A hernia is defined as a protrusion of a portion of an organ or tissue through an abnormal opening. For groin (inguinal or femoral) hernias, this protrusion is into a hernial sac. Whether or not the mere presence of a hernial sac (or processus vaginalis) constitutes a hernia is debated. Inguinal hernias in children are almost exclusively indirect type. Those rare instances of direct inguinal hernia are caused by previous surgery and floor disruption.
An indirect inguinal hernia protrudes through the internal inguinal ring, within the cremaster fascia, extending down the spermatic cord for varying distances. The direct hernia protrudes through the posterior wall of the inguinal canal, i.e., medial to deep inferior epigastric vessels, destroying or stretching the transversalis fascia. The embryology of indirect inguinal hernia is as follows: the duct descending to the testicle is a small offshoot of the great peritoneal sac in the lower abdomen.
During the third month of gestation, the processus vaginalis extends down toward the scrotum and follows the chorda gubernaculum that extends from the testicle or the retroperitoneum to the scrotum.
During the seventh month, the testicle descend into the scrotum, where the processus vaginalis forms a covering for the testicle and the serous sac in which it resides. At about the time of birth, the portion of the processus vaginalis between the testicle and the abdominal cavity obliterates, leaving a peritoneal cavity separate from the tunica vaginalis that surrounds the testicle.
Approximately 1-3% of children have a hernia. For infants born prematurely, the incidence varies from 3-5%. The typical patient with an inguinal hernia has an intermittent lump or bulge in the groin, scrotum, or labia noted at times of increased intra-abdominal pressure. A communicating hydrocele is always associated with a hernia. This hydrocele fluctuates in size and is usually larger in ambulatory patients at the end of the day. If a loop of bowel becomes entrapped (incarcerated) in a hernia, the patient develops pain followed by signs of intestinal obstruction. If not reduced, compromised blood supply (strangulation) leads to perforation and peritonitis. Most incarcerated hernias in children can be reduced.
The incidence of inguinal hernia (IH) in premature babies (9-11%) is higher than full-term (3-5%), with a dramatic risk of incarceration (30%). Associated to these episodes of incarceration are chances of: gonadal infarction (the undescended testes complicated by a hernia are more vulnerable to vascular compromise and atrophy), bowel obstruction and strangulation. Symptomatic hernia can complicate the clinical course of babies at NICU ill with hyaline membrane, sepsis, NEC and other conditions needing ventilatory support. Inguinal Hernia symptom
Symptoms of an inguinal hernia may include:
* Groin discomfort or groin pain aggravated by bending or lifting * A tender groin lump or scrotum lump * A non-tender bulge or lump seen in children * Heaviness, swelling, and a tugging or burning sensation in the area of the hernia, scrotum, or inner thigh. * Discomfort and aching relieved only when the person lies down. This is often the case as the hernia grows larger.
Repair should be undertaken before hospital discharge to avoid complications. Prematures have: poorly developed respiratory control center, collapsible rib cage, deficient fatigue-resistant muscular fibers in the diaphragm that predispose then to potential life-threatening post-op respiratory complications such as: need of assisted ventilation (most common), apnea and bradycardia, emesis, cyanosis and re-intubation (due to laryngospasm).
Outpatient repair is safer for those prematures above the 60 wk. of postconceptual age. The very low birth weight infant with symptomatic hernia can benefit from epidural anesthesia. At times, the indirect inguinal hernia will extend into the scrotum and can be reduced by external, gentle pressure. Occasionally, the hernia will present as a bulge in the soft tissue overlying the internal ring. It is sometimes difficult to demonstrate and the physician must rely on the patient's history of an intermittent bulge in the groin seen with crying, coughing or straining.
Independent risk factors associated to this complications are (1) history of RDS/bronchopulmonary dysplasia, (2) history of patent ductus arteriosus, (3) low absolute weight (< 1.5 Kg), and (4) anemia (Hgb < 10 gm- is associated to a higher incidence of post-op apnea). Postconceptual age (sum of intra- and extrauterine life) has been cited as the factor having greatest impact on post-op complications. These observation makes imperative that preemies (with post conceptual age of less than 45 weeks) be carefully monitored in-hospital for at least 24 hours after surgical repair of their hernias. Inguinal Hernia treatment - inguinal hernia surgery
Elective herniorrhaphy at a near convenient time is treatment of choice. Since risk of incarceration is high in children, repair should be undertaken shortly after diagnosis. Simple high ligation of the sac is all that is required. Pediatric patients are allowed to return to full activity immediately after hernia repair. Patients presenting with incarceration should have an attempt at reduction (possible in greater than 98% with experience), and then admission for repair during that hospitalization. Bilateral exploration is done routinely by most experienced pediatric surgeons. Recently the use of groin laparoscopy through the hernial sac permits visualization of the contralateral side.
Approximately 1% of females with inguinal hernias will have the testicular feminization syndrome. Testicular feminization syndrome (TFS) is a genetic form of male pseudohermaphroditism (patient who is genetically 46 XY but has deficient masculinization of external genitalia) caused by complete or partial resistance of end organs to the peripheral effects of androgens. This androgenic insensitivity is caused by a mutation of the gene for androgenic receptor inherited as an X-linked recessive trait. In the complete form the external genitalia appear to be female with a rudimentary vagina, absent uterus and ovaries.
The infant may present with inguinal hernias that at surgery may contain testes. Axillary/pubic hair is sparse and primary amenorrhea is present. The incomplete form may represent undervirilized infertile men. Evaluation should include: karyotype, hormonal assays, pelvic ultrasound, urethrovaginogram, gonadal biopsy and labial skin bx for androgen receptor assay. This patients will never menstruate or bear children. Malignant degeneration (germ cell tumors) of the gonads is increased (22-33%). Early gonadectomy is advised to: decrease the possible development of malignancy, avoid the latter psychological trauma to the older child, and eliminate risk of losing the pt during follow-up. Vaginal reconstruction is planned when the patient wishes to be sexually active. These children develop into very normal appearing females that are sterile since no female organs are present.
The inguinal hernia is the protrusion of an intestinal segment or a part of the abdominal layer called peritoneum inside the inguinal canal. It occurs in the groin area due to a weaker point of the abdominal wall. Inside the inguinal canal are the spermatic cord in men and the round ligament of the uterus in women localized.
Most highly exposed to developing a hernia are usually men, obese persons and persons who have recently suffered a surgical intervention on the abdomen that might have weakened the outer wall. Inguinal hernia can theoretically appear in both children and adults but the risk increases with age; inguinal hernias have also proven to be influenced by hereditary factors.
The responsible weakness of the abdominal layer can be congenital in some cases but can also be induced by high and rapid weight gain or loss, high lifting or pregnancies. A chronic pulmonary condition causing intense coughing may be responsible for in time developing hernia, an enlarged prostate may cause straining in the abdomen or straining during bowel movements caused by constipation, which can also lead to the apparition of an inguinal hernia in time.
Inguinal hernias appear as painless bulge in the groin and can even extend to the scrotum in men if not treated in time. The bulge may sometimes create discomfort and tenderness while proceeding to heavy lifting. Hernias often disappear while the patient is lying down and can be pushed back inside the abdomen in incipient stages. When segments of intestines or a fragment of the peritoneum becomes trapped inside the inguinal canal, the hernia is called irreducible and usually causes more pain and trouble to the patient. A part of the intestines can be trapped inside the inguinal canal forming the strangled hernia; in this case the blood supply is cut off and the intestinal fragment can die causing huge complications without a proper rapid intervention.
The actual diagnose of an inguinal hernia is established by the surgeon after a physical examination while he may ask the patient to cough to see the movements of the groin bulge. The most effective treatment for hernias is the surgical herniorraphy when the hernial content is pushed back into the abdomen and the weak spot of the abdominal wall is repaired. A hernioplasty is also possible and the surgeon can in this case reinforce the abdominal wall by placing a synthetic material on the abdomen layer. A more modern intervention is the laparoscopic procedure with the exact same technique as in the classical operation but with the use of two small incisions for a small camera and for surgical instruments.
We can protect ourselves from non-congenital hernias by not lifting heavy objects, preventing constipation, keeping a normal body weight and avoid cigarette smoking.
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