Inguinal Hernia
Inguinal Hernia: Excerpt from The 5-Minute Pediatric Consult
Eugene Schneider, MD
Inguinal Hernia - BASICS
Inguinal Hernia - description
A hernia is defined as the protrusion of an organ or its portion through the wall that normally contains it. Inguinal hernia is a protrusion of abdominal contents (intestine, omentum) through the inguinal canal outside the peritoneal cavity.
Inguinal Hernia - epidemiology
- Extremely common; represents the most frequent problem requiring surgical intervention in the pediatric age group
- Much more common in boys (90% of cases) than girls, has a definite familial tendency, and presents more frequently on the right side as a result of later descent of the right testis and delayed obliteration of the right processus vaginalis
- Clinical presentation is on the right side in 60% of cases, on the left side in 30%, and bilateral in 10%.
Inguinal Hernia - incidence
Incidence varies with age and ranges from 3–5% in full-term babies to 7–30% in preterm infants.
Inguinal Hernia - risk factors
- Prematurity
- Urologic conditions: Cryptorchidism, hypospadia, epispadia, bladder exstrophy
- Abdominal wall defects: Gastroschisis, omphalocele
Conditions that increase intra-abdominal pressure: Ascites, peritoneal dialysis, ventriculoperitoneal shunt
- Meconium peritonitis
- Cystic fibrosis
- Congenital dislocation of the hip
- Connective tissue disease: Marfan syndrome, Ehlers-Danlos syndrome
- Mucopolysaccharidoses
- Family history
Inguinal Hernia - pathophysiology
- In boys, during the seventh month of gestation, the testes begin their descent from the peritoneal cavity, where they developed, through the inguinal canal and down into the scrotum.
- Between the 7th and 9th months of gestation, the testes reach the scrotum, at which point the processus vaginalis—an outpouching of the peritoneum attached to the testes—begins to obliterate spontaneously, leaving a small potential space adjacent to the testes, called tunica vaginalis.
- In girls, although the ovaries do not leave the abdomen, the round ligament (part of the gubernaculum) travels through the inguinal ring into labium majus. When the processus vaginalis remains open, it is called the canal of Nuck.
- Incomplete obliteration of the processus vaginalis leaves a sac of peritoneum extending all the way from the internal inguinal ring to the scrotum or labium majus, from which an inguinal hernia may develop.
Inguinal Hernia - DIAGNOSIS
Inguinal Hernia - signs & symptoms
Inguinal Hernia - history
- Location of the bulge:
- Swelling or bulge in the inguinal area is the most common presenting sign of inguinal hernia. Location of the bulge may be helpful in differentiating a complete inguinal hernia (descends into the scrotum) from an incomplete one (does not descend into the scrotum).
- Does the bulge change in size, and if so, what activities bring about these changes? The usual history is of an intermittently appearing bulge, especially noted at times of increased intra-abdominal pressure, such as during crying or straining.
- Does the child appear to be bothered by the swelling (extreme fussiness during diaper changes in babies or complaints of pain/discomfort in older children)? Hernias are usually asymptomatic. The parents may perceive the bulge as being painful to the baby because it often is more pronounced when the baby is crying. However, if the parents provide definitive history of a painful bulge in the inguinal region, incarcerated inguinal hernia must be suspected.
Inguinal Hernia - physical exam
- Examine the child in the supine and standing positions.
- If the bulge is apparent in the standing position but disappears when the child is supine, presence of a hernia is strongly suggested.
- If the bulge is not readily apparent, perform maneuvers that increase intra-abdominal pressure (have the patient blow up balloons, gently press on his or her abdomen, or have him or her cough or strain).
- Transillumination of the scrotum may help in differentiating hernias, which usually do not transluminate, from hydroceles, which typically do (unreliable sign).
- When the hernia sac is palpated over the cord structures, the sensation may be similar to that of rubbing 2 layers of silk together. This finding is known as “the silk sign” and is highly suggestive of an inguinal hernia.
- Always consider an incarcerated hernia, testicular torsion, epididymitis, orchitis, or trauma when examination reveals a tender scrotal mass.
- Try to reduce the hernia with the child in the supine or head-down position so that gravity assists the maneuver. Use a pacifier to calm the infant. Do not force a difficult incarcerated hernia.
- Sliding hernia occurs when one wall of the hernia is composed of viscera.
- Richter hernia results from the herniation of only a part of the bowel wall, which results in bowel ischemia without bowel obstruction (very rare).
- Hernia of Littre has Meckel diverticulum in the hernia sac.
Inguinal Hernia - tests
Karyotyping should be considered when a testis is palpable in the inguinal canal or found at herniorrhaphy in phenotypic females, because there is an association between androgen insensitivity and inguinal hernia.
Inguinal Hernia - imaging
The diagnosis of an inguinal hernia can usually be made on the basis of the clinical history and examination. However, in some cases, use of scrotal or inguinal ultrasonography is indicated:
- Suggestion of torsion (use duplex ultrasound to evaluate blood flow)
- Suggestion of the spermatic cord or testicular tumor
- Scrotal trauma and concern about testicular rupture
Inguinal Hernia - diag proced-surgery
Consult a pediatric surgeon when a diagnosis of inguinal hernia or hydrocele is suspected. In the event of incarceration and/or strangulation, request an urgent consultation.
Inguinal Hernia - differencial diagnosis
- Lymphadenopathy
- Hydrocele
- Retractile testis
- Undescended testis
- Varicocele
- Testicular tumor
Inguinal Hernia - TREATMENT
Inguinal Hernia - initial stabilization
An inguinal hernia will not resolve spontaneously; herniorrhaphy (an outpatient procedure) is accepted universally as the treatment of choice.
Inguinal Hernia - surgery
Herniorrhaphy:
- Complication rate after an elective repair is low (1–2%) but increases dramatically (∼20%) if the hernia becomes incarcerated. This excessive morbidity, along with a fairly high rate of incarceration in the 1st year of life, is responsible for the recommendation to repair pediatric inguinal hernias soon after they are diagnosed.
- ~10% of patients develop a contralateral hernia after a unilateral repair. Routine contralateral inguinal exploration in children with unilateral hernia has been a topic of debate for more than 50 years.
Inguinal Hernia - FOLLOW UP
Inguinal Hernia - complications
- Incarceration (>50% of cases occur within the 1st 6 months of life)
- Strangulation
- Intestinal infarction leading to perforation and peritonitis
- Testicular/ovarian ischemia or infarction
Inguinal Hernia - bibliography
- Erez I, Rathause V, Vacian I, et al. Preoperative ultrasound and intraoperative findings of inguinal hernias in children: A prospective study of 642 children. J Pediatr Surg. 2002;37:865–868.
- Geisler DP, Jegathesan S, Parmley MC, et al. Laparoscopic exploration for the clinically undetected hernia in infancy and childhood. Amer J Surg. 2001;182:693–696.
- Kapur P, Caty MG, Glick PL. Pediatric surgery for the primary care pediatrician, part I. Pediatr Clin North Amer. 1998;45:773–789.
- Sheldon CA. The pediatric genitourinary examination: Inguinal, urethral, and genital diseases. Pediatr Clin North Amer. 2001;48:1339–1380.
- Tackett LD, Breuer CK, Luks FI, et al. Incidence of contralateral inguinal hernia: A prospective analysis. J Pediatr Surg. 1999;34:684–688.
- Toki A, Watanabe Y, Sasaki K, et al. Ultrasonographic diagnosis for potential contralateral inguinal hernia in children. J Pediatr Surg. 2003;38:224–226.
Inguinal Hernia - CODES
Inguinal Hernia - icd9
550.9 Inguinal (direct) (double) (encysted) (external) (funicular) (indirect) (infantile) (internal) (interstitial) (oblique) (scrotal) (sliding)
Inguinal Hernia - PATIENT TEACHING-MED
Inguinal Hernia - activity
Following operative repair, avoidance of major physical activity for 1 week is recommended.
Inguinal Hernia - FAQ
- Q: Are trusses helpful to keep the hernia from incarcerating?
- A: No. Surgery is the accepted treatment.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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