Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This is one of the commonest conditions seen in children, more often in boys than in girls. This is noticed as a swelling in the groin or inguinal region – that increases on crying, coughing or straining. The swelling is hardly visible or decreases when the child is asleep, quiet.
Why? : During the formation of the child in the womb of the mother, both the testes in a boy are formed originally in the abdomen, just below the developing kidneys. With growth of the fetus, the testes descend down towards the scrotum. An outpouching of the abdominal (peritoneal) cavity occurs at the 3rd month of gestation (pregnancy). This pouch goes from the abdomen through the 3 abdominal muscles in the inguinal (groin) canal and down into the scrotum. This is a passage meant for the testis to follow and pass into the scrotum where it resides for the rest of its life. Normally this open passage, called Processus vaginalis, closes spontaneously after the testis descends into the scrotum. Incomplete or non obliteration of the passage gives rise to a Hydrocele or Hernia respectively. In a Hernia the intestines that are within the abdominal cavity can now come out through the muscles and descend up to the scrotum and can go back into the abdomen.(Fig 1)
Inguinal & umbilical
hernia in an infant
In a Hydrocele in a child the passage being partly closed, does not allow the intestines but will allow only the free fluid in the abdominal cavity to trickle down through the open passage into the scrotum. However, there may be 20 – 30% of adults having an open passage yet no visible hernia or hydrocele.
When? : Just the presence of a patent passage is not sufficient to cause a hernia. Other factors like excessive straining for various reasons such as straining to pass stool, urine, continuous long standing cough, non descended testis, excess of free fluid in the abdomen (ascites) etc are precipitating factors. Hernias are seen in 1 – 4 % of children but the chances of having a hernia are much higher in those children born prematurely and in infants. Boys seem to have a higher incidence of hernia than girls and the ratio is 3 – 10 : 1, and is more common on the right side. About 60% of children have right sided hernia, 30% a left sided hernia and only 10% both sides at detection. In a child having hernia, there is a 11.5% chance of someone else in the family having had a hernia.
What happens if no therapy is given? An inguinal hernia does not resolve spontaneously and requires surgery to correct it. If left alone, without opting for surgery, there are many complications that are known to occur. Irreducibility – when the intestines come out when the child is crying or straining but do not go back into the abdomen. This will give rise to pain, blocking of the lumen of the intestines that are in the passage and intestinal obstruction with abdominal distension, vomiting.(Fig) If not relieved, this can further lead to compression of the blood vessels of the bowel caught in the passage and gangrene of the intestines. A unique complication that occurs in infants is that the intestines in the passage press against the blood vessels of the testis and cut off the blood flow to the testis – resulting in a black testis that needs to be removed. (Fig)
Complications result in the need for surgery as an emergency and not only is the surgery more difficult but the chances of complications after this surgery are also much higher. This can be avoided if the surgery is done electively. The ideal time for surgery to be finished is as soon as possible after the diagnosis is made. Age and weight are no criteria for postponing the surgery. Once a definitive diagnosis of hernia is made, surgery should be planned within 15 – 20 days.
Surgery is done usually as a day care case, and the child can go home the same day or in case of infants the next day. In surgery, the inguinal region is exposed through the incision, the sac or the patent passage is identified and carefully separated from the vessels and the vas deferens going to the testis and is tied off as close to the abdominal cavity as possible. The technical difficulty in children is that the structures going to the testis are very tiny, delicate and a slight jerk or pull is adequate to break or tear them and cause irreversible damage that will be known years after the damage has been done to the function. Also the sac of the hernia in children can be very thin and easily torn if not done delicately.
Complications: Even after a routine surgery for hernia or hydrocele, there are a few complications that are known. One of these is that due to the surgery of separating the cord structures from the hernial sac, there may be a dependant swelling or edema in the scrotum of the side of surgery. This swelling comes up within a day or two after surgery and disappears on its own after a few days there is no need for worry or concern. At times, there may also be a discoloration of the scrotum due to trickling of blood into the scrotum. Also swelling in the inguinal region that lasts for a few weeks is seen after surgery and again goes away by itself. There is one complication that can occur if the surgery is not done delicately and will not be obvious at that time, that is, the damage or rupture or crushing of the vas deferens due to rough handling of the tubular structure that takes the sperms from the testis into the urethra for ejaculation at a later date. The vas is blocked and the sperms cannot reach in the urethra and the number is reduced. This will be known only later in life when the child is a man and is being investigated for infertility. Wound infection or reaction to the suture material used is another common complication. This settles down by itself with medicines. After this operation, at least 6 weeks are required for the muscles that have been sutured to get their proper strength back. Till this time the child is not allowed sports and exercises. The chances of recurrence of this hernia are very little unless a high ligation of the sac was not done at the time of the surgery. When surgery has been done on one side, it is advisable to tell the mother to look for a similar swelling coming up on the other side later. The chances are remote in children above 3 –4 years, but in infants, there may be a 50 % chance of the other side also being open but becoming obvious later. In such cases the opposite side needs to be done whenever it presents.
Last Updated: 27th January 2009