Paediatric Hernia

Inguinal hernias are congenitally present in children. Operative treatment is mandatory for all paediatric inguinal hernias to prevent complications of incarceration and strangulation. Inguinal hernia occurs as a result of failure of luminal obliteration of the processus vaginalis. At this time the abdominal contents herniated into a ready-made sac. The common type of hydrocele is the communicating hydrocele where abdominal cavity fluid freely enters into the scrotal sac with patency of the proximal processus vaginalis.

image for pediatric hernia surgery

Physical examination

A physical exam clearly reveals a bulge or swelling in the internal or external ring in the scrotum. It is present in the inguinolabial region for the females and inguinoscrotal region for the males. The infant may not experience any pain. When there is delayed descent of the right testicle indirect hernias are observed on the right side. Patient is examined in standing and supine positions. There is a presence of a palpable but smooth mass. The mass is noticeable with a Valsalva maneuver or while coughing.

image of pediatric hernia causes

Causes

  • Low birth weight
  • Premature birth
  • Urologic conditions such as epispadias, ambiguous genitalia, hypospadias and cryptorchidism
  • Abdominal wall defects such as omphalocele and gastroschisis
  • Family history of cystic fibrosis, connective tissue disease, meconium peritonitis, congenital hip dislocation, fetal hydrops and mucopolysaccharidosis
image for pediatric ingual hernia

Imaging studies and procedure

An ultrasonography and peritoneography may be performed as imaging studies. Where the ultrasonography may help differentiate between a hydrocele and inguinal hernia, the peritoneography with contrast dye is conducted to determine the presence of a patent processus vaginalis.

A general endotracheal anaesthesia can be safely administered to children with tracheal intubation. A caudal anaesthetic or intraoperative injection with bupivacaine may also be given in the inguinal region as postoperative analgesia. Elective herniorraphy is done to prevent the complications of incarceration and strangulation.

A laparoscopic needle-assisted repair of the inguinal hernia is conducted using a total laparoscopic approach. Standard laparoscopy with a 5 mm umbilical port and 30 deg, angle laparoscope, is performed. The indirect inguinal hernia is identified and clearly defined. Under direct laparoscopic control and visualization, a 22-gauge Tuhoi spinal needle along with 2-0 Prolene thread is passed under the peritoneum and the inguinal ligament. It travels lateral to the inguinal ring and away from the vas and spermatic vessels. The thread is pushed through the needle barrel into the abdominal cavity. This creates an internal loop. The Prolene thread is left inside the abdomen and the needle is pulled out. The threaded end is again introduced into the barrel once again and passed through the same puncture point. As the needle comes to a desired position, the Prolene thread is wrapped around the inguinal ring under the peritoneum and purse-string suture is created. With the knot tide to close the inguinal ring and opening of the hernia, it is buried into the subcutaneous tissue.