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MikaVenhola

Hernias in Children

Essentials

  • A hernia is a common finding in children and almost always congenital.
  • Some hernias do not need surgical management whereas others must always be managed surgically, even though hernias in children are often neither symptomatic nor is there a risk of strangulation.
  • A good referral letter to specialist care should include information about the symptoms, results of the physical examination and a description of the child's general state of health. A good referral letter will render an extra hospital examination unnecessary, and an appointment time can be allocated for the necessary procedure on the basis of the referral letter.
  • Hernia surgery is generally carried out as a day case procedure, and it is very rare for a hernia to recur after a surgical repair.

Abdominal hernias

Epigastric hernia

  • Situated in the linea alba, through an opening in the muscular fascia between the rectus abdominis muscles.
  • A small bulge can be felt or seen between the umbilicus and the sternum in the body midline.
  • The hernia consists of preperitoneal fat protruding through a small opening in the fascia; intestines will not protrude into the hernia and there is no hernia sac.
  • Symptoms may include pain. However, an epigastric hernia is usually asymptomatic.
  • Cosmetic deformity is usually negligible, but painful or disfiguring hernias may be repaired surgically.
  • The surgical repair consists of closing the opening in the linea alba with sutures. The incision is made at the site of the hernia.

Diastasis recti (abdominal separation)

  • Not actually a hernia but is often wrongly interpreted as being a hernia.
  • Caused by laxity of the muscle fascia between the rectus abdominis muscles; no abdominal wall opening or defect is present.
  • In an infant or child, diastasis recti manifests in the upper abdomen as a raised ridge running down the body midline between the umbilicus and the sternum when the abdominal wall muscles are contracted.
  • An examination should be carried out with the infant lying down on his/her back. As the infant lifts his/her head, a wide bulge becomes visible at the area of the linea alba as the abdominal muscles are contracted. An older child is able to reproduce the same phenomenon by contracting his/her abdominal muscles.
  • Diastasis recti does not cause symptoms and no treatment is required. The condition is self-limiting.

Paraumbilical hernia

  • Very similar to an umbilical hernia, but the hernia does not protrude through the umbilicus itself but just above it through the linea alba.
  • Clinical findings include a mass on the upper margin of the umbilicus the size of which may slightly vary.
  • Palpation may occasionally reveal an opening in the linea alba or a reducible hernia. In most cases, however, the hernia contains fat which cannot be reduced during an ordinary appointment.
  • A paraumbilical hernia is usually asymptomatic. The risk of strangulation is nonexistent.
  • The hernia will not resolve spontaneously, and surgery is always required. The hernia is repaired as a day case procedure by closing the opening in the fascia with sutures. The incision is done in the upper umbilical margin.

Umbilical hernia

  • The incidence of an umbilical hernia in newborn infants is at least 10% and even higher in premature infants.
  • The majority will heal spontaneously; after a few years only about one tenth of the hernias are present.
  • The smaller the hernia and the longer the watchful waiting period, the more likely the hernia is to close.
  • A characteristic finding is a non-discharging bulge in the umbilicus, from which the contents of the hernia can easily be reduced and an opening felt at the base of the umbilicus.
  • The size of the hernia typically changes as the child cries or strains, but the hernia does not usually cause crying or have other symptoms. The risk of strangulation is extremely small.
  • Even a large umbilical hernia may close spontaneously. The crucial factor is the diameter of the hernial opening: if the opening is so small that the index finger of the examining doctor cannot pass through, spontaneous closing is likely.
  • Taping an umbilical hernia down does not speed or assist the repair of the hernia. Taping the hernia may, however, cause a troublesome rash and it is therefore considered to be contraindicated.
  • Surgery is indicated if signs of incarceration develop or if the hernia, in a child aged over 4 years, causes anxiety due to its cosmetic appearance.
  • The day case procedure consists of the removal of the hernia sac, closure of the opening at the base of the umbilicus with sutures and suturing the umbilicus back in situ to the surface of the muscle fascia. The incision is hidden in the lower umbilical margin.

Inguinal hernias

In general

  • Processus vaginalis (vaginal process) is an outpouching of the peritoneum that extends through the inguinal canal to the scrotum in boys and to the labial region in girls. It normally closes spontaneously around birth.
  • However, in many children the closing does not occur, and this leaves an open route from the abdominal cavity to the groin enabling the formation of a hernia.
  • This does not mean though that all affected children will go on to develop an inguinal hernia or hydrocele.

Differential diagnosis of inguinal masses

  • Not all lumps in the groin are hernias. Table T1 shows some of the causes of lumps in the inguinal or testicular area that are important in differential diagnosis.

Differential diagnosis of lumps in the groin area

CauseNote
Mass in the groinUndescended testicleNo testicle in the corresponding scrotum, the lump is mobile and non-tender. The testicle cannot be drawn into the scrotum.
Retractile testicle (testis saltans)No testicle in the corresponding scrotum, but the testicle is palpable in the groin, and it can readily be moved to the scrotum
LymphadenitisA mobile and often slightly tender lump caused either by a systemic infection or an infection in the leg
A mass in the scrotumHenoch-Schönlein purpuraBilateral scrotal swelling and redness, other signs and symptoms of the underlying disease
Acute idiopathic scrotal oedemaAs above without the systemic symptoms
EpididymitisUnilateral pain and swelling, often with extensive redness. The testicle is non-tender and in situ.
Torsion of appendix testis or appendix epididymisUnilateral painful swelling, the testicle is in situ and non-tender, in some cases a few millimetres long necrotic appendix testis can be palpated or viewed with fluoroscopy
Testicular torsionUnilateral painful swelling, the testicle is noticeably tender on palpation and often retracted. If the condition has lasted for some time, redness is also noted on the scrotum.

Hydrocele testis

  • A condition that only affects boys; a failure of the processus vaginalis closure will cause peritoneal fluid to accumulate either only to the inguinal canal or up to the testis.
  • Hydrocele occurs in about one in ten boys, but in the majority of cases the condition resolves spontaneously during the first years of life as the processus vaginalis closes and the fluid is reabsorbed.
  • The condition hardly ever produces symptoms, and there is no risk of strangulation since intestines will not protrude into the hydrocele.
  • The characteristic clinical finding is a bulge of varying size that resembles a hernia either in the groin or scrotum.
  • On examination, a hydrocele is virtually always detectable, it can rarely be reduced and shining a light through the hydrocele (transillumination) will reveal a collection of translucent fluid.
  • Surgery is indicated if the hydrocele is very large, symptomatic, develops for the first time after early infancy or if it occurs in a child aged more than 4 years.
  • The day case procedure is carried out through a groin incision, and the patent processus vaginalis is closed followed by an evacuation of the hydrocele contents. Various surgical hydrocele repair procedures developed for adults are not indicated in children.

Inguinal hernia

  • The most common surgery-requiring hernia both in boys and girls, caused by either intestines, omentum or an ovary (in girls) herniating into a patent processus vaginalis thus causing a visible bulge in the groin.
  • The incidence of inguinal hernia is a few percent. It is about six times more prevalent in boys than in girls, and a right-sided hernia is more common. Approximately one in ten patients will have a bilateral inguinal hernia.
  • Direct (medial) inguinal hernia is remarkably rare in children.
  • Inguinal hernia can be painful, and the risk of incarceration is highest in children less than 12 months old. Signs of incarceration are observed in up to a quarter of infants with inguinal hernia, but the risk of incarceration is noticeably less than 10% when the child is over 12 months old.
  • Inguinal hernia may be visible and palpable in the groin when examining the child. In this case it is always possible to reduce it. The hernia is often neither visible nor palpable on examination, but a reliable history from the parents of an intermittent mass, at a site typical of inguinal hernia, is adequate for diagnosis.
  • The treatment of an inguinal hernia in a child always consists of surgical repair. The processus vaginalis is closed with sutures via a groin incision; there is no need to proceed with a separate hernia repair surgery.

Treatment of an incarcerated inguinal hernia

  • The child is often known to have a hernia.
  • The child will present with a painful mass in the groin that does not reduce spontaneously.
  • Palpation will often reveal a very firm, even hard, lump, which is not very mobile. Palpation is usually painful for the child.
  • In the early stages of incarceration, oedema due to blocked venous return to the herniated tissues must be addressed; it is the most important aspect of reduction.
  • Before manual reduction, the child must be given premedication (see treatment of pain in a child Wounds and Abrasions in Children) or the child is given a dummy soaked in a sugary solution to suck during the reduction procedure. Feeding is not recommended since emergency surgery may be necessary should the reduction fail. Reduction can be aided by placing the child in the Trendelenburg position.
  • Bimanual reduction is carried out as follows: firm lateral pressure is applied with one hand to the hernia to bring about a gradual reduction in venous congestion. Simultaneously, the apex of the hernia is grasped with the reducing hand and gradually increasing pressure is applied to the contents of the hernia towards the abdominal cavity. The reduction grasp must be maintained for several minutes.
  • After a successful reduction, the child should be kept under observation for some time, and then sent home provided that the pain is relieved and the child does not vomit. Surgical repair is indicated without undue delay since there is a risk of recurrence.
  • If reduction fails, the child must be referred immediately to an appropriate hospital for emergency surgery. The risk of intestinal necrosis or perforation due to strangulation is, however, very small in children.

Femoral hernia

  • Very rare in children: incidence has been estimated to be about 0.2% of all cases of groin hernias.
  • The site of a femoral hernia is slightly more lateral and lower than that of an inguinal hernia.
  • A femoral hernia is treated with surgery.

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