Inguinal Hernias: Diagnosis and Management

Hey there, listeners. This is Rod from Cincinnati Children's. If you haven't already, make sure to download the Stay Current in Pediatric Surgery app. It's in the Apple App Store. It's in the Google Play Store. You can listen to podcasts like this. You can watch videos. You can look at infographics. We've got so much content on there. You're going to love it. But until then, enjoy the episode. Inguinal hernia repair is the second most common surgery that pediatric surgeons perform. So today, we're going to talk about the basics of the pediatric inguinal hernia. And to do that, we brought on Dr. Mira Kodagal. She's a pediatric surgeon from Cincinnati Children's Hospital. And I got some help from a couple other residents. As a quick anatomy refresher. That's Ray Hanke. She's a general surgery resident. Indirect hernias are a defect above the inguinal ligament and lateral to the epigastric vessels. A direct hernia is a defect above the inguinal ligament and medial to the epigastric vessels. And femoral hernia is a defect below the inguinal ligament. So let's kick it off with our first question from Jillian Goddard, another general surgery resident. Do we see direct, indirect, and femoral hernias in children? The incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns. That's Dr. Mira Kodagal. And this increases to about 13% in premature infants who are less than 32 weeks of gestational age. Most of these hernias are largely indirect, over 90% in children. Direct hernias are pretty rare in children and are much more commonly found in adolescents. And femoral hernias are also very rare in children and, as in adults, are more common in females. Where do indirect hernias come from? So indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth. These inguinal hernias occur as a result of the failure of the processus vaginalis to fuse. In utero during gestation, the processus vaginalis should fuse to become the tunica vaginalis. The right processus vaginalis usually obliterates after the left, so that explains the higher prevalence of right-sided hernias. Okay, but what if it just, like, narrows and it doesn't totally close or obliterate? You can get a communicating hydrocele where fluid can move from the peritoneal cavity through the inguinal canal and into the scrotum. Oh my god, that makes so much sense. So then if the proximal part closes and the distal part isn't obliterated? Then you get a non-communicating hydrocele where some fluid is trapped. What factors are associated with an increased risk of inguinal hernias in children? The number one risk factor for inguinal hernias in children is prematurity. As we mentioned before, premature infants have a much higher rate and risk of inguinal hernias than those who are full term. Some of the other factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undecended testicle or hydroseal, and a connective tissue disorder. Now, when it comes to the patients who are going to present more symptomatic, that's going to be patients who have increased intra-abdominal pressure. So think cystic fibrosis, chronic ventilation, chronic constipation, patients who have VP shunts, patients who need peritoneal dialysis. All right, let's jump into a case that Ray has for us. A one-year-old male presents with a right-sided bulge in his groin. What's on your differential? The differential diagnosis for a groin mass in a child includes an inguinal hernia, most likely indirect, although there's a rare chance it could be direct, hydroseils, or lymphadenopathy. If that groin mass is associated with significant pain, your differential diagnosis should also include testicular torsion, epididymitis, or orchitis, or torsion of the appendix testes. Hey, Rod, hold up. Yeah, what's up, Todd? I want to add to that differential. Yeah, let's hear it. Sometimes people can be fooled by a retractile testicle, or even an undescended testicle in the groin, and think it may be a hernia. Okay, so how do we tell? Always make sure that both testicles are in the scrotum when you see a bulge in the groin. If the patient is asymptomatic, this is really an elective surgery. So when's the best time to repair it? And let's not even get into the thought of COVID postponing elective surgeries. So timing for decisions about repairs of inguinal hernias really has to balance the risks of anesthesia with the risks of incarceration associated with the hernia. It is, in general, considered an elective operation and does not need to be urgently performed. But we do know that younger children have a higher rate of incarceration. Honestly, it's surprising. More than half of incarcerations are in patients that are less than six months, and then two-thirds of incarcerations are in patients who are less than a year. And then you tack on if they're premature. If their corrected gestational age is less than 60 weeks, then they have a high risk for premature apnea postoperatively. So you've got to admit them after surgery to monitor. You confirm the diagnosis of inguinal hernia and schedule the child for an elective repair. However, before you fix the hernia, he presents to the ER. Well, I imagine that the presentation will be a little bit different from clinic, right? Children with an incarcerated hernia may present most commonly with pain, particularly groin pain. They may also have abdominal distension or emesis if obstruction is present due to bowel being in the incarcerated hernia. Prolonged incarceration can result in strangulation, particularly of bowel contents. And so those patients who have a strangulated hernia may present with fever, tachycardia, leukocytosis, severe pain, or overlying erythema in the skin. You examine the child and see he has an incarcerated inguinal hernia. What technique can you use to try to reduce it at bedside? One of the most important things, I think, in being able to reduce an incarcerated hernia is helping to keep the patient calm. Sometimes that means pain control and sedation, because if the kid's crying and you're trying to reduce the hernia, you're going to have a bad time. You can place the patient's supine and in the Trendelenburg position with her head down. And then generally, we use two hands to try to reduce the hernia. So one hand to guide the contents through the inguinal ring and the other hand applies gentle, steady pressure. This last point is really important. 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 reduce the hernia. Hey, Rod. Yeah, talk to me, Todd. Hold up. I want to add one more thing. Go for it. When you're doing a reduction of an incarcerated hernia in the emergency room, you also have to be patient because it doesn't usually just reduce right away. You have to squeeze the incarcerated bowel so that the edema gets pushed out of the bowel and that allows it to be reduced. It doesn't just happen right away. Sometimes it can take several minutes for this to go down. Okay. So let's say you get the patient to the OR. Anesthesia goes in. The patient falls asleep. Their abdominal wall relaxes. You're able to reduce it. Is that enough or what? I would recommend not just reducing the bowel after the patient is asleep, that you should put a laparoscope in so you could watch the bowel being reduced to make sure it's viable. Totally makes sense. But Todd, we're getting ahead of ourselves. Here's Ray with another question. When should you repair an incarcerated inguinal hernia? The timing on when you repair an incarcerated inguinal hernia depends on whether or not you're able to reduce it. So if you can reduce it, then you want to go to the OR within the first 24 to 72 hours after the reduction. Hey, Rod, hold up. Hey, Todd, what's up? I want to add something else to this. Speak your truth, man. You know, we always have been taught that if there's an incarcerated hernia, you should wait till the next day after you reduce it to let the swelling go down so the operations savor it easier. Textbook. But I will challenge that now that with laparoscopy, you don't necessarily need to wait because it's really not that much more difficult in a laparoscopic case if there's swelling. In fact, sometimes the edema can help lift the peritoneum off. So I would challenge that we may be changing the paradigm 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 go ahead and do the laparoscopic repair, which is not that difficult even after an incarceration. Okay, so if it's incarcerated, then you got to go to the operating room and you could use laparoscopic if you want to. Now, here's a question from Jillian. In general, how do you approach repair of an inguinal hernia in a child? You can approach the repair of a pediatric inguinal hernia either laparoscopically or in an open fashion. The most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open. You should consider evaluation of the contralateral side depending on the age of the child. Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia. When should you consider laparoscopic versus open repair of an inguinal hernia in a child? As with all operations, the most important thing is that you do the operation that you're comfortable with. Okay, but what about outcomes? The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic. Okay, we don't have to get into controversies here, but are there any factors that would push you more towards an open repair? Particularly 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. Hey, Rod, hold up, hold up, hold up. Hey, there you are, Todd. So I have a few comments to make here. A few? All right, man, just go for it. When I have patients that have an undescended testicle, you can also do those laparoscopically. I actually do those through the scope. It's a really nice, easy operation, and then I can deal with the hernia if I want to at the time. Now, what's interesting is when people have been doing orchidopexies, they don't necessarily stitch the hole closed. And from that, we learned that you actually may not ever actually need to stitch. That scar alone may be enough. And so there are a lot of surgeons who just go and cut the sac but don't actually ligate anything. And we learned that from the fact that patients usually do not get a hernia after an orchidopexy is done and the hole is not ever ligated shut. When is it necessary to perform a floor repair in addition to a high ligation? A floor repair should be considered in children who have longstanding or very large hernias where you note that the floor might be blown out or unsupported. In those instances, you should consider a floor repair in order to buttress the repair. What post-operative complications are you worried about? Complications are fairly rare after an ingle and horn repair in children. The most common are superficial site infection, which occur in less than 1% of kids and some risk of recurrence. The rates of recurrence vary from 1% to 5%, depending on which studies you look at. And then there's the rare stuff like testicular atrophy or damage to the vas deferens. But there's something else that maybe is more common. It's the presence of a seroma after a hernia repair. It's really important to explain to parents that they might see fluid or something that looks like a bulge again after the repair and that that seroma will resolve with time. Hey, Rod, hold up, hold up. Yeah, what's up, Todd? So I have not really seen a seroma very often. Okay, you seeing something else? I will tell you that in the lap repair, you can get a post-operative hydrocele. And of all the ones I've seen, which has been two or maybe three in 15 years. Dude, I didn't know you're that old. Those all have resolved on their own. Cool. So I'll keep an eye out for a post-operative hydrocele. Now here's Jillian with another question. What typical post-operative instructions do you give after a hernia repair? In general, we don't try to limit activities in children after a hernia repair. Oh, so I don't need to use my adult thought phrase where it's like, don't do any heavy lifting for four to six weeks? In general for children, we don't do this. Most children can return to normal activities within one to two days. Cool. Let's try another case. A child presents with a small bowel obstruction associated with an incarcerated inguinal hernia that you were unable to reduce. What should you be worried about and what operative approach should you take? So the thing that's most concerning when you have an incarcerated hernia and you're not able to reduce it, particularly if you start to see overlying skin changes or things that might suggest strangulation, is that you would worry about bowel ischemia and necrosis. In the event that you happen to identify bowel that is necrotic, you can approach resecting that either through a groin incision or through a small midline incision. Then you can evaluate the bowel. And if you have to, you can even resect through that groin incision. Otherwise, you can approach laparoscopically and run the bowel in order to evaluate for ischemia at that point and then turn to fix the hernia either laparoscopically or open. Jeez, you got more options than Tom Brady. 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. All right, let's do a more difficult case. A patient has an inguinal hernia and a palpable undescended testicle in the inguinal canal. How do you approach this repair? This is an important point related to your preoperative workup of patients with an inguinal hernia. It's really important to do a thorough exam and make sure you understand whether or not those patients have undescended testes at the time of your pre-op evaluation. If a patient does have an undescended testicle that's palpable in the inguinal canal, then you should plan to do an orchiopexy at the time of your inguinal hernia repair. You're doing an inguinal hernia repair in an infant and find that the patient has an absent vas deferens. So what does the patient need to be worked up for postoperatively? 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. A male child is experiencing ipsilateral testicular pain and tenderness after a hernia repair. What are you most concerned about and what should you do? The thing that concerns you most if patients are having significant testicular pain after a hernia repair is testicular ischemia. The best way to evaluate that is to get an ultrasound looking for Doppler flow. In general, these patients are monitored and observed with pain control and we only frankly remove a necrotic testicle and not necessarily one that is partially ischemic. All right. Awesome. Ray, how about a little bit of a summary? Inguinal hernias are very common. They're more common in premature infants. Incarceration tends to happen before one year. You can repair open or laparoscopically. And you should consider evaluating the contralateral side in younger children, especially those who are premature. Thank you so much, Ray. And thank all of you for listening. Now, if you heard any point in there that you disagree with and you do something different for inguinal hernias, you don't got to wait for the next clubhouse discussion to argue with us. You can leave a comment in the Stay Current app right under the media player. You can like, share, comment, tag another surgeon, start a discussion. You can do all of that in the Stay Current and pediatric surgery app. So download it now in the Apple App Store or the Google Play Store. But until then, I'm Rod from Cincinnati Children's. And remember, knowledge should be free. and I'm team. I'm sure. I'm on ant. I'm a jing-a-d-b. I'm aor-a-b. I'm a-a-b. I'm a-a-b. I'm a-a-b. I'm a-a-b. I'm a-a-b. I'm a-a-b. I'm a-a-b. I'm a-a-b. Thank you.