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Inguinal hernias in children occur with a prevalence ranging from 3 to 5%. The likelihood of a symptomatic patent processus vaginalis is significantly higher in preterms, as reported by most series. As a consequence, inguinal hernia represents the most common condition requiring surgical repair in the neonate and preterm baby. Surgery aims at avoiding and preventing intestinal and gonadal lesions related to incarceration. Nonetheless, hernia repair is technically demanding, with a relatively high risk of complications including recurrence and testicular atrophy. This paper will address some of most debated aspect of inguinal hernia management in preterms babies. The authors will discuss anesthesiological implications, available surgical techniques, optimal timing for surgery, and reasons for possible contralateral groin exploration. The authors will also discuss literature evidences and will propose their own behavior to provide an algorithm for the correct management of neonates and ex-preterms with inguinal hernia.