From
Dr. Meera Kotagal
Pediatric inguinal hernia diagnosis, management, and complications
With Dr. Rae Hanke & Dr. Gillian Goddard & Dr. Mira Kotigal
Chapter 1 of 7
Anatomy & types
Introduction and Anatomy of Pediatric Inguinal Hernias
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
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.
A femoral hernia is a defect below the inguinal ligament.
The incidence of inguinal hernias overall ranges from about 1 to 5% in full-term newborns.
The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.
Over 90% of inguinal hernias in children are indirect.
Direct hernias are pretty rare in children and are much more commonly found in adolescents.
Femoral hernias are very rare in children, and as in adults are more common in females.
Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.
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, which explains the higher prevalence of right-sided hernias.
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.
If the proximal part closes and the distal part isn't obliterated, then you get a non-communicating hydrocele where some fluid is trapped.
The number one risk factor for inguinal hernias in children is prematurity.
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.
The differential diagnosis for a groin mass in a child includes an inguinal hernia (most likely indirect, although rarely direct), hydrocele, or lymphadenopathy.
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.
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.
Timing for decisions about repairs of inguinal hernias has to balance the risks of anesthesia with the risks of incarceration associated with the hernia.
Inguinal hernia repair is in general considered an elective operation and does not need to be urgently performed.
Younger children have a higher rate of incarceration.
Children with an incarcerated hernia may present most commonly with pain, particularly groin pain.
Children with incarcerated hernias may 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.
Patients with a strangulated hernia may present with fever, tachycardia, leukocytosis, severe pain, or overlying erythema in the skin.
One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm.
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.
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.
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 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.
If you can reduce an incarcerated hernia, you want to go to the OR within the first 24 to 72 hours after the reduction.
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 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.
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.
The most important thing is that you do the operation that you're comfortable with.
The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.
If a child needs an orchiopexy in addition to their hernia repair, most would approach that hernia in an open fashion.
Todd does orchiopexies for undescended testicles laparoscopically through the scope, and can deal with the hernia at the time.
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.
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.
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.
Complications are fairly rare after an inguinal hernia repair in children.
The most common complications 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.
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.
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.
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.
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.
If you identify necrotic bowel, you can approach resecting it either through a groin incision or through a small midline incision.
You can approach laparoscopically and run the bowel to evaluate for ischemia, and then turn to fix the hernia either laparoscopically or open.
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.
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.
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.
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.
If patients are having significant testicular pain after a hernia repair, the most concerning thing is testicular ischemia.
The best way to evaluate testicular ischemia is to get an ultrasound looking for Doppler flow.