Hernia in children

Hernia

A hernia is the bulging or protrusion of a portion of an organ through an abnormal opening in the abdominal wall muscles. Normally hernia comes out when the pressure increases and then goes back when the pressure decreases. The danger from hernia arises when the organ protruding through the opening is pinched or constricted to the extent that circulation is stopped or when the protruding organ impairs the function of other structures.

Introduction – Inguinal hernia

Inguinal hernias account for about 80% of all hernias and these hernias appear more frequently in boys than in girls. In the developing baby, the testes initially develop inside the belly near the kidney. The testes drop down to scrotum by 8-9 months of pregnancy. An inguinal hernia results from persistence of all or part of the processus vaginalis, the tube of peritoneum that lays the pathway for the testicle to follow into the scrotum. Following the location of testicles into the scrotum, the processus vaginalis closes automatically and a small portion of it remains as testicular covering called the tunica vaginalis. If the passage remains open, fluid from the abdomen or an abdominal organ itself (usually the intestines) can bulge out and be forced into passage towards scrotum causing a bulging or mass that can be felt. The process vaginalis may extend only partly or completely into the scrotum.

Normal Scortum

Inguinal Hernia

Normal scrotum: The processus vaginalis and tunica vaginalis are closed and contain no fluid or abdominal contents

Inguinal hernia: The processus vaginalis has remained open allowing abdominal contents (fluid and loops of bowel) to enter into the scrotum

Symptoms & Diagnosis

Usually inguinal hernia does not have any other symptoms except a groin or a scrotal swelling which appears when abdominal organs come out into the sac. Swelling can be seen in the groin area or scrotum when a baby is crying or straining or when an older child coughs, plays, strains or stands for a prolonged time. If the bulging can be easily reduced or pressed back into the abdomen, the hernia is known as a reducible hernia. If the bulge cannot be reduced back, then this is known as an incarcerated (irreducible) hernia. An infant or a child will show signs of irritability, loss of appetite, tenderness and swelling of the abdomen or have trouble having a bowel movement. With incarceration, the intestines have entered the sac and are being strangled. This portion of the intestines could die. This is life-threatening and child should be immediately taken to the emergency services.

Treatment

Inguinal hernias in children require a surgery called Herniotomy. This can be done by conventional approach or by laparoscopic means. Surgery is done under a short general anesthesia. This is mostly a Day Care Surgery whereby the child is admitted in the morning and discharged in the evening. All the stitches are absorbable and need not be removed.

Can inguinal hernia be repaired laparoscopically in children?

Yes, hernia can be operated laparoscopically easily even in small kids. For this purpose we use 3mm small equipment and telescope. We generally offer laparoscopic hernia repair to selected circumstances only after a detailed discussion with the family. Straightforward indications of Laparoscopic hernia repair are – bilateral hernia, recurrent hernia after a failed repair and a girl child with suspected internal organ problems.

Are any tests required for diagnosing or treating hernia?

The diagnosis of hernia is made clinically by a thorough examination. Most of the times further testing is not required.

Routine blood tests and a simple urine test is done for assessing fitness for surgery.

Can hernia occur again?

Recurrence of hernia is rare in hands of experienced surgeons. There is 5% chance of hernia appearing on the other side when one sided hernia is operated. This primarily occurs as the defect leading to hernia on one side may be already there on the other side too but clinically not significant initially. This may manifest clinically anytime in the coming few years. Routine both sided surgery for one sided hernia is no longer recommended as 19 children will have to be operated to prevent hernia per one child.

Can hernia occur in girls?

Inguinal hernias can occur in girls and girls comprise about 10% of all children coming to the clinic with hernias. With girls, an ultrasound is mandatory before surgery to rule out any internal problems like malformation or absence of internal reproductive organs. Rarely, a karyotype may be required if any such issues is suspected on ultrasound.

Clinical picture of a small boy with inguinal hernia on the left side