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Hernias in Pediatric Surgery

Inguinal Hernia

Incidence & Epidemiology:

  • Affects 3% to 5% of term infants and 9% to 11% of premature infants.
  • Male predominance: 6 times more common in boys than girls.
  • Laterality:
    • Right-sided: 60%.
    • Left-sided: 30%.
    • Bilateral: 10%.
  • Indirect and congenital in almost all cases due to the persistence of the processus vaginalis.

Pathophysiology:

  • The processus vaginalis is a peritoneal diverticulum that accompanies the descent of the testicle into the scrotum.
  • Failure of the processus vaginalis to obliterate results in conditions like scrotal hernia (containing intestine, ovaries, or omentum) or a communicating hydrocele.

Clinical Diagnosis:

  • History and physical examination are the primary diagnostic tools.
  • Transillumination of the scrotum can differentiate a hydrocele from a hernia, but may be misleading.
  • "Silk glove sign": Palpation of the cord reveals a sliding sensation caused by rubbing of the peritoneal membranes of the empty sac.
  • Thickened cord on palpation with a history of intermittent bulge may indicate a hernia.

Associated Conditions:

  • Sudden onset of hydrocele can be associated with:
    • Epididymitis.
    • Testicular torsion.
    • Torsion of the testicular appendage.

Complications:

  • Major risks of inguinal hernia include:
    • Bowel incarceration.
    • Strangulation, particularly in premature infants during the first year of life.

Management:

  • Elective Repair:
    • Timing of repair in premature infants is under debate. Some advocate for repair before hospital discharge; however, delaying surgery until postoperative apnea risk decreases at around 1 year may be a better option due to concerns about the risks of general anesthesia.
  • Incarcerated Hernia:
    • Initial reduction is performed, followed by surgical repair 24 to 48 hours later after tissue edema subsides.
    • A nonreducible, incarcerated hernia is a surgical emergency.
  • Contralateral Exploration:
    • High incidence of contralateral patent processus vaginalis (4%-65%) warrants contralateral exploration during symptomatic hernia repair in infants.
    • Routine exploration in asymptomatic contralateral hernias in children under 2 years remains controversial.
  • Surgical Approaches:
    • Laparoscopic vs. open repair: No clear advantage of one technique over the other based on recent meta-analyses.

Umbilical Hernia

Natural History:

  • 80% of umbilical hernias in children close spontaneously, often by the age of 5.
  • Incarceration is rare, but elective repair may be needed if the hernia enlarges or the fascial defect is larger than 2 cm.

Management:

  • Elective repair is typically deferred until around 5 years of age unless there is:
    • Progressive enlargement.
    • Fascial defect >2 cm.
    • Cosmetic concerns, as large skin proboscis (>3 cm) may develop, leading to poor cosmesis post-surgery.
  • Primary repair of the hernia is always achieved without the use of a prosthetic patch.

This summary highlights key aspects of pediatric inguinal and umbilical hernia, focusing on diagnosis, management, and potential complications.