• More than two thirds of all incarcerations occur in children younger than

1 year.

•Girls are more likely to develop incarceration of an inguinal hernia; the incidence in girls is 17.2 %, whereas the incidence in boys is 12 % (Fig. 17.18).

2.Strangulation (Figs. 17.19, 17.20, and 17.21):

•Once the vascular supply of the herniated contents becomes compromised, the hernia becomes strangulated.

•This may lead to ischemic necrosis and intestinal perforation.

•This is an indication for emergency surgical exploration.

•A rare complication of inguinal hernia is migration of ventriculoperitoneal shunt into the hernial sac (Figs. 17.22 and 17.23).

17.2.6 Treatment

•All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as incarceration or strangulation.

•Most inguinal herniatomies are performed on an outpatient basis.

•Laparoscopic hernia repair in children is not performed as commonly as in adults.

•Contralateral inguinal hernia exploration:

–There is controversy about whether the contralateral groin should be explored.

–Today, most surgeons do not routinely perform a contralateral exploration unless a contralateral inguinal hernia or patent processus vaginalis can be demonstrated either by preoperative ultrasonography or intraoperative laparoscopy.

–A hernia develops in the other side of the groin in up to 30 % of children who have had hernia surgery. This is more so if the initial hernia was on the left side.

–When an inguinal hernia is present, some pediatric surgeons perform a contralateral groin exploration.

–This is to detect an occult patent processus vaginalis that may lead to a hernia on the opposite side (metachronous contralateral hernia). This is present in less than 5 % of cases.

–The Goldstein test can be used to determine when to perform a contralateral exploration. In this test, the abdomen is insufflated with gas through the already open hernia sac. Crepitus in the opposite groin is a positive test result, suggesting a contralateral patent processus vaginalis and warranting a contralateral exploration. This test may not be conclusive.

–An alternative approach is laparoscopy which can be used to detect an occult contralateral patent processus vaginalis.

–This can be done through a separate incision at the umbilicus or through the already opened hernia sac. This allows inspection of the contralateral inguinal ring and assessment of its patency.