Inguinal Hernias: Diagnosis and Management
With Dr. Mira Kodagal & Dr. Ray Hanke & Dr. Jillian Goddard · StayCurrentMD
Part of
Inguinal Hernia 28 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.
The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.
Most inguinal hernias in children are largely indirect, over 90%.
Direct hernias are pretty rare in children and are much more commonly found in adolescents.
Femoral hernias are very rare in children and, as in adults, are more common in females.
Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.
Inguinal hernias occur as a result of the failure of the processus vaginalis to fuse.
The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.
The number one risk factor for inguinal hernias in children is prematurity.
Other factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undescended testicle or hydrocele, and a connective tissue disorder.
More than half of incarcerations are in patients that are less than six months, and two-thirds of incarcerations are in patients who are less than a year.
If corrected gestational age is less than 60 weeks, patients have a high risk for premature apnea postoperatively and need to be admitted after surgery to monitor.
One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes requiring pain control and sedation.
For hernia reduction, one hand guides the contents through the inguinal ring and the other hand applies gentle, steady pressure, which must be maintained in a slow, gentle fashion.
During reduction of an incarcerated hernia, you have to squeeze the incarcerated bowel so that the edema gets pushed out, which can take several minutes.
If you can reduce an incarcerated inguinal hernia, you want to go to the OR within the first 24 to 72 hours after the reduction.
With laparoscopy, you don't necessarily need to wait after reducing an incarcerated hernia because it's not that much more difficult in a laparoscopic case if there's swelling; in fact, sometimes the edema can help lift the peritoneum off.
The most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.
Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.
The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.
If a child needs an orchidopexy in addition to their hernia repair, most would approach that hernia in an open fashion.
When people have been doing orchidopexies and don't stitch the hole closed, patients usually do not get a hernia afterward, suggesting that scar alone may be enough and you may not need to ligate anything.
A floor repair should be considered in children who have longstanding or very large hernias where the floor might be blown out or unsupported.
The most common complications after inguinal hernia repair in children are superficial site infection, which occur in less than 1% of kids, and recurrence, with rates varying from 1% to 5%.
Rare complications include testicular atrophy or damage to the vas deferens.
Post-operative hydrocele can occur after laparoscopic repair, and all observed cases have resolved on their own.
In general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within one to two days.
A lot of times, once the patient is put under anesthesia, an incarcerated hernia that was unable to be reduced in the emergency department may actually spontaneously reduce with the patient's relaxation.
If a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair.
Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.
If patients are having significant testicular pain after a hernia repair, the main concern is testicular ischemia, best evaluated with ultrasound looking for Doppler flow.
In cases of testicular ischemia after hernia repair, patients are monitored and observed with pain control, and surgeons only remove a necrotic testicle, not necessarily one that is partially ischemic.