Understanding Inguinal Hernia in KidsRasik ShahMBBS, MS (General Surgery), M Ch (Pediatric Surgery) , MD (USA)

Paediatric & Laparoscopic Surgeon: Hinduja Hospital, Mahim, Mumbai

President Elect (2012-13): Indian Association of Paediatric Surgeon

Ex Chairman (2011-13): Paediatric Endoscopy Surgeon – India Section of Indian Association of Paediatric Surgeon

WHAT IS A HERNIA?

•A hernia occurs due to weakness in the abdominal wall through which there is protrusion of the abdominal viscera.

•It presents as bulge under the skin.

Inguinal Hernia in Children• As a male fetus grows and matures during pregnancy, the

testicles develop in the abdomen and then move down into the scrotum through an area called the inguinal canal

• Shortly after the baby is born ▫ the inguinal canal closes, preventing the testicles from moving

back into the abdomen

▫ If this canal does not close off then it forms a communication between the abdomen and scrotum allowing abdominal contents to protrude through the canal into the scrotum

• Although girls do not have testicles, they do have an inguinal canal, so they can develop hernias in this area as well

What is the difference between Hernia and Hydrocele in Children?

• If the communication is small then only fluid gets collected in the scrotum and known as hydrocele

• If the communication is large then the intestine, omentum

• In girl child even tubes and ovaries can protrude in the inguinal canal

Incidence of Inguinal Hernia & Hydrocele

•It affects 1%-5% of full-term babies

•In premature babies (7%-30%)

•Boys are 4-8 times more likely to have inguinal hernia as compared to the girls

WHO ARE PRONE TO DEVELOP HERNIA?• Ten percent of the kids whose parent or sibling were

operated for hernia are likely to develop hernia

• Seventy percent of patients who have Undescended testes are likely to have hernial sac

• Abnormalities of the urethra

• Cystic Fibrosis

• Patients having abdominal wall defects like, omphalocele and exstrophy of bladder

HOW THE DIAGNOSIS OF HERNIA IS DONE?

• It can present at any age from newborn to elderly person

• It appears as a bulge or swelling in the groin or scrotum

• The swelling may be more noticeable when the baby cries, and may get smaller or go away when the baby relaxes

• Occasionally hernia is not seen at the time of the visit to the physician and then the history given by the parents is very important to reach to the diagnosis

• The diagnosis of hernia can be confirmed by ultrasound examination but it is rarely necessary to perform such a test

WHAT ARE THE COMPLICATIONS OF INGUINAL HERNIA?

• Hernia is usually reducible.

• It can become irreducible hernia (bowel cannot be gently pushed back into the abdominal cavity)

• This can get complicated further

▫ by obstruction to the bowel lumen

▫ by loss of blood supply to the bowel loop which is stuck

▫ this bowel can become gangrenous if not operated immediately

• Planned hernia surgery has very less risk compared to emergency surgery and hence hernia should be preferably operated electively at the time of diagnosis

Symptoms of an incarcerated inguinal hernia

▫ Ill child

▫ Pain in the groin

▫ Nausea and vomiting and Swollen abdomen

▫ Fever

▫ Swelling

red or dusky in color

markedly tender

it does not change in size with crying

Incidence of patent contra-lateral processus vaginalis

▫Boys Less than 2 years 38 % 2 to 8 years 20 % 8 years 8 % Lifetime risk is 15 % chance of development

of hernia

▫Girls 60 %

Advantages & disadvantages of surgery on the unaffected side

• Advantages include:▫ Same hospital admission and anaesthesia

• Disadvantages include:▫ Lifetime incidence of contra-lateral hernia is 15 % so

unnecessary surgery

▫ There is a small risk of damage to the testicle and vas deferens (the tube that transports sperm from the testicle) on the other side

Pre operative Preparation• Investigation:

▫CBC

• Optional Investigations

▫Urine

▫X-ray Chest

▫PT, PTT

Pre operative Orders• NBM

▫ For Breast Milk : 4 hours

▫ Clear Fluids : 4 hours

▫ Top Feeds: 6 hours

▫ Solids: 8 hours

• Consent for Surgery

Anaesthesia• GA (Ketamine + Midazolam)

• Caudal Block

• Endotracheal intubation

▫Infants

▫Laparoscopic repair

Treatment of Inguinal Hernia• Surgery is necessary in all cases• Recurrence rates are < 1%• Elective surgery

▫ small scar▫ no long term complications

• Complications of hernia ▫ immediate life-threatening events▫ including bowel obstruction,▫ bowel perforation ▫ even death

• The testes in the male and ovaries in the female, both of which can have the blood supply cut off and therefore waste away.

Open Surgery• The duration in operating room is ¾ to 1 ½ hour

▫ One side or two side▫ Age of the child

Premature, Newborn, Infant and Older child▫ Incarcerated hernia▫ Sliding hernia

• Small cut (2.5 to 3 cm) in the groin at the natural skin crease

• The contents are emptied back into the abdomen • The sac is tied off • The wound is closed with dissolvable sutures• Mesh coverings are generally not required in children• All wounds heal with a scar

▫ In Children with time they become inconspicuous

Laparoscopic Surgery

• Advantages▫ One can diagnose and treat the opposite side patent processus▫ Magnification of laparoscopy is likely to decrease the incidence of injury

to vas and vessels▫ Access trauma is less▫ Highest possible ligation of the sac▫ Minimal injury to the lymphatics so scrotal edema is less▫ In girls: evaluation of internal organs

• Disadvantages▫ Controlled general anaesthesia▫ Surgery through the abdomen▫ Need of specialised equipment and experienced personnel▫ Reported higher incidence of recurrences

(with the authors technique of Laparoscopic IDES repair of inguinal hernia, so far no recurrences have been reported in

more than 200 cases)

Laparoscopic Repair of Inguinal Hernia

• The child is given general anaesthesia• Three small tubes are inserted in abdomen

▫One 5 mm and two 3 mm• Five mm tube is used to look the inside of

abdomen by inserting telescopic camera • The 3 mm tubes are used to carry out the surgery• At the end of the surgery, tubes and instruments

are removed• The incisions are approximated

Are there any risks with this surgery?

• Complications are very rare in good hands

• General Complications:

▫ Risks of anaesthetic side-effects

▫ Wound infection and bleeding

• Complications specific to hernia repair:

▫ Injury to the vas and testicular vessels

▫ If a hernia is incarcerated then the testicle may already have been damaged from lack of blood supply

▫ Damage to the nerve supplying skin sensation over the wound. This will result in numbness over the wound

Duration of Stay in Hospital• It is usually a day care procedure

• Overnight stay in the hospital for observation in hospital is recommended

▫ If the hernia repair was performed as an emergency

▫ If premature then till the child completes gestational age of 60 weeks (conception to time of surgery)

▫ Full term born child who is less than 6 weeks old

▫ If the child has some other associated illness like heart disease, VP Shunt, etc.

What follow-up is needed?▫ Usually the dressing is removed on OPD basis after 5-7 days

▫ Early follow up if

Child develops a high fever

wound becomes infected (red, swollen, leaking fluid)

If you have any other concerns

▫ Dressing can be removed by local family physician and patient may follow up only if required

▫ Usually sponge bath until the dressing is removed

▫ Normal activities can be started as and when the child feels sufficiently comfortable 

▫ It is better to avoid contact sports and strenuous exercise for few weeks

Remember▫ There is nothing you did or did not do that caused the

hernia to develop.

▫ A hernia is a bulge under the skin through a weakness or opening in the muscle wall of the abdomen. 

▫ Once the diagnosis of a hernia is made, surgical repair (herniotomy) will be performed.

▫ In any surgical procedure, there are risks of anaesthetic side-effects, wound infection and bleeding. The risk of these happening is less than one in a hundred.

▫ Hernia repair is usually a day procedure, with your child able to go home afterwards. In some circumstances, your child may need to stay overnight in the hospital for observation.

THANK YOUFor Appointments of Dr. Rasik Shah

Contact: 022-39818181 and 022-24452439

Clinic Time at Hinduja Hospital MahimTuesday: 1.30 pm to 3.00 pmFriday: 12 noon to 1.30 pm

Mobile Number: +91-9820148131

E mail: rasiksshah@yahoo.co.in