I. Inguinal hernia Pediatric inguinal hernia (IGH) are all hiatal hernias and are almost always congenital unclosed sphincters, characterized by the posterior wall of the hernia sac in close proximity to the spermatic cord. Not all open sphincters will develop inguinal hernias. Statistically, 57% of infants up to 1 year of age are found to have an open sphincter at autopsy, while the number of those with clinical manifestations of hernias is much lower. Hernias are formed only when abdominal organs are squeezed into the unclosed sphincter. Increased intra-abdominal pressure is a precipitating factor for hernias, such as violent crying, prolonged coughing, constipation and difficulty in urination in children. In addition, the inguinal canal in children is very short, about 1 cm, and leads nearly vertically from the inner ring to the outer ring. When abdominal pressure increases, the pressure is directed subcutaneously, without the cushioning constraint of the oblique inguinal canal. Infants are often supine, and both hips are often flexed, externally rotated and abducted, resulting in relaxation of the abdominal muscles and weakened contraction, which makes hernias easily occur in infancy. Clinical manifestations] Inguinal hernia in infants can appear in the first violent cry after birth, especially in premature infants, because their sheaths are not yet completely occluded, the incidence of hernia is higher. However, they are usually found at 2 to 3 months of age or somewhat later. The mass only protrudes in the external ring when crying or straining, and disappears if fed or when quiet. In inguinal hernias in young children or older children, the bulging mass increases with the number of episodes and extends towards the upper pole of the scrotum, and in some cases the mass enters the scrotum and even the scrotal base and stays longer outside the abdominal cavity, disappearing after lying down. The inguinal hernia without complications is usually not painful except for the swelling. Growth and development also do not differ from normal pediatric patients. Local examination of the groin reveals smaller inguinal hernias located in the external ring and at the beginning of the scrotum, which are oval in shape. Larger ones may descend into the scrotum and resemble a heart shape. The mass is soft and elastic, with the upper pole gradually disappearing into the inguinal canal in the external ring with indistinct borders. The mass can be returned into the abdominal cavity by gently squeezing the mass upward with the hand, and a grunting sound can be heard. After repositioning, pressure is applied to the inner ring with a finger and the impulse can be felt when the child coughs. Removing the finger, the mass reappears. In many cases, no mass appears at the time of consultation, and the hernia is still not seen after increasing abdominal pressure. Careful comparison of the inguinal region on both sides should be made, and sometimes a slight bulge can be found on the side with the hernia. The thickened spermatic cord can be felt by sliding the finger back and forth over the inguinal ligament and there is a sensation of two layers of silk rubbing against each other. Treatment】 Although the peritoneal sphincter can continue to be occluded after birth, children with hernias rarely have the possibility of self-healing. Therefore, inguinal hernias should be surgically treated after diagnosis to prevent repeated occurrences of clamped-closure hernias, even in premature infants. Surgical treatment of inguinal hernia is already quite safe and can be performed regardless of age. However, because of the elective nature of the surgery, it is appropriate to choose the appropriate period. In children who are frail and prone to upper respiratory tract infections, long-term coughing may lead to frequent hernia and parents are often more eager to request treatment. Children with serious diseases, such as cyanotic congenital heart disease, malnutrition, and general weakness after infectious diseases, are advised to postpone surgery. Incarcerated inguinal hernia refers to the inability of the abdominal organs to reset themselves after entering the hernia sac and staying in the sac. It is a common complication of pediatric inguinal hernia. If not properly treated, strangulated intestinal obstruction may occur with serious consequences. Clinical manifestations】 When the inguinal hernia is clamped shut, a painful mass appears in the groin or scrotum. The child cries and is restless, and later gradually develops nausea and vomiting. If not treated in time, the symptoms of intestinal obstruction gradually worsen, abdominal distension is obvious, and vomiting is intestinal contents. After the clamp closure, the venting and defecation mostly stop. If there are bloody stools, along with symptoms of poisoning, it mostly suggests intestinal necrosis. Examination reveals a bulging mass in the groin or scrotum, which is hard, with little pushing and obvious tenderness. In more advanced cases, the scrotal skin is red and congested, which does not necessarily indicate intestinal necrosis in the hernia, but is difficult to distinguish from scrotal inflammation caused by intestinal necrosis. Treatment】 Pediatric pincer inguinal hernia should be treated urgently. 1.Manual repositioning: Due to the anatomical and physiological characteristics of pediatric patients, the development of hernia content from clamp closure to necrosis is slow; after hernia clamp closure, the tissues around the hernia sac are edematous and the anatomical relationship is unclear, and the wall of the hernia sac is originally thin in pediatric patients, so it is more likely to be torn after edema, which increases the difficulty of emergency surgery or produces some unexpected complications. Therefore, for pediatric hiatal hernia with a duration of about 12 hours, surgery is usually not urgent, and a trial of manual repositioning can be performed first. If the repositioning is successful, surgery can be performed after the edema has subsided for 24 to 48 hours. Although manual repositioning can make the hernia disappear immediately and has its advantages, it can also have serious consequences and the following conditions should be contraindicated: ① the clamping time has exceeded 12 hours; ② the trial of manual repositioning has failed; ③ the contents of the girl’s clamped hernia are often ovaries or fallopian tubes, most of which are not easily repositioned; ④ the newborn cannot estimate the clamping time of the hernia; ⑤ the general condition is poor or there are signs of strangulation such as blood in stool. 2. Surgical treatment: Emergency surgery should be performed in all cases where manual repositioning has failed or is not suitable for manual repositioning. The prognosis is better in cases of clamped inguinal hernia without intestinal necrosis. Late stage cases with poor general condition, especially in neonates, may have more serious consequences despite active treatment. The syringomyelia (hydroce1es) in children is due to incomplete occlusion of the sphincter, so that the syringomyelia canal remains open or partially open. Because of the small diameter of the syringomyelia, the intestinal canal cannot pass, allowing only the abdominal fluid to flow through the syringomyelia canal and accumulate in the sphincter cavity, forming a syringomyelia. The sphincter in female fetuses is called Nück’s canal, and if fluid accumulation occurs, it is called Nück’s cyst. Clinical manifestations] Syringomyelia generally has no systemic symptoms, only localized masses of varying sizes that grow slowly and do not cause pain. Larger masses may have a feeling of swelling. The masses of syringomyelia often appear to be filled and swollen with high tension after walking activities during the day; they may be slightly shriveled when waking up in the morning. Syringomyelia in newborns may occur unilaterally or bilaterally. If the syringomyelia occludes itself during development, the syringomyelia will gradually disappear. Diagnosis】 A cystic mass in the scrotum or groin on the side of the syringomyelia with clear borders and no obvious stalk tip into the abdominal cavity and a positive transillumination test of the mass is diagnostic. In some cases, the mass can be reduced in tension after repeated squeezing without significant volume reduction, or can provide a clear history of being larger at night and smaller in the morning, which can be considered as a traffic sphincter effusion. If the mass is confined to the spermatic cord area, it is usually small and ovoid in size, and the testis can be clearly visualized underneath the mass. The mass may move when the testicle is pulled, and this is a spermatic cord syringomyelia. In testicular syringomyelia, the mass is located at the bottom of the scrotum and is oval or cylindrical in shape, and the testicle cannot be felt when the tension is high. Treatment] If the syringomyelia is not large and the tension is not high, there is no urgency for surgical treatment, especially in infants within 1 year of age, and there is still a chance for it to subside on its own. If the tension is high, it may affect the blood supply to the testes and produce testicular atrophy, and surgery is not restricted by age.