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