Inguinal hernias
- Commonest surgical condition encountered in childhood
- 2.5% of children require an operation for an inguinal hernia
- Incidence is increased in premature and low birth weight infants
- Male: female ratio is 9:1
- 5% new born male have an inguinal hernia
- 70% are right sided
- 25% are left sided
- 5% are bilateral
- 99% are indirect hernias
- 30% present within the first year of life
- 15% present with incarceration
- 75% incarcerated hernias present less than one year of age
Embryology
- Testis descends into scrotum during 7th month of gestation
- Preceded by processus vaginalis - an outpouching of peritoneum
- Processus normally begins to obliterate prior to birth
- Closure normally complete during first year of life
- Persistence of all or part of the processus can result in:
- Inguinal hernia
- Communicating hydrocele
- Non-communicating
- Hydrocele of the cord
Clinical features
- Usually presents with intermittent groin lump
- In girls the lump is in the upper part of the labia majora
- Hernias can be difficult to detect in a quiet child
- Increases in size with straining or crying
- May reach into the scrotum
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
- Scarpa's fascia is divided
- External ring is identified
- Sac is dissected off the cord and divided
- Dissection is continued proximally until the peritoneal reflection is identified
- Sac is then transfixed and excised
- The wound is closed and the testis pulled back into the scrotum
- 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
Complications
- Wound infection
- Recurrence
- Vas injury
- Undescended testis
- Testicular atrophy
Paediatric umbilical hernia
- Common surgical problem of newborn infants
- Present in 10% caucasian babies
- Seen in 90% of babies of Afro-Caribbean descent
- Incidence is increased
- Low birth weight
- Down's syndrome
- Beckwith-Wiedemann syndrome
- Hernia is usually symptomless
- Strangulation is extremely rare
- 95% spontaneously close by 2 years of age
- Surgical repair only needs to be considered if present beyond this age
Picture provided by Sandoval Lage, University Gama Filho, Rio de Janeiro, Brazil
Bibliography
Ballantyne A, Jawaheer G, Munro F D. Contralateral groin exploration is not justified in infants
with unilateral inguinal hernias. Br J Surg 2001; 88: 720-723.
Davenport M. ABC of general paediatric surgery. Inguinal hernia, hydrocele and the undescended
testis. Br Med J 1996; 312: 564-571.
Phelps S. Agrawal M. Morbidity after neonatal inguinal herniotomy. J Pediatric Surg 1997;
32: 445-447. |