Inguinal Hernia in Child                                         Back             Home

Today, inguinal hernia repair is one of the most common pediatric operations performed. Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Most hernias that are present at birth or in childhood are indirect inguinal hernias. Other less common types of ventral hernias include umbilical, epigastric, and incisional hernias.

Some Statistics

About 3% to 5% of healthy, full-term babies may be born with an inguinal hernia and one third of hernias of infancy and childhood appear in the first 6 months of life.  In premature infants the incidence of inguinal hernia is substantially increased, up to 30%.  In just over 10% of cases, other members of the family have also had a hernia at birth or in infancy.

Mortality/Morbidity

An incarcerated or strangulated inguinal hernia can result in severe complications and even death. An incarcerated or strangulated inguinal and/or femoral hernia may also result in significant sequela, depending on which visceral structure is involved in the hernia sac. Such sequela can range from life-threatening complications to gonadal dysfunction, including intestinal necrosis and perforation, intestinal obstruction, intestinal stricture, testicular necrosis, testicular atrophy, ovarian necrosis, ovarian atrophy, and tubal stricture.

Sex

Inguinal hernias are much more common in males than in females. The male-to-female ratio is estimated to be 4-8:1.

Age

Premature infants are at an increased risk for inguinal hernia, with the incidence ranging from 7-30%. Moreover, the associated risk of incarceration is more than 60% in this population. Most pediatric ventral and inguinal hernias are detected in the first year of life. Occasionally, hernias may remain asymptomatic and unnoticed by the parents until later in life. Finding an adult patient with an indirect inguinal hernia that has been present since birth is not unusual.

Etiology of Inguinal hernias in Children

The etiology of inguinal hernia in children can be termed an abnormality of embryologic development of the fetus. However, some children may present with an acquired form of inguinal hernia, also called a direct inguinal hernia. In this type of hernia, weakness of the inguinal floor is present, which allows for protrusion of viscera from the abdominal cavity. The hernia sac is composed of the peritoneal fold that contains the hernia.

• The following are associated with an increased risk of inguinal hernia:
  • Prematurity and low birth weight (Incidence approaches 50%.)
  • Urologic conditions
    • Cryptorchidism
    • Hypospadias
    • Epispadias
    • Exstrophy of the bladder
    • Ambiguous genitalia
  • Patent processus vaginalis, which may be present because of increased abdominal pressure due to ventriculoperitoneal shunts, peritoneal dialysis, or ascites
  • Abdominal wall defects
    • Gastroschisis
    • Omphalocele
  • Family history
    • Meconium peritonitis
    • Cystic fibrosis
    • Connective tissue disease
    • Mucopolysaccharidosis
    • Congenital dislocation of the hip
    • Ehlers-Danlos syndrome
    • Marfan syndrome
    • Cloacal exstrophy
    • Fetal hydrops
    • Liver disease with ascites
    • Ventriculoperitoneal shunting for hydrocephalus

Fast facts

• Figures regarding inguinal hernia incarceration indicate the following risk patterns:
  • Incarceration occurs in 17% of right-sided hernias and 7% of left-sided hernias.
  • More than 50% of cases of incarceration occur within the first 6 months of life; the risk gradually decreases after age 1 year.
  • Premature infants have twice the risk of incarceration than the general pediatric population.
  • 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%.

Classification:-Inguinal

Inguinal hernia in children can be divided into two types

1.    Complete scrotal ( Total funicular hernia of Herzfeld

2.    Incomplete Bubonocoele( Partial funicular hernia of Herzfeld)

About 5% of Inguinal hernias in male infants are of the complete variety.

Clinical Presentations

1. Hallmark of an indirect inguinal hernia is a groin bulge at the top of the scrotum or within the scrotum. 
2. Bulge most visible during periods of increased intra-abdominal pressure.
3. Hernia may reduce spontaneously or may be manually reduced.
4. Physical exam may only reveal a thickened spermatic cord(silk-glove) sign.
5. Communicating hydroceles frequently present with a history of a scrotal mass that changes in size; the scrotal size increases during crying, defecation and decreases after periods of inactivity, e.g. sleeping. This is due to the exchange of fluid from the peritoneal cavity to the scrotum through a narrow communication (persistent patency of the processus.) 
6. In males, the most common content is bowel, in females, the ovary.
7. Hernias are often first discovered by parents who notice a bulge in groin area during diaper changes.
8. Most hernias are painless, but at times the initial presentation may be an incarcerated loop of bowel.
9. Hydroceles may be differentiated from incarcerated hernias by the absence of pain and symptoms of bowel obstruction.
10. Increased fat in the pubic area may make the diagnosis difficult. A hernia not felt on careful examination is unlikely to incarcerate.
11. Must differentiate from retractable testes that may appear as an inguinal bulge. 
12. Most hydroceles disappear during the first year of life.

Management

·      Less than one year old should be operated on as urgent elective cases

·      Older one year old surgery is less urgent

·      Can often be performed as a day case procedure

·      Inguinal herniotomy is performed

·      Transverse incision made in lowest inguinal skin crease

·      20% children develop a contralateral hernia

·      Controversial as to whether contralateral exploration should be performed

Irreducible hernias

·      Initial management should be with with reduction by taxis

·      Required gentle pressure usually without sedation

·      Forcible reduction under general anaesthesia is contraindicated

·      If remains irreducible should be operated on within 24 hours

·      If intestinal obstruction present preoperative resuscitation is essential

Surgical Care

For inguinal hernia, elective herniorrhaphy is indicated to prevent incarceration and subsequent strangulation. Hernia repair is an outpatient procedure in the otherwise healthy full-term infant or child. Postpone the operation in the event of upper respiratory tract infection, otitis media, or significant rash in the groin.

Repair of the pediatric inguinal hernia

In babies and young children , the inguinal canal has not yet developed its oblique adult anatomy . The superficial ring is directly anterior to the deep ring and the sac is indirect. There is no acquired deformity of the canal.In these cases the fascia transversalis is normal and a simple herniotomy is all that is necessary. Straightforward inguinal herniotomy should give a 100% success.

Inguinal hernia surgery in girls: In little girls, sometimes an ovary can slip into a similar weakness in the same general area, and may slip all the way down into the labium majorum. The ovary also can get twisted and strangulated, so it gets fixed promptly as well.

Surgeons have long believed that if a male infant or child develops an inguinal hernia on one side of the body, the other side should be explored and repaired if an early defect is found. A large study in Japan reported in the Journal of Pediatric Surgery in July '98 refutes this idea. The low (11.7%) eventual incidence of subsequent hernia on the other side contrasted with the fairly significant risk of damage to reproductive structures on the side of exploration is high enough to lead the researchers to recommend: leave the apparently normal side alone.

•  In girls, a sliding hernia may contain the ovary or a portion of the fallopian tube. These structures should be carefully dissected from the internal wall of the sac before suture ligation. An alternate procedure involves incising the sac along the ovary and tube on either side and folding the flap into the peritoneum. A pursestring suture can then be used to close the sac. In the female, the sac can be sutured closed after division of the round ligament because no important structures pass through the inguinal ring.

TOP