# Indirect Hernia — GCMD Library living collection Everything in the library about indirect hernia — built automatically from dossiers that name it. Updated: n/a · 3 episodes · 121 cited statements ## Episodes ### Fundamentals - [Inguinal Hernias: Diagnosis and Management](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891) — podcast · 16:29 · [machine version](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891.md) - [Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457) — video · [machine version](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457.md) ### In-Depth Reviews - [Pediatric inguinal hernia diagnosis, management, and complications](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594) — podcast · 15:59 · [machine version](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=0) Introduction and Epidemiology of Pediatric Inguinal Hernias (Ep 1) - [3:25](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=205) Clinical Presentation and Differential Diagnosis (Ep 1) - [5:11](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=311) Management of Incarcerated Inguinal Hernias (Ep 1) - [8:43](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=523) Surgical Approach and Postoperative Management (Ep 1) - [12:37](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=757) Complex Cases and Special Considerations (Ep 1) - [0:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=0) Anatomy and epidemiology of pediatric inguinal hernias (Ep 2) - [3:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=180) Risk factors and differential diagnosis (Ep 2) - [6:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=360) Timing considerations and incarceration risk (Ep 2) - [9:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=540) Presentation and bedside reduction technique (Ep 2) - [12:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=720) Surgical approach and technique (Ep 2) - [15:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=900) Post-operative complications and special scenarios (Ep 2) - [0:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=0) Introduction and Anatomy of Pediatric Inguinal Hernias (Ep 3) - [1:56](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=116) Embryology, Risk Factors, and Epidemiology (Ep 3) - [3:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=205) Differential Diagnosis and Timing of Elective Repair (Ep 3) - [5:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=311) Incarcerated Hernia: Presentation and Bedside Reduction (Ep 3) - [7:31](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=451) Surgical Repair: Timing, Approach, and Technical Considerations (Ep 3) - [10:48](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=648) Postoperative Complications and Special Scenarios (Ep 3) - [13:29](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=809) Special Cases: Undescended Testis and Absent Vas (Ep 3) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - Inguinal hernia repair is the second most common surgery performed by pediatric surgeons. — Meera Kotagal (epidemiological) [Ep 2 · 0:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=0) - The incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns. — Meera Kotagal (epidemiological) [Ep 2 · 1:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=60) - The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age. — Meera Kotagal (epidemiological) [Ep 2 · 1:15](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=75) - Most inguinal hernias in children are largely indirect, over 90%. — Meera Kotagal (epidemiological) [Ep 2 · 1:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=90) - Direct hernias are pretty rare in children and are much more commonly found in adolescence. — Meera Kotagal (clinical) [Ep 2 · 1:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=100) - Femoral hernias are very rare in children, and as in adults, are more common in females. — Meera Kotagal (epidemiological) [Ep 2 · 1:50](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=110) - Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth. — Meera Kotagal (clinical) [Ep 2 · 2:10](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=130) - Indirect inguinal hernias occur as a result of the failure of the processus vaginalis to fuse. — Meera Kotagal (clinical) [Ep 2 · 2:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=145) - The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias. — Meera Kotagal (clinical) [Ep 2 · 2:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=165) - The number one risk factor for inguinal hernias in children is prematurity. — Meera Kotagal (clinical) [Ep 2 · 3:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=210) - More than half of the incarcerations that we see are in patients that are less than six months old. — Meera Kotagal (epidemiological) [Ep 2 · 7:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=420) - Two-thirds of incarcerations are in those patients that are less than a year. — Meera Kotagal (epidemiological) [Ep 2 · 7:15](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=435) - If the corrected gestational age is less than 60 weeks, premature patients are at a pretty increased risk of post-operative apnea, so you got to admit those patients after you do the repair. — Meera Kotagal (clinical) [Ep 2 · 7:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=450) - One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes that means pain control and sedation. — Meera Kotagal (clinical) [Ep 2 · 9:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=570) - You have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to release the hernia. — Meera Kotagal (clinical) [Ep 2 · 10:20](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=620) - If you can reduce an incarcerated hernia, then you want to go to the OR within the first 24 to 72 hours after the reduction. — Meera Kotagal (clinical) [Ep 2 · 11:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=690) - The most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open. — Meera Kotagal (clinical) [Ep 2 · 13:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=810) - Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia. — Meera Kotagal (clinical) [Ep 2 · 14:10](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=850) - The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic. — Meera Kotagal (opinion) [Ep 2 · 14:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=865) - If you're considering that the child needs an orchidopexy in addition to their hernia repair, then most would approach that hernia in an open fashion. — Meera Kotagal (clinical) [Ep 2 · 14:55](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=895) - A floor repair should be considered in children who have long-standing or very large hernias, where you note that the floor might be blown out or unsupported. — Meera Kotagal (clinical) [Ep 2 · 15:35](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=935) - Superficial site infections occur in less than 1% of kids after inguinal hernia repair. — Meera Kotagal (epidemiological) [Ep 2 · 16:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=985) - The rates of recurrence after pediatric inguinal hernia repair vary from 1 to 5% depending on which studies you look at. — Meera Kotagal (epidemiological) [Ep 2 · 16:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=1000) - In general, we don't try to limit activities in children after a hernia repair, and most children can return to normal activities within one to two days. — Meera Kotagal (clinical) [Ep 2 · 17:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=1045) - If a patient does have an undescended testicle that's palpable in the inguinal canal, then you should plan to do an orchidopexy at the time of your inguinal hernia repair. — Meera Kotagal (clinical) [Ep 2 · 19:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=1185) - Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period. — Meera Kotagal (clinical) [Ep 2 · 20:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=1230) - If patients are having significant testicular pain after a hernia repair, the thing that concerns you most is testicular ischemia, and the best way to evaluate that is to get an ultrasound looking for Doppler flow. — Meera Kotagal (clinical) [Ep 2 · 21:10](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=1270) - In general, patients with testicular ischemia after hernia repair are monitored and observed with pain control and we only frankly remove a necrotic testicle and not necessarily one that is partially ischemic. — Meera Kotagal (clinical) [Ep 2 · 21:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=1300) - The incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns. — Meera Kotagal (epidemiological) [Ep 1 · 1:26](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=86) - The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age. — Meera Kotagal (epidemiological) [Ep 1 · 1:26](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=86) - Most inguinal hernias in children are largely indirect, over 90%. — Meera Kotagal (epidemiological) [Ep 1 · 1:26](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=86) - Direct hernias are pretty rare in children and are much more commonly found in adolescents. — Meera Kotagal (clinical) [Ep 1 · 1:26](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=86) - Femoral hernias are very rare in children and, as in adults, are more common in females. — Meera Kotagal (epidemiological) [Ep 1 · 1:26](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=86) - Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth. — Meera Kotagal (clinical) [Ep 1 · 1:59](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=119) - Inguinal hernias occur as a result of the failure of the processus vaginalis to fuse. — Meera Kotagal (clinical) [Ep 1 · 1:59](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=119) - The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias. — Meera Kotagal (clinical) [Ep 1 · 1:59](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=119) - The number one risk factor for inguinal hernias in children is prematurity. — Meera Kotagal (clinical) [Ep 1 · 2:47](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=167) - Other factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undescended testicle or hydrocele, and a connective tissue disorder. — Meera Kotagal (clinical) [Ep 1 · 2:47](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=167) - More than half of incarcerations are in patients that are less than six months, and two-thirds of incarcerations are in patients who are less than a year. — Meera Kotagal (epidemiological) [Ep 1 · 4:31](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=271) - If corrected gestational age is less than 60 weeks, patients have a high risk for premature apnea postoperatively and need to be admitted after surgery to monitor. — Meera Kotagal (clinical) [Ep 1 · 4:31](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=271) - One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes requiring pain control and sedation. — Meera Kotagal (clinical) [Ep 1 · 5:59](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=359) - For hernia reduction, one hand guides the contents through the inguinal ring and the other hand applies gentle, steady pressure, which must be maintained in a slow, gentle fashion. — Meera Kotagal (clinical) [Ep 1 · 5:59](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=359) - During reduction of an incarcerated hernia, you have to squeeze the incarcerated bowel so that the edema gets pushed out, which can take several minutes. — Todd (clinical) [Ep 1 · 6:41](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=401) - If you can reduce an incarcerated inguinal hernia, you want to go to the OR within the first 24 to 72 hours after the reduction. — Meera Kotagal (clinical) [Ep 1 · 7:34](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=454) - With laparoscopy, you don't necessarily need to wait after reducing an incarcerated hernia because it's not that much more difficult in a laparoscopic case if there's swelling; in fact, sometimes the edema can help lift the peritoneum off. — Todd (opinion) [Ep 1 · 7:50](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=470) - The most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open. — Meera Kotagal (clinical) [Ep 1 · 8:57](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=537) - Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia. — Meera Kotagal (clinical) [Ep 1 · 8:57](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=537) - The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic. — Meera Kotagal (clinical) [Ep 1 · 9:31](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=571) - If a child needs an orchidopexy in addition to their hernia repair, most would approach that hernia in an open fashion. — Meera Kotagal (clinical) [Ep 1 · 9:44](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=584) - When people have been doing orchidopexies and don't stitch the hole closed, patients usually do not get a hernia afterward, suggesting that scar alone may be enough and you may not need to ligate anything. — Todd (opinion) [Ep 1 · 9:59](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=599) - A floor repair should be considered in children who have longstanding or very large hernias where the floor might be blown out or unsupported. — Meera Kotagal (clinical) [Ep 1 · 10:54](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=654) - The most common complications after inguinal hernia repair in children are superficial site infection, which occur in less than 1% of kids, and recurrence, with rates varying from 1% to 5%. — Meera Kotagal (epidemiological) [Ep 1 · 11:10](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=670) - Rare complications include testicular atrophy or damage to the vas deferens. — Meera Kotagal (clinical) [Ep 1 · 11:10](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=670) - Post-operative hydrocele can occur after laparoscopic repair, and all observed cases have resolved on their own. — Todd (clinical) [Ep 1 · 11:52](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=712) - In general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within one to two days. — Meera Kotagal (clinical) [Ep 1 · 12:19](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=739) - A lot of times, once the patient is put under anesthesia, an incarcerated hernia that was unable to be reduced in the emergency department may actually spontaneously reduce with the patient's relaxation. — Meera Kotagal (clinical) [Ep 1 · 13:26](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=806) - If a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair. — Meera Kotagal (clinical) [Ep 1 · 13:49](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=829) - Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period. — Meera Kotagal (clinical) [Ep 1 · 14:18](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=858) - If patients are having significant testicular pain after a hernia repair, the main concern is testicular ischemia, best evaluated with ultrasound looking for Doppler flow. — Meera Kotagal (clinical) [Ep 1 · 14:35](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=875) - In cases of testicular ischemia after hernia repair, patients are monitored and observed with pain control, and surgeons only remove a necrotic testicle, not necessarily one that is partially ischemic. — Meera Kotagal (clinical) [Ep 1 · 14:35](https://library.globalcastmd.com/watch/inguinal-hernias-diagnosis-and-management-3891?t=875) - Indirect hernias are a defect above the inguinal ligament and lateral to the epigastric vessels. — Rae Hanke (clinical) [Ep 3 · 1:01](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=61) - A direct hernia is a defect above the inguinal ligament and medial to the epigastric vessels. — Rae Hanke (clinical) [Ep 3 · 1:07](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=67) - A femoral hernia is a defect below the inguinal ligament. — Rae Hanke (clinical) [Ep 3 · 1:07](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=67) - The incidence of inguinal hernias overall ranges from about 1 to 5% in full-term newborns. — Meera Kotagal (epidemiological) [Ep 3 · 1:27](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=87) - The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age. — Meera Kotagal (epidemiological) [Ep 3 · 1:34](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=94) - Over 90% of inguinal hernias in children are indirect. — Meera Kotagal (epidemiological) [Ep 3 · 1:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=100) - Direct hernias are pretty rare in children and are much more commonly found in adolescents. — Meera Kotagal (epidemiological) [Ep 3 · 1:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=105) - Femoral hernias are very rare in children, and as in adults are more common in females. — Meera Kotagal (epidemiological) [Ep 3 · 1:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=105) - Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth. — Meera Kotagal (clinical) [Ep 3 · 1:59](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=119) - Inguinal hernias occur as a result of the failure of the processus vaginalis to fuse. — Meera Kotagal (clinical) [Ep 3 · 2:06](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=126) - In utero during gestation, the processus vaginalis should fuse to become the tunica vaginalis. — Meera Kotagal (clinical) [Ep 3 · 2:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=131) - The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias. — Meera Kotagal (clinical) [Ep 3 · 2:17](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=137) - If the processus vaginalis narrows but doesn't totally close, you can get a communicating hydrocele where fluid can move from the peritoneal cavity through the inguinal canal and into the scrotum. — Meera Kotagal (clinical) [Ep 3 · 2:28](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=148) - If the proximal part closes and the distal part isn't obliterated, then you get a non-communicating hydrocele where some fluid is trapped. (clinical) [Ep 3 · 2:35](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=155) - The number one risk factor for inguinal hernias in children is prematurity. — Meera Kotagal (epidemiological) [Ep 3 · 2:47](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=167) - Risk factors for inguinal hernias in children include male sex, family history of inguinal hernias, a history of an undescended testicle or hydrocele, and a connective tissue disorder. — Meera Kotagal (epidemiological) [Ep 3 · 2:57](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=177) - The differential diagnosis for a groin mass in a child includes an inguinal hernia (most likely indirect, although rarely direct), hydrocele, or lymphadenopathy. — Meera Kotagal (clinical) [Ep 3 · 3:35](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=215) - If a groin mass is associated with significant pain, the differential diagnosis should also include testicular torsion, epididymitis, orchitis, or torsion of the appendix testis. — Meera Kotagal (clinical) [Ep 3 · 3:47](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=227) - A retractile testicle or undescended testicle in the groin can be mistaken for a hernia; always make sure both testicles are in the scrotum when you see a bulge in the groin. — Todd (clinical) [Ep 3 · 4:03](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=243) - Timing for decisions about repairs of inguinal hernias has to balance the risks of anesthesia with the risks of incarceration associated with the hernia. — Meera Kotagal (clinical) [Ep 3 · 4:31](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=271) - Inguinal hernia repair is in general considered an elective operation and does not need to be urgently performed. — Meera Kotagal (guideline) [Ep 3 · 4:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=280) - Younger children have a higher rate of incarceration. — Meera Kotagal (epidemiological) [Ep 3 · 4:43](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=283) - Children with an incarcerated hernia may present most commonly with pain, particularly groin pain. — Meera Kotagal (clinical) [Ep 3 · 5:24](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=324) - Children with incarcerated hernias may have abdominal distension or emesis if obstruction is present due to bowel being in the incarcerated hernia. — Meera Kotagal (clinical) [Ep 3 · 5:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=330) - Prolonged incarceration can result in strangulation, particularly of bowel contents. — Meera Kotagal (clinical) [Ep 3 · 5:37](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=337) - Patients with a strangulated hernia may present with fever, tachycardia, leukocytosis, severe pain, or overlying erythema in the skin. — Meera Kotagal (clinical) [Ep 3 · 5:37](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=337) - One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm. — Meera Kotagal (clinical) [Ep 3 · 5:59](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=359) - To reduce an incarcerated hernia, place the patient supine in Trendelenburg position with their head down, and use two hands: one to guide the contents through the inguinal ring, and the other to apply gentle steady pressure. — Meera Kotagal (clinical) [Ep 3 · 6:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=371) - You have to keep applying pressure in a slow, gentle fashion, and not just come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia. — Meera Kotagal (clinical) [Ep 3 · 6:28](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=388) - When reducing an incarcerated hernia in the emergency room, you have to be patient because it doesn't usually reduce right away; you have to squeeze the incarcerated bowel so that the edema gets pushed out, which allows it to be reduced. This can take several minutes. — Todd (clinical) [Ep 3 · 6:41](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=401) - Todd recommends not just reducing the bowel after the patient is asleep, but putting a laparoscope in so you can watch the bowel being reduced to make sure it's viable. — Todd (opinion) [Ep 3 · 7:17](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=437) - If you can reduce an incarcerated hernia, you want to go to the OR within the first 24 to 72 hours after the reduction. — Meera Kotagal (guideline) [Ep 3 · 7:34](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=454) - Todd challenges the traditional teaching that you should wait till the next day after reducing an incarcerated hernia; with laparoscopy, you don't necessarily need to wait because it's not that much more difficult if there's swelling, and the edema can actually help lift the peritoneum off. — Todd (opinion) [Ep 3 · 7:50](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=470) - Todd suggests that if it's in the middle of the day and you have time availability and a patient has an incarcerated hernia, you could not even try to reduce it in the emergency room and just go straight to the operating room under laparoscopy, watch it get reduced under visualization, and then do the laparoscopic repair, which is not that difficult even after an incarceration. — Todd (opinion) [Ep 3 · 8:19](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=499) - You can approach the repair of a pediatric inguinal hernia either laparoscopically or in an open fashion. — Meera Kotagal (clinical) [Ep 3 · 8:57](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=537) - The most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open. — Meera Kotagal (clinical) [Ep 3 · 9:03](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=543) - You should consider evaluation of the contralateral side depending on the age of the child. — Meera Kotagal (guideline) [Ep 3 · 9:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=551) - Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia. — Meera Kotagal (clinical) [Ep 3 · 9:15](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=555) - The most important thing is that you do the operation that you're comfortable with. — Meera Kotagal (opinion) [Ep 3 · 9:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=565) - The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic. — Meera Kotagal (clinical) [Ep 3 · 9:31](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=571) - If a child needs an orchiopexy in addition to their hernia repair, most would approach that hernia in an open fashion. — Meera Kotagal (guideline) [Ep 3 · 9:44](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=584) - Todd does orchiopexies for undescended testicles laparoscopically through the scope, and can deal with the hernia at the time. — Todd (opinion) [Ep 3 · 10:01](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=601) - When people do orchiopexies, they don't necessarily stitch the hole closed, and from that we learned that you may not ever actually need to stitch, that scar alone may be enough. — Todd (clinical) [Ep 3 · 10:15](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=615) - There are surgeons who just cut the sac but don't actually ligate anything, based on learning that patients usually do not get a hernia after an orchiopexy is done and the hole is not ever ligated shut. — Todd (clinical) [Ep 3 · 10:32](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=632) - A floor repair should be considered in children who have long-standing or very large hernias, where you note that the floor might be blown out or unsupported, in order to buttress the repair. — Meera Kotagal (clinical) [Ep 3 · 10:54](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=654) - Complications are fairly rare after an inguinal hernia repair in children. — Meera Kotagal (epidemiological) [Ep 3 · 11:10](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=670) - The most common complications are superficial site infection, which occur in less than 1% of kids, and some risk of recurrence. — Meera Kotagal (epidemiological) [Ep 3 · 11:14](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=674) - The rates of recurrence vary from 1 to 5%, depending on which studies you look at. — Meera Kotagal (epidemiological) [Ep 3 · 11:21](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=681) - A more common complication is the presence of a seroma after a hernia repair; it's important to explain to parents that they might see fluid or something that looks like a bulge again after the repair, and that seroma will resolve with time. — Meera Kotagal (clinical) [Ep 3 · 11:34](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=694) - Todd has not seen a seroma very often, but in laparoscopic repair you can get a postoperative hydrocele; all the ones he's seen (2 or maybe 3 in 15 years) have resolved on their own. — Todd (opinion) [Ep 3 · 11:48](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=708) - In general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within 1 to 2 days. — Meera Kotagal (guideline) [Ep 3 · 12:21](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=741) - The most concerning thing when you have an incarcerated hernia that you're unable to reduce, particularly if you see overlying skin changes or signs of strangulation, is bowel ischemia and necrosis. — Meera Kotagal (clinical) [Ep 3 · 12:51](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=771) - If you identify necrotic bowel, you can approach resecting it either through a groin incision or through a small midline incision. — Meera Kotagal (clinical) [Ep 3 · 13:03](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=783) - You can approach laparoscopically and run the bowel to evaluate for ischemia, and then turn to fix the hernia either laparoscopically or open. — Meera Kotagal (clinical) [Ep 3 · 13:17](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=797) - A lot of times, once the patient is put under anesthesia, an incarcerated hernia that you noted and were unable to reduce in the emergency department may actually spontaneously reduce with the patient's relaxation. — Meera Kotagal (clinical) [Ep 3 · 13:29](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=809) - It's important to do a thorough exam and make sure you understand whether or not patients have undescended testes at the time of your pre-op evaluation. — Meera Kotagal (guideline) [Ep 3 · 13:50](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=830) - If a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair. — Meera Kotagal (guideline) [Ep 3 · 14:01](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=841) - Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period. — Meera Kotagal (guideline) [Ep 3 · 14:18](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=858) - If patients are having significant testicular pain after a hernia repair, the most concerning thing is testicular ischemia. — Meera Kotagal (clinical) [Ep 3 · 14:36](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=876) - The best way to evaluate testicular ischemia is to get an ultrasound looking for Doppler flow. — Meera Kotagal (clinical) [Ep 3 · 14:42](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=882) - In general, patients with testicular ischemia after hernia repair are monitored and observed with pain control, and we only frankly remove a necrotic testicle, and not necessarily one that is partially ischemic. — Meera Kotagal (clinical) [Ep 3 · 14:46](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=886) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - Dr. Todd Ponsky states that with laparoscopy, you don't necessarily need to wait for bowel edema to come down because it's really not that much more difficult in a laparoscopic case if there's swelling, and sometimes the edema can help lift the peritoneum off. — Meera Kotagal summarizing a resource [Ep 2 · 12:10](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=730) - Dr. Todd Ponsky suggests that if it's in the middle of the day and you have time availability and a patient has an incarcerated hernia, you could not even try to reduce it in the emergency room and just go straight to the operating room under laparoscopy. — Meera Kotagal summarizing a resource [Ep 2 · 12:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-in-brief-presentation-workup-diagnosis-perioperative-c-4457?t=765) - Inguinal hernia repair is the 2nd most common surgery that pediatric surgeons perform. — Rod summarizing the discussion [Ep 3 · 0:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=30) - Patients with increased intraabdominal pressure (cystic fibrosis, chronic ventilation, chronic constipation, VP shunts, peritoneal dialysis) present more symptomatically with hernias. — Rod summarizing the discussion [Ep 3 · 3:09](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=189) - More than 50% of incarcerations are in patients that are less than 6 months, and 2/3 of incarcerations are in patients who are less than 1 year. — Rod summarizing the discussion [Ep 3 · 4:51](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=291) - If a premature infant's corrected gestational age is less than 60 weeks, they have a high risk for premature apnea post-operatively, so you have to admit them after surgery to monitor. — Rod summarizing the discussion [Ep 3 · 5:02](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=302) - Pain control and sedation help with hernia reduction because if the child is crying, reduction will be difficult. — Rod summarizing the discussion [Ep 3 · 6:05](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=365) - Rare complications include testicular atrophy or damage to the vas deferens. — Rod summarizing the discussion [Ep 3 · 11:26](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=686) - You can resect bowel through a groin incision. — Rod summarizing the discussion [Ep 3 · 13:12](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=792) ## Changelog - Nov 7: 3 items added automatically --- Educational content from recorded physician discussions — not medical advice. 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