(a) Inguinal hernia Pediatric inguinal hernia is almost always a congenital failure of the sphincter to close. Not all open sphincters will develop inguinal hernias. Statistically, 57% of infants under the age of 1 year are found to have an open sphincter at autopsy, and far fewer have clinical manifestations of hernias. 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. The infant lies 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 preterm infants, where the incidence of hernia is higher because the sphincter has not been completely occluded. 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 after 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 done 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 The inguinal canal may remain occluded for up to 6 months after birth, but children with hernias are rarely likely to heal spontaneously. Therefore, after diagnosis, inguinal hernias can be observed within 6 months and should be treated surgically after 6 months to prevent repeated occurrences of clamped hernias, even in preterm 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. (2) Clamped inguinal hernia Clamped inguinal hernia means that the abdominal organs cannot reset themselves after entering the hernia sac and stay in the sac. This is a common complication of pediatric inguinal hernia. If not treated appropriately, strangulated intestinal obstruction and intestinal necrosis can occur with serious consequences. Clinical manifestations When an inguinal hernia is clamped shut, a painful mass appears in the groin or scrotum. The child cries and fusses, and later gradually develops nausea and vomiting. If left untreated, the symptoms of intestinal obstruction gradually worsen, abdominal distension is obvious, and vomiting is the 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. Treatment Pediatric pincer inguinal hernia should be treated urgently. After the hernia is clamped closed, the tissue around the hernia sac is edematous and the anatomical relationship is unclear. The wall of the hernia sac is originally thin in children and is more likely to be torn after edema, which makes emergency surgery more difficult or produces some unexpected complications. Therefore, for a pediatric clamped 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 will be performed after the edema has subsided. The following conditions should be contraindicated: (1) the clamping time has exceeded 12 hours; (2) the clamping time has failed; (3) the contents of the girl’s clamped hernia are often ovaries or fallopian tubes, which are mostly not easy to reset; (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 fails or is not suitable for manual repositioning. The prognosis is better in cases of clamped inguinal hernia without intestinal necrosis. In late stage with poor general condition, especially in neonates, more serious consequences can still occur despite active treatment.