exclude a hernia because the intestine, especially when incarcerated, is often fluid filled It is often difficult to differentiate a tense hydrocele in the scrotum from an incarcerated hernia If the child has had a hydrocele, a sudden increase in fluid in the tunica vaginalis may produce discomfort and concern for an incarcerated hernia However, it is uncommon for a hernia to appear in the presence of a communicating hydrocele because of the narrowness of the patent processus vaginalis that is associated with the hydrocele The acute hydrocele presents only in the scrotum but may extend superiorly toward the inguinal canal With a hydrocele, however, no mass should be palpable up the inguinal canal at the level of the internal ring Management Unless the child is ill with signs of intestinal obstruction or toxic from a gangrenous bowel, a manual reduction of the incarcerated hernia should