PEDIATRIC INGUINAL HERNIAS AND HYDROCELES

HERNIAS

Definition:

A hernia is the presence of tissues that normally reside in one body cavity (like the abdomen or the chest) outside that cavity. Hernias present as a bulge just above the crease of the thigh that contains intestines (bowels) that have escaped from the abdomen or belly.  In boys, the bulge may extend all the way down into the scrotum (pouch) containing the testicles.

Why do inguinal hernias occur?

When we think of hernias we usually think of words such as “rupture” or tear. We think of a person tearing a muscle by straining or lifting something too heavy and then seeing a bulge appear in the groin area where the torn muscle cannot keep the intestines and other abdominal contents in place.

In children that is not the case. Children have what is called a “congenital” hernia. They are born with it. They do not develop hernias because they cry too hard or because they have trouble with their bowels or because they play too rough. They were born with it, even though, sometimes the hernia only shows itself later in life.

  During a child's development before birth, a little tunnel forms between the abdominal cavity and the groin in all children. Approximately one month before birth this tunnel should close. In some cases this does not happen and the little tunnel joining the abdomen and the groin remains open and the contents of the abdomen can be pushed through this canal into the groin area: a hernia. Neither the father nor the mother are to blame for this, it just happens.

As you can see there is no damage to the muscles and the cure will not involve reconstruction of torn muscles, so important in adults.

How often are hernias diagnosed?

In their lifetime, 4 to 9% of boys born at term and much less often in girls. Premature infants may have hernias 16 to 25% of the time.t is important to remember that in approximately 15% of cases a hernia will appear on the other side as well, even if it is not seen.

How do I know my child has a hernia?

An inguinal hernia appears as a bulge in the groin that usually swells or grows into the scrotum with crying or straining. It is usually not tender and should be easily coaxed back into the abdomen with gentle massage in the calm baby or child.

If the baby or child is inconsolable and/or you cannot reduce the hernia you should bring the child to your doctor's or the emergency room's attention immediately; the hernia may be incarcerated and require immediate surgical attention.

What is the cure?

Your doctor will recommend an operation on a hernia for several reasons. Hernias never go away on their own and waiting simply allows time for complications to occur. The hernia may cause your child pain.  If the intestines descend into the canal and get stuck (incarceration), the blood supply may be cut off and cause the bowels to die (strangulation).  This can be a life-threatening situation, which requires emergency surgery and may result in the loss of a portion of intestine.  In some cases, the testicle or ovary may be damaged.  Infection and a prolonged hospital stay are possible.  For these reasons, hernias are usually repaired as soon as they are diagnosed.

What is the operation like?

It is a routine operation that is performed under general anesthesia in many cases as an outpatient (same day surgery). General anesthesia is used to avoid pain and  psychological trauma and is very safe when administered by anesthetists with special pediatric experience.

Contrary to adult hernia repairs pediatric repairs do not require patches or sutures to repair the abdominal muscles. Pediatric hernias are congenital and therefore only require closure and removal of the little tunnel (hernia sac) that never closed.

Another difference with adult hernias is the possibility of a silent hernia on the opposite side; this possibility leads surgeons to check for hernias on the opposite side either directly or with a little telescope during the surgery (diagnostic laparoscopy)

The operation is followed by a very speedy recovery with little or no restrictions on activity.

What are the risks?

RISKS OF NOT TREATING THE HERNIAS.

1)     A hernia will not resolve by itself. It will continue to grow in time and cause pain and other complications.

2)     Incarcerated  hernia: the hernia will not reduce back into the abdominal cavity and the bowel and abdominal contents become stuck. Sometimes this can cause problems of intestinal obstruction. As time passes the organs in the hernia can proceed to strangulation

3)     Strangulated hernia: the contents of the hernia (intestines or ovaries in girls) swell and finally do not receive enough blood to keep them alive. Sometimes strangulation can also cause loss of a testicle. When a hernia strangulates, doctors have only a few hours to salvage the organs involved. Strangulation can be a life threatening condition.

RISKS OF SURGERY

The risks of surgery in the uncomplicated hernia are very small:

1) Bleeding and infection can happen in any surgery but are fortunately very rare.
               
2) Recurrence: the hernia can come back in less than 1% of cases. As a frame of reference, in adults the figure is closer to 2.5%.

3) Damage to the testicle: if the hernia is not incarcerated, the risk is extremely low, especially since pediatric surgeons now perform the bulk of these operations.

What can I expect after the surgery?

 Since we do not need to repair of the abdominal muscles in the groin, children tolerate this surgery very well. There is usually some discomfort especially the first night but this is well controlled with Tylenol, Advil or other similar medications.Sometimes some swelling or bruising of the groin and scrotum occur but these resolve within a week or two.The scars are typically very small and tend to disappear in the hair line as the child grows up.  Children can return to school as soon as they recover, usually no more than two or three days. They can eat, drink and play as before except:No bathing, swimming for a week No bicycle riding or contact sports until seen in the follow-up visit approximately 10-15 days after surgery.

HYDROCELES

Definition:

The accumulation of liquid around the testicle is called a hydrocele.

Why do hydroceles occur?

The hydrocele is usually caused by the persistence of the same canal between the abdomen and the scrotum as the one that leads to hernias. In this case however the canal has almost completely closed and only a tiny little opening is still present. This little opening allows water but not other structures to pass from the abdomen to the scrotum.

How often are hydroceles diagnosed?

Many boys are born with fluid around the testicles, this normally resolves by age one or two without any help from the surgeon. The only thing you need to do is to have a surgeon see your child to make sure that what you are seeing is a hydrocele and not a hernia because the two can look alike. If the hydroceles appear after age two or persist beyond age one or two a surgical repair is in order.

What kind of surgery is performed?

Hydroceles are caused by the same mechanism as hernias and receive the same surgery with very good results. The surgery is performed under general anesthesia and involves the simple closure of the little canal that allows liquid to fill the scrotum about the testicle.

What are the risks of the surgery?

The risks of surgery are very small:

1)     Recurrence: the hydrocele can come back in less than 1% of cases.

2)     Damage to the testicle: while present, the risk is extremely low, especially since surgeons specialized in children now perform the bulk of these operations.

What can I expect after the surgery?

  Since we do not need to repair of the abdominal muscles in the groin, children tolerate this surgery very well. There is usually some discomfort especially the first night but this is well controlled with Tylenol, Advil or other similar medications.Sometimes some swelling or bruising of the groin and scrotum occur but these resolve within a week or two.The scars are typically very small and tend to disappear in the hair line as the child grows up.  Children can return to school as soon as they recover, usually no more than two or three days. They can eat, drink and play as before except:No bathing, swimming for a week No bicycle riding or contact sports until seen in the follow-up visit approximately 10-15 days after surgery.

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