Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

incarcerated hernia

1st line – surgical repair following attempted reduction

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ACUTE
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incarcerated hernia
1st line – 

surgical repair following attempted reduction

If an individual with an unrepaired umbilical hernia presents with discomfort or a tender umbilical mass, incarceration with or without strangulation should be suspected and treated immediately, regardless of age or size. Incarceration occurs if intra-abdominal contents (e.g., abdominal viscera or omentum) become trapped in the protruding hernia sac. This is termed "strangulation" if the blood supply to the bowel is compromised, causing ischemia.[2]

Management consists of immediate attempt at reduction (in the absence of signs of peritonitis) by milking air or fluid out of the incarcerated loop of intestine and applying firm, steady pressure on the mass. If reduced, the patient should be admitted and observed for peritonitis, with surgical repair the following day. If the hernia cannot be reduced, emergency repair is indicated. Assessment of bowel integrity should be part of the procedure, particularly if bloody peritoneal fluid is encountered at operation.

ONGOING

large or symptomatic hernia

1st line – elective outpatient surgical repair

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ONGOING
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large or symptomatic hernia
1st line – 

elective outpatient surgical repair

Fascial defects >0.6 to 0.8 inches (>1.5 to 2 cm) are unlikely to close spontaneously, so many surgeons advocate elective repair at 2 to 3 years of age for such hernias.[10] Earlier repair is also indicated if intermittent symptoms of incarceration or recurring pain develop.[11] There is some evidence that complications may be increased in children undergoing repair at an earlier age; a study suggests deferring elective repair until the child is 4 years of age or older, and this was the management strategy used most commonly in a survey of American Pediatric Surgical Association members.[12][13] Compression therapy (such as abdominal binders) have no role in management and may prove harmful or complicate the repair.

small and asymptomatic hernia

1st line – observation

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ONGOING
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small and asymptomatic hernia
1st line – 

observation

Traditional management of small hernias (<0.6 inches [<1.5 cm]) involves observation until 4 or 5 years of age.[2] This allows for spontaneous closure in up to 80% of children.[5] If a hernia incarcerates during the period of observation, it should be reduced by manual pressure and repaired surgically, generally within 24 hours. If an incarcerated hernia cannot be reduced, an emergency operation is indicated. It can be challenging to convince the child's caregivers that observation alone will be successful in most cases and that an operation is not indicated.

2nd line – elective outpatient surgical repair

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ONGOING
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small and asymptomatic hernia
2nd line – 

elective outpatient surgical repair

If the hernia persists beyond 4 to 5 years of age, it can be managed with elective outpatient surgical repair due to risk of incarceration. However, the risk of complications in older children, as well as the likelihood of eventual spontaneous closure, cannot be clearly defined from the available data.[9]​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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