No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Inguinal hernia repair in early infancy
Abstract
Controversy regarding the management of inguinal hernias in young infants stimulated this study. It was our hypothesis that inguinal hernia in young infants can and should be repaired at the time of presentation. In order to address this issue, the following questions were examined: How frequently are these hernias incarcerated and how should this be managed? What is the best timing of repair? Should the asymptomatic contralateral groin be explored? How do the recurrence and complication rates compare with those in older children? Have advances in anesthesia affected the treatment of these infants? The records of 384 infants less than 2 months of age who underwent inguinal herniorrhaphy from January 1985 to January 1990 at Children's Hospital and Medical Center in Seattle were reviewed. Nearly one fourth (24%) of the patients had incarcerated hernias. Preoperative reduction was successful 96% of the time. The hernia was then repaired within 48 hours. Six patients required urgent operation, but bowel resection was not necessary in any. Contralateral groin exploration was performed 96% of the time and was positive in 85%. The recurrence rate was 1.0%. Complications occurred in 2.3% of patients. There were no hernia-related deaths. Spinal anesthesia was used in 63 patients with no postoperative apnea. An aggressive approach toward prompt repair of hernias in this age group can result in a very low incidence of hernia-related complications. Repair can be carried out safely in the first 2 months of life with recurrence and complication rates comparable with those in older children. Spinal anesthesia may lower the rate of postoperative apnea.
... Fourteen articles fulfilled the inclusion criteria and did not meet the exclusion criteria. 1,4,[8][9][10][11][12][13][14][15][16][17][18][19] Figure 1 provides a detailed overview of the selection process. ...
... We present the review characteristics in Table 1. Eight studies were conducted in the USA, 1,4,9,10,[15][16][17]19 two studies were reported from Germany, 11,12 and one study each took place in Turkey, 8 New Zealand, 13 China, 14 and the UK. 18 The study years that were covered ranged from 1967 to 2021. ...
... There were no data about repeated operations in seven studies. 8,9,13,[15][16][17][18] The surgical management for RPIHs with comorbidities were only high ligation, 1,4 high ligation of the sac, and snugging of a large internal inguinal ring, 4 iliopubic tract repair, 4 Bassini repair, 10 Grobs procedure, 11 reconstruction of the transversalis fascia and the muscular borders, 12 Ferguson's open repair, 14 Andrew's repair, 19 laparoscopic repair, 14 and mesh repair. 1 ...
Background:
Higher risk of recurrence has been reported in pediatric inguinal hernia patients with specific comorbidities. The purpose of this systematic review was to investigate which comorbidities predispose to recurrent pediatric inguinal hernias (RPIHs).
Methods:
A comprehensive search of six databases was performed, reviewing the literature to date on RPIHs and the co-occurrence of comorbidities. English-language publications were considered for inclusion. The primary surgical technique (e.g., Potts procedure or laparoscopic repair) was not considered.
Results:
Fourteen articles published between 1967 and 2021 fulfilled the inclusion criteria and did not meet the exclusion criteria. They reported a total of 86 patients diagnosed with RPIHs with 99 comorbidities. Thirty-six percent of patients had conditions with increased intra-abdominal pressure, such as ventriculoperitoneal shunt for hydrocephalus, posterior urethral valves, bladder exstrophy, seizure disorder, asthma, using continuous positive airway pressure for respiratory distress syndrome, and gastroesophageal reflux disease. Twenty-eight percent of patients had diseases with weakness of the anterior abdominal wall, specifically mucopolysaccharidosis, giant omphalocele, Ehlers-Danlos syndrome, connective-tissue disorders, and segmental spinal dysgenesis.
Conclusions:
The main comorbidities of RPIHs were conditions with increased intra-abdominal pressure and weakness of the anterior abdominal wall. Although these comorbidities are rare, the risk of recurrence must be noted.
... In Sulaiman et al study out of 157 cases of groin hernia, 153 cases were inguinal hernias (97.5%) and only 4 cases were of femoral hernia (2.5%) (9) . The current study showed the peak incidence was in the first decade of life which was in agreement with Moss study (18) . ...
... The undescended testes present-in 11 patient (6.87%) which is comparable to other studies (18,20) . Hydrocele present in 20 patients (12.5%) which is higher than British studies 5% (16) . ...
... 29 Lawrence R. Moss and Hatch EI reviewed patients who underwent inguinal hernia repair. 30 Nearly one fourth (24%) of the infants in the series had incarcerated hernias. Reduction was successful in 96%. ...
... 35 Moss LR in a study of 384 patients who underwent inguinal hernia repair during a 5 years period found 9 minor post-operative complications. 30 Study by Shahnam et al shows hematoma as common complication among other complications of inguinal hernia surgery. 36 In the study period of 5 months there was no recurrence case in the follow up. ...
Background: Inguino-scrotal swellings are one of the commonest problems in infancy and childhood throughout the world. They represent the conditions most frequently requiring surgical repair in the paediatric age group. In many of these cases, clinical examination may suffice to obtain a definite diagnosis, but when the diagnosis is inconclusive, ultrasonography can play an important role. Post-operative complications are usually rare following elective operation whereas minor complications do occur after emergency operation. In this study we evaluated various presentations of inguino-scrotal swellings, their management and complications in paediatric age group.Methods: This is a hospital based prospective study, to have an overview of a spectrum of the paediatric cases admitted in the department of surgery with inguino-scrotal swelling that includes 40 patients with age below 13 years, irrespective of sex. Data regarding clinical features, birth history, immunization, family history various blood and radiological investigations was noted. Incidences of associated anomalies, complications and any form of treatment given to the patient were recorded and findings were analysed.Results: Out of 40 cases, all were males with maximum number of cases between the age group of 3-4 years.24 cases were right sided, 12 left sided and 4 bilateral. Hydrocele was associated with 10 of the cases, undescended testis with 2 cases and 1 had encysted hydrocele of the cord. There were no complicated cases like incarceration, obstruction or strangulation. Post-operative complications were noted in 4 cases, out of which 2 were wound haematoma and one case each of wound infection and stitch granuloma.Conclusions: Childhood inguinal hernias are more common on right side due to delay in descent of right testis and males are more commonly affected. Congenital hydrocele may involutes spontaneously, so we should observed at least upto 1 year of age before considering repair but not in the case of congenital inguinal hernia. Inguinal herniotomy in children is a safe and effective operation.
... This because of fear of incarceration, although its exact risk has not been studied in paediatric watchful waiting studies. Additionally between 24 and 30 % of patients present with incarcerated inguinal hernia (Moss & Hatch, 1991; Puri et al., 1984). Manual reduction is successful in a majority of patients (Moss & Hatch, 1991; Puri et al., 1984; Stringer et al., 1991). ...
... Additionally between 24 and 30 % of patients present with incarcerated inguinal hernia (Moss & Hatch, 1991; Puri et al., 1984). Manual reduction is successful in a majority of patients (Moss & Hatch, 1991; Puri et al., 1984; Stringer et al., 1991). Many paediatric surgeons hospitalize children after successful manual reduction of incarcerated inguinal hernia and repair the hernia within 24-48 hours. ...
... But for these cases regular follow up was done and found that 1 case developed C/L inguinal hernia on right side after 6 months. Hata S., Takahashi [8] guidelines of the Association of Surgeon of the Netherlands there is no indication for routine C/L exploration [9] . In this study only the side with an obvious hernia was operated. ...
... It is also used to examine the possibility of involvement on the other side. The ultrasound scan should be done on both inguinal regions, as it has been observed that a clinically undetectable hernia on the opposite side can be detected in 88% of patients [14,15]. ...
An indirect inguinal hernia is a commonly seen congenital condition that can impact infants within their first year of life. An inguinal hernia arises when a portion of the intestines, omentum, or reproductive structures herniate into the scrotal sac or labia through the patent processus vaginalis. These hernias occur more frequently in preterm newborns. The contents of a hernia often consist of the small bowel, colon, omentum, and either the ovary or testicle. The occurrence of a uterus in a herniated sac is uncommon. The presence of a uterus, ovary, and fallopian tube is exceptionally rare, with only a few cases reported in the literature.
We present a unique case of a 10-day-old female neonate who was delivered at 37 weeks of gestation and brought to the Paediatric Outpatient Department with swelling in the left inguinal region that had been present for the past five days. During the clinical examination, an irreducible mass was found in the left inguinal region. The ultrasound scan showed the uterus, ovary, fallopian tube, and minimal free fluid in the herniated sac. Colour Doppler evaluation of the uterus and ovaries revealed good vascularity. A diagnosis of a left inguinal hernia containing the uterus, left ovary, and fallopian tube, with no signs of ovarian torsion, was established. We performed a surgical procedure in which the likelihood of adhesions was taken into consideration, and the organs were removed from the hernial sac. We conducted the reintegration of the organs back into the pelvis, ligation of the high sac, and further repair of the internal inguinal ring to prevent the recurrence of the hernia. The surgical procedure was successful, and the postoperative period was without any complications. After the surgery, the patient was advised to have clinical and radiological follow-up for a period of one year. We recommend that a high-resolution ultrasound (HRUS) scan be routinely performed in neonates with an asymptomatic or symptomatic palpable mass in the inguinal region for early diagnosis and characterization of the herniated structures, as well as to assess their viability.
... Because the opposite side can be explored without the risk of significant damage to the vas and vessels, pediatric surgeons are increasingly using laparoscopic exploration [25] to detect and repair contralateral PPV [26]. Rather than routinely performing contralateral exploration, several studies of IHs in children have recommended age-specific exploration [22,27]. According to Holcomb et al. [28], bilateral IHs occurred in 50% of children younger than 1 year, 45% of children younger than 2 years, and 37% of those younger than 5 years suggesting that the younger they were, the more common a bilateral IH was. ...
Purpose:
Inguinal hernia (IH) repair is very commonly performed in children. While open repair (OR) is the standard approach, laparoscopic repair is increasingly used. This study was aimed to investigate safety and feasibility of laparoscopic repair of pediatric IH compared to OR.
Methods:
We retrospectively enrolled 105 pediatric patients with IH repair between January 2011 and October 2019. The laparoscopic procedures performed were laparoscopic percutaneous extraperitoneal closure (LPEC), and three-port mini-laparoscopic repair (TLR). The OR was performed as per usual technique.
Results:
Thirty-nine patients underwent OR, 16 LPEC, and 50 TLR. The preoperative laterality of IH was 45 patients (42.9%) on the right side, 50 (47.6%) on the left side, and 10 (9.5%) on both sides. It was, however, diagnosed postoperatively in 27 patients (25.7%) on the right side, 38 (36.2%) on the left side, and 40 (38.1%) on both sides. Of the 63 patients who presented with unilateral IH in the laparoscopic groups, 32 (50.8%) had synchronous contralateral patent process vaginalis (PPV) which were simultaneously repaired. This was significantly more common in children under 3 years of age. Operative time in unilateral or bilateral repair was significantly shorter in the laparoscopic repair groups (p < 0.001). Ipsilateral recurrence was not observed in any group. Metachronous contralateral IH occurrence was not significantly different between groups.
Conclusion:
Laparoscopic IH repair may have benefit in terms of shorter operation time and diagnosis of unpredicted contralateral PPV compared to OR.
... The estimated recurrence rates of hydrocele were higher in another investigation by Davies et al. [35], which estimated a rate of 11% in male patients that underwent surgeries for inguinal hernia (> 3 kg), or hydrocele. However, another investigation by Moss et al. [36] reported that only 2 cases (0.6%) among their 328 operated neonates developed postoperative recurrent hydrocele. This indicates that recurrence is a potential complication although it might not be common. ...
Hydrocele can be found as a collection of fluid within the testicular tunica vaginalis. According to the etiology and pathophysiology of the disease, it can be classified into primary and secondary. Furthermore, primary hydrocele might include the closed or non-communicating, the communicating type, the congenital and or neonatal type. Many management approaches have been proposed for both the communicating and non-communicating hydrocele with different post-operative and prognostic outcomes. In this literature review, we have discussed the current management approaches and prognosis of communicating and non-community hydrocele. Adequate diagnosis of the condition is the first step to achieve favorable management outcomes. Although the reported management outcomes are reported to be effective in the literature, the surgical approaches seem to be superior. However, many side effects might be associated with these operations. Estimates show that following varicocelectomy procedures, ipselateral (left) hemi-scrotal varicocele is the most common condition to occur, which might even develop following the procedure by several months and years (in some cases). Further investigations are still needed because the current evidence is largely based on case reports and small case series investigations. Therefore, larger studies are needed to help draw effective management protocols and enhance the outcomes and prognosis.
... 33,34,[37][38][39]41,45,47,48,50,[52][53][54] Six studies (n ¼ 1,096 patients) reported that contralateral exploration increases the total anesthesia time by on average 15 to 20 minutes. ...
Introduction Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia.
Materials and Methods The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.
Results Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality.
Conclusion Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.
... The most common hernia repairs performed today in the pediatric population are for an inguinal hernia. The incidence of hernia recurrence of children is 1% [1] . The use of prosthetic cone mesh for repair of a huge recurrent congenital inguinal hernia in infants is still rare. ...
Introduction The most common hernia repairs performed today in the pediatric population are for an inguinal hernia. The incidence of hernia recurrence of children is 1% [1]. The use of prosthetic cone mesh for repair of a huge recurrent congenital inguinal hernia in infants is still rare. Also, laparoscopic intervention in pediatric necessitates available equipment and well-trained staff [2]. Here we focus on the ability to use a cone mesh plug for the large internal ring in male infants with recurrent huge congenital inguinal hernia without opening of the inguinal canal.
... [14] Ultrasound examination should include both inguinal canals because a clinically inapparent contralateral hernia can be found in 88% of cases. [15] Uterus appears as a hypoechoic structure with echogenic internal endometrium. Ultrasonography finding of solid masses containing multiple cysts of varying size is a useful sign for the identification of ovary containing hernias. ...
An inguinal hernia occurs when an intestinal loop or part of the omentum or genital organs passes into the scrotal cavity or labia through an incompletely obliterated processus vaginalis. Inguinal hernias are most common in preterm neonates, especially at 32-weeks gestation. Content of hernia is mostly bowel and ovary/testicles. Presence of uterus in herniated sac is rare, and only few cases are reported in literature. Hernia is more frequently located on the right side because the right processus vaginalis closes later than the left. Physical examination is sufficient to enable diagnosis in most cases. Ultrasound examination is indicated in patients with inconclusive physical findings, in patients with acute scrotum, and to investigate contralateral involvement in patients in whom only a unilateral hernia is clinically evident. Routinely, color or power Doppler imaging is used in inguinal-scrotal hernia to investigate intestinal and testicular/ovarian perfusion. Urgent surgery is indicated in patients with an akinetic dilated bowel loop (a sign of strangulation) or impaired testicular/ovarian perfusion.
... 32 In a singleinstitution, retrospective analysis, Moss et al observed low recurrence and complication rates up to 5 years after surgical repair in infants younger than 2 months of age. 33 Conversely, a retrospective analysis by Baird et al revealed a higher rate of complications in infants who were 43 weeks' corrected gestational age or younger, compared with those who underwent repair at an older age. 34 They speculated that the greater friability of the hernia sac in former preterm infants predisposes to repair failure. ...
This Clinical Report was reaffirmed May 2021
Inguinal hernia repair in infants is a routine surgical procedure. However, numerous issues, including timing of the repair, the need to explore the contralateral groin, use of laparoscopy, and anesthetic approach, remain unsettled. Given the lack of compelling data, consideration should be given to large, prospective, randomized controlled trials to determine best practices for the management of inguinal hernias in infants.
... Searching through the published data, we may see that the given incidence of a contralateral inguinal hernia is as high as 57% to 85% according to the proponents of bilateral exploration (16,17) . The incidence of a PPV on the other hand, is reported as 80% in the first 2 months of life, steadily decreasing over the next 2 years (18,19) . ...
... Our study demonstrated no difference in complication rates between emergent and elective cases. This finding differs from previous reports documenting an increase in major complications in patients undergoing repair for an incarcerated hernia [12,13]. Although our data did not reach statistical significance, we postulate that our sample size was likely underpowered to detect this difference. ...
Inguinal hernia repair (IHR) remains the most common procedure in pediatric surgery. Although postoperative sequelae are well described, we examined if prematurity and age were important determinants of postoperative complications.
A retrospective review of children younger than 2 years undergoing IHR from 2004 to 2007 was performed, with a minimum of 1-year follow-up. Patients were segregated into groups based on age at diagnosis (A, 0-3; B: 4-26; C: 27-52; D: 53-104 weeks), with or without prematurity. Incarceration rates were investigated. Complications were categorized as major (vas injury, recurrence, testicular atrophy) or minor (wound infection, "high" testicle, hydrocele) and compared.
Two hundred sixty-eight patients were analyzed (98 premature), with 14 major complications (5.2%) and 26 (9.7%) minor complications overall. Groups A and B accounted for more major (12/14) and minor complications (22/26) when compared with groups C and D (P < .005). In patients less than 26 weeks (groups A and B), premature infants had more complications than term infants (27.7% vs 12.1%, P = .01). Of 22 patients with incarcerated hernias, 2 (9.1%) had major complications (P < .5 vs nonincarcerated patients).
Our study suggests that prematurity, rather than age at operation or incarceration, affects complication rates after IHR. This information should be used to frame the discussion of informed consent for this commonly performed procedure.
Objectives
: To evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.
Methods
: Medline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analysed using fixed and random effects meta-analysis (RevManv5.4).
Results
: Out of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I² = 0%, p<0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I² = 40%, p<0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I² = 0%, p = 0.94) between early and delayed groups.
Conclusion
: While early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.
Testicular torsion in neonates is a urologic emergency with an incidence of 6.1 per 100,000 live births. Incarcerated inguinal hernia is also an emergency with an incidence of approximately 6% to 31% in children with inguinal hernia. Functional testicular torsion from an incarcerated inguinal hernia is a rare event in children, often not considered in the initial evaluation. A 19-day-old newborn boy was admitted to our neonatal intensive care unit after visiting a primary clinic. He presented with inconsolable crying and right scrotal swelling. Upon initial physical examination, a hard palpable mass and swelling was found in the inguinoscrotal region, accompanied with redness and warmth of the scrotum. Scrotal ultrasound with color Doppler showed inguinal hernia with strangulation and scanty blood flow to the testis. The patient underwent a right orchiectomy and partial resection of the affected small bowel. Surgical findings confirmed a testicular torsion and incarcerated inguinal hernia with testis with small bowel necrosis. Here, we report a rare case of a newborn with functional testicular torsion as a result of prolonged spermatic cord compression due to incarcerated inguinal hernia.
Inguinal masses are one of the most common reasons for referral to pediatric surgeons. Not all inguinal masses are the same, and they frequently require a very different work-up and management. Inguinal hernias and hydroceles can occur in any child and present at any age. There is a rising incidence of inguinal hernias in more premature and low birth weight children. This chapter will focus on the embryology, clinical presentation, and management of inguinal hernias and hydroceles in the pediatric patient.
Hydrocele is a collection of fluid within the tunica vaginalis. Based upon the etiology and the pathophysiology, it is divided into, the primary and secondary. The primary hydrocele includes the neonatal or the congenital, the communicating and the non-communicating or the closed or the adult type. The secondary hydrocele can develop in the substrate of a pre-existing disease. After systematic and thorough systematic and thorough research of the relevant literature, we aim at describing all the aspects of this entity, with specific emphasis on the issues that remain unanswered from the scientific community.
Uvod. Pri otrocih je dimeljska kila najpogostejše stanje, ki zahteva kirurško zdravljenje. Ker ukleščena kila lahko ogroža prekrvitev črevesa, je nujno stanje. Ukleščeno kilo moramo pravočasno prepoznati in ustrezno ukrepati.
Metode. Pregledali smo literaturo in opravili statistični pregled obravnav ukleščenih kil v Univerzitetnem kliničnem centru Ljubljana v petletnem obdobju od januarja 2015 do septembra 2019.
Rezultati. Po navedbah v literaturi delež ukleščenih kil pri otrocih ocenjujejo na 0,9−3 %. V Univerzitetnem kliničnem centru Ljubljana smo v obdobju od januarja 2015 do septembra 2019 obravnavali 32 ukleščenih kil in jih v 12 primerih uspešno reponirali. Sicer smo v tem obdobju pri otrocih elektivno operirali 897 dimeljskih kil. Delež ukleščenih kil je bil 2,1 %.
Zaključek. Delež ukleščenih kil pri nas je primerljiv s podatki v literaturi. Za otroke do 2. leta starosti je smiselna centralizirana obravnava v ustanovah z ustrezno usposobljenim osebjem, ki otrokom nudi optimalno predoperativno oskrbo ter medoperativno in pooperativno podporo. Na vsak način moramo ukleščene kile čim prej prepoznati in jih reponirati.
Aim
Prolapsed ovary (PO) in an inguinal hernia (IH) may cause torsion and infarction; however, the management of IH with PO in very low birthweight (VLBW) infants during neonatal intensive care unit (NICU) hospitalisation remains inconsistent.
Methods
The medical records of 47 IHs in 30 VLBW infants during NICU hospitalisation between 2008 and 2017 were reviewed retrospectively.
Results
Of the 47 IHs, PO was diagnosed in 18 (38.3%). Post‐natal age and body weight at diagnosis of IH with PO were 71 (44–172) days and 2120 (1305–2965) g, respectively. Seventeen IHs with PO underwent surgery for correction electively just before discharge from the NICU at the age and body weight of 94 (51–187) days and 2645 (2340–2945) g, respectively. Therefore, the time interval between diagnosis and surgery was 15 (7–90) days. There was no torsion of ovary before surgery and no postoperative complications, including apnoea and recurrence.
Conclusions
The high incidence of IH with PO in VLBW infants during NICU hospitalisation was confirmed in this study. Under careful observation, elective IH repair just before discharge from the NICU could be one acceptable option for the management of IH with PO in VLBW infants during NICU hospitalisation to prevent torsion and infarction of ovary.
Inguinal hernias in babies and children predominantly develop secondary to the underlying abnormality of a patent processus vaginals. This leads to the development of a congenital (indirect) inguinal hernia or hydrocele. The treatment of these hernias has been descried for centuries. Open approaches are well established. However, management options continue to evolve with recent advances in minimally invasive techniques, which are discussed in this chapter. Ultimately, the approach used depends on the competencies of the surgeon performing the procedure and the available resources. All inguinal hernias in babies and children should be managed operatively and there is no role for conservative management. Incarceration is the predominant complication and if present the hernia requires urgent reduction and, if achieved, expedited surgical management. If reduction is not possible, they require emergency surgical intervention.
Purpose:
We aimed to describe the incidence, timing, and predictors of recurrence following inguinal hernia repair (IHR) in children.
Methods:
We used the TRICARE claims database, a national cohort of >3 million child dependents of members of the U.S. Armed Forces. We abstracted data on children <12y who underwent IHR (2005-2014). Our primary outcome was recurrence (ICD9-CM diagnosis codes). We calculated incidence rates for the population and stratified by age, time from repair to recurrence, and multivariable logistic regression to determine predictors.
Results:
Nine thousand nine hundred ninety-three children met inclusion criteria. Age at time of IHR was ≤1y in 37%, 2-3y in 23%, 4-5y in 16%, and 5-12y in 24%. Median follow-up time was 3.5y (IQR:1.6-6.1). 137 patients recurred (1.4%), with an incidence of 3.46 per 1000 person-years. Over half occurred in children 0-1y at repair (60%). The majority occurred within a year following repair (median 209 days [IQR:79-486]). Children 0-1y had 2.53 times greater odds of recurrence (compared to >5y). Children with multiple comorbidities had 5.45 times greater odds compared to those with no comorbidities.
Conclusions:
The incidence of recurrence following IHR is 3.46 per 1000 person-years. The majority occurred within a year of repair. Children ≤1y and those with multiple comorbidities were at increased risk.
Level of evidence:
Prognosis Study, Level II.
Defective closure of the embryonic abdominal wall can occur at three different levels — epigastric, umbilical, or hypogastric — thereby leading to celosomia (Geoffroy Saint-Hilaire, 1832–1837) in the superior, middle, or inferior position (Wolff 1936, 1938; Morin and Neidhardt 1977).
Objective: Inguinal hernias require early elective repairs when diagnosed within the first six months of life. In this period, the risk of incarceration increases as the age decreases. The aim of the study was to evaluate perioperative findings and postoperative complications of the inguinal hernias in the newborn period. Material and Methods: The 95 newborns (73 male, 22 female), who were operated for inguinal hernias in our clinic between 1991 and 2005 were retrospectively assessed. Results: The age at diagnosis for male and female patients was 27 days and 28 days, respectively. Inguinal hernia repair was performed unilaterally in 72 patients (75.8%) and bilaterally in 23 patients (24.2%). High ligation was the surgical approach for all patients (right 60, left 12, bilaterally 23, and total 118). 80 patients were operated electively (84.2%) and 15 patients had emergent operation due to incarceration (15.8%). The incarcerated tissues were small or large bowels in 10 patients and ovary in 3 patients. Spontaneous reduction due to general anesthesia ensued in 2 patients. Postoperative early complication was wound infection in 4 patients (26.7%) and postoperative late complication was testicular atrophy in 1 patient (9.1%) in the incarcerated group. Thirteen patients of the electively operated group had sliding hernias. Sliding organ was appendix in 2 patients, ovary in 6 patients, ovary and uterine tubes in 4 patients and round ligament in 1 patient. Postoperative early complication was wound infection in 2 patients (1.7%) and postoperative late complication was testicular atrophy in 1 patient (1.2%) in the electively operated group. Neither recurrence nor mortality was seen. Conclusion: Newborn inguinal hernias require early elective repairs because of the high incarceration risks they comprise. Incarceration of newborn hernias not only challenges the surgical practice but also increases the postoperative morbidity.
Objectives: Controversial issues in the diagnosis and management of inguinal hernia in children, with a relatively high rate of reported postoperative complications (up to 8%), suggested the examination of our current policy in the management of pediatric inguinal hernia. The determination of risk factors, predisposing to postoperative complication may be identified so as to improve postoperative outcome. Methods: A prospective audit of 499 children with inguinal hernias, treated in a teaching hospital between 1987 and 1995 was performed. A detailed protocol was used to record the data. There were 394 boys and 105 girls between one day and 14 years of age. There were 130 (26%) neonates. Out of 499 patients, 478 were operated upon either electively (429) or as emergency (46). Results: The hernia was correctly diagnosed by the parents 366 times and by a physician 118 times. All emergency cases underwent a routine attempt of conservative reduction; this was successful in 33 of 46 (56%) cases. Patients discharged after conservative reduction for delayed elective operation defaulted in 12 of 33 (36.4%) cases. A hernia appearance on the opposite side was noticed in 17 (3.4%) cases. In 5% complications such as wound infection, recurrence, misplaced testis, respiratory distress, ileus, bleeding per rectum and anesthesia were recorded. Low educational level of the surgeon, prematurity, younger age or both of the patient and emergency operation were identified as risk factors predisposing to complications. Conclusion: Parental Finding of an inguinal swelling is an acceptable diagnosis for hernia in children. Failure to demonstrate the hernia should not be considered an indication for invasive diagnostic procedure like herniography. Following conservative reduction, herniotomy must be performed within 24-48 hours because of high rate of default (36.4%), if herniotomy is delayed. We do not advocate a routine contralateral exploration as the incidence of the appearance of a hernia is small (3.4%). Pédiatrie herniotomy is not a suitable operation for unsupervised training.
Congenital inguinal hernia is one of the most frequent developmental anomalies in children. The incidence of inguinal hernia in children ranges from 0.8 to 4.4%. Its creation is result of persistent processus vaginalis and clinical presentation is stimulated by diseases with increased intraabdominal pressure. During foetal period processus vaginalis appears to play an integral role in testicular descent in boys and round ligament transit through the internal inguinal ring in girls. It should obliterate spontaneously. The diagnosis of hernia is established by physical examination and history. US examination helps with differential diagnostics. The most serious complication of inguinal hernia is its incarceration which is life-threatening state and needs urgent surgical intervention. The presence of inguinal hernia is an indication to surgical repair. The age of patient is not a contraindication. Hernia repair is the most frequently performed procedure in general paediatric surgery and is done in the outpatient surgical unit at present. The complications after surgical treatment are rare and occur in less than 1% of operated patients.
An extremely-low-birth-weight male infant, weighing 840 grams, was treated for a huge scrotal hernia on the left side by traditional surgery consisting of high ligation of the sac and sewing of the internal inguinal ring at 241 days after birth.
He developed a recurrent left inguinal hernia 2 months after the surgery and underwent re-surgery laparoscopically at the age of 1 year 8 months. The left internal inguinal ring showed an enlarged orifice of about 15 mm, and the new hernia sac was shown to be the prolonged processus vaginalis itself. He was treated by the advanced laparoscopic percutaneous extraperitoneal closure method (LPEC with iliopubic tract repair to reinforce the posterior wall of the inguinal canal). He was discharged on postoperative day 1 without any complications, and he has not developed a recurrent hernia 21 months after surgery.
The advanced LPEC method is a highly effective procedure recommended for the treatment of huge inguinal hernias in immature infants.
Purpose: We evaluated the contralateral patent processus vaginalis (CPPV) by transinguinal laparoscopy in boys with unilateral inguinal hernia, to determine its incidence and the association with various clinical parameters. We also investigated the factors responsible for the development of a metachronous inguinal hernia. Materials and methods: One hundred sixty seven boys with unilateral inguinal hernia were analyzed. The morphology of the ring was classified into four patterns (type 1, 2a, 2b, and 3). We analyzed the morphology of the internal ring and the variables related to a CPPV by age, laterality and the size of the ipsilateral and/or bilateral hernia sac. Results: The incidence of a CPPV was 33.9%. The positive predictive value was 94.9% (56/59). There was no statistical difference in the incidence of a CPPV by laterality. The incidence of a CPPV was significantly higher in the group with a larger size ≥ 1cm) compared to the smaller abnormalities (< 1cm). The incidence of the type 3 pattern was higher than the type 2b pattern in the group with larger abnormalities. With increasing age, type 1 and 2a patterns increased in frequency, but type 2b decreased and the type 3 pattern was stable. The size of the contralateral hernia sac was significantly larger with the type 3 pattern than the type 2b. Conclusions: The results of our study showed that the size of the hernia sac and patient age were related to the presence of a CPPV. A type 3 pattern was associated with a more primitive morphology, a wider hernia sac and no change in the incidence with advancing age. Therefore, the findings of this study suggest that a metachronous inguinal hernia develops more commonly in patients with a type 3 pattern internal ring.
Assessment of the neonatal reproductive tract requires an understanding of embryology, awareness of common clinical presentations, and familiarity with normal newborn variation. This review of the neonatal reproductive tract emphasizes the use of sonography in the evaluation of developmental, acquired, and neoplastic conditions in male and female newborns. Anchored in embryologic origins, the discussion also includes descriptions of findings that may be encountered in prenatal imaging. Comments on clinical correlation are included to guide appropriate triaging of these complex cases. Imaging pearls and pitfalls are incorporated into this review, including the recognized effects of maternal hormones in female infants.
Copyright © 2015 Elsevier Inc. All rights reserved.
The purpose of this study is to identify the incidence of metachronous contralateral inguinal hernia (MCH) and how early patients visit hospital upon discovering the presence of a lump on the contralateral side after initial hernia repair.
Background
Inguinal hernia repair is the most frequently performed surgical procedure in infants and children. Especially in premature infants, prevalence reaches up to 30 % in coincidence with high rates of incarceration during the first year of life. These infants carry an increased risk of complications due to general anesthesia. Thus, spinal anesthesia is a topic of growing interest for this group of patients. We hypothesized that spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants even at high risk and cases of incarceration.
Methods
Between 2003 and 2013, we operated 100 infants younger than 6 months with inguinal hernia. Clinical data were collected prospectively and retrospectively analyzed. Patients were divided into two groups depending on anesthesia procedure (spinal anesthesia, Group 1 vs. general anesthesia, Group 2).
Results
Spinal anesthesia was performed in 69 infants, and 31 infants were operated in general anesthesia, respectively. In 7 of these 31 infants, general anesthesia was chosen because of lumbar puncture failure. Infants operated in spinal anesthesia were significantly smaller (54 ± 4 vs. 57 ± 4 cm; p = 0.001), had a lower body weight (4,047 ± 1,002 vs. 5,327 ± 1,376 g; p
Hernias of the abdominal wall constitute an important public health problem and often pose a surgical dilemma even for the most skilled surgeon.1 In most countries, hernioplasty and cholecystectomy are the most common forms of elective surgery. In the United States alone, between 500,000 and 750,000 patients are operated on for inguinal hernia each year.2 Yet, in spite of its great incidence, precise epidemiological data about inguinal hernia are difficult to obtain.
Articles published in the English language report that 15-20% of the inguinal hernias in female children are sliding hernias. These studies do not specify the age at moment of surgery, neither the age distribution of sliding hernia. We retrospectively evaluated inguinal canal pathologies to answer these questions.
We retrospectively evaluated the records of the patients operated on at the Pediatric Surgery Clinics of the Ordu, Usak and Denizli State Hospitals and the Afyon Obstetrics and Gynecology Hospital.
A total of 3105 cases had been operated on for an inguinal hernia between January 2008 and December 2010 and 673 (21.6%) were female. The most common age at surgery was between 0 and 1 years (26.5%). A sliding hernia was found in 22.4% (n = 151) of all cases. The sliding hernia rate was 45.8 (n = 82) and 14.9% (n = 69) in children younger and older than 1 year of age respectively (p < 0.05). The most frequently sliding organ in both groups was the ovary, followed by the fallopian tubes.
A sliding hernia is more common in female children under the age of 1 year and surgical treatment should be planned within a short period once the diagnosis is made. In addition, this recent statistical value for subjects aged 0 to 1 year and over 1 year can be used in new clinical studies.
El tratamiento quirúrgico de las hernias inguinales del niño difiere considerablemente del tratamiento del adulto debido a particularidades anatómicas y fisiopatológicas importantes. Se trata de una intervención muy frecuente pero no simple, debido al riesgo de lesión gonadal inherente a la disección del pedículo espermático. En este capítulo se exponen las indicaciones, la vía de acceso, los principios y las modalidades de la herniorrafia, así como las particularidades del tratamiento en caso de hernia estrangulada, en la niña y en el prematuro. Por último, plantea el interés de las nuevas técnicas, como la cirugía laparoscópica, teniendo en cuenta indicaciones bien precisas.
The exact etiology of metachronous hernia is unclear. Does a contralateral patent processus vaginalis proceed to form a hernia sac, or does the contralateral side have a silent hernia, present from birth? Diagnostic laparoscopic evaluation for a potential contralateral hernia is a simple, accurate, fast, and effective way to reduce negative explorations. It is easily learned and requires less time than routine bilateral exploration. Despite these benefits, there remains the risk of iatrogenic injury in a situation that might never lead to a clinical hernia. The question of how to determine when the anatomy of the processus vaginalis foretells a future hernia is explored.
The inguinal hernia, malformations caused by persistence of peritonea-vaginal duct, is frequent in children. It is a benign affection as long as it is not strangled. During our five-year-retrospective study, we have found 32 cases (30 boys and 2 girls) of strangled inguinal hernia. There are 78,12% of cases under five years old. In 54%, the hernia was on the right side. Malnutrition and inguinoscrotal hernia are very exposed to strangulation. We observed obstruction syndrome in 81,25% of cases. We have to deplore one case of scrotal fistulae by intestinal necrosis and two cases of testicle necrosis. For all of our patients, the peritonea-vaginal duct was closed with ligature, associated with pre-funicular parietal refection. One case of recurrence is found in postoperative time.
Inguinal hernia is a frequent surgical disease during infancy, occuring in 1 to 2% of all mature newborns and rise up to 30% of all premature babies. In 9.5% a contralateral hernia is found after unilateral operation. In our own patients this rate was 5.6%. The development of a contralateral hernia was significantly more often found in boys than in girls. If the hernia occured during the first two months of life, a contralateral hernia developed later highly significant (p>0.0001). Within the first two postoperative years the second hernia arose in 84.9%. We recommended to routinely operation for a contralateral hernia in all children younger than two months.
Background and aims:
A systematic review of the literature is presented with regard to urological complications resulting from inguinal hernia surgery. Considering the amount of inguinal hernia operations performed, the resulting complications, which may be urological in presentation, have potential late irreversible and medico-legal implications.
Methods and results:
A Pubmed search of 'urological' 'complications' and 'inguinal hernia surgery' was carried out and clinical practice was also taken into consideration.
Discussion:
Approximately 75% of hernias occur in the groin; two-third of these are indirect and about one-third direct. Most of these repairs are carried out by the general surgeons and any complication, including urological, are often initially managed by the operating general surgeon. Often a urological opinion is sought late for conditions which may be reversible. We present potential urological complications, their presenting features and management.
Conclusion:
Recognition, timely referral and appropriate treatment of urological complications after hernia surgery are necessary to avoid potential consequences and long-term morbidity.
It is impossible to determine whether or not a child will develop a contralateral hernia after inguinal hernia repair. There exists no risk score for the occurrence of a contralateral hernia. This well-known fact prompted us to perform the underlying study. In a retrospective trial, we reviewed the files of all children operated on for inguinal hernias in our department from January 1986 until December 1994. During this period, we performed 1721 hernia repairs on 1708 children aged 0–16 years. In 96 (5.6%) of these patients, the indication to operate was a contralateral hernia following previous unilateral repair. Comparison of the ages at the time of primary inguinal repair of those children who developed a contralateral hernia (n=96) and those who did not (n=1612) showed a significantly increased incidence of contralateral hernias if the primary operation was performed before the age of two months (p<0.0001). Diseases predisposing to hernias were found in 38% of all children (prematurity, dystrophia, ventriculo-peritoneal shunt, ascites, asthma). The authors recommend a contralateral exploration for children under the age of two months if they have any predisposing disease.
Die Inzidenz von Leistenhernien im Kindesalter beträgt 1–2%, bei Frühgeborenen steigt sie bis auf 30% an. In 9,5% der Fälle
ist nach unilateraler Hernienversorgung mit der Ausbildung einer kontralateralen Hernie zu rechnen. Bei den eigenen Patienten
bildete sich bei 96 Kindern (5,6%) eine kontralaterale Hernie aus. Signifikante Unterschiede bestanden hinsichtlich des Geschlechts.
Jungen sind häufiger von der Ausbildung einer kontralateralen Hernie betroffen als Mädchen. War eine Hernie in den ersten
2 Lebensmonaten aufgetreten, so mußte im späteren Leben hochsignifikant mit dem Auftreten einer kontralateralen Hernie gerechnet
werden (p>0,0001). Diese tritt in 84,9% der Fälle innerhalb der beiden ersten postoperativen Jahre auf. Daher halten wir die routinemäßige
Simultanoperation der kontralateralen Seite bei Kindern <2 Monaten für indiziert.
Inguinal hernia is a frequent surgical disease during infancy, occuring in 1 to 2% of all mature newborns and rise up to 30%
of all premature babies. In 9.5% a contralateral hernia is found after unilateral operation. In our own patients this rate
was 5.6%. The development of a contralateral hernia was significantly more often found in boys than in girls. If the hernia
occured during the first two months of life, a contralateral hernia developed later highly significant (p>0.0001). Within
the first two postoperative years the second hernia arose in 84.9%. We recommended to routinely operation for a contralateral
hernia in all children younger than two months.
In view of the complications of general, spinal, and caudal anaesthesia for inguinal hernia repair in high-risk neonates, an evaluation of lumbar epidural anaesthesia (LEA) was undertaken to assess its technical feasibility, effectiveness and incidence of complications. In 18 consecutive cases, gestational age 26 ±2.6 wk, birth weight 877 ±310 g, 16 (89%) had bronchopulmonary dysplasia and 12 (67%) were oxygen-dependent at the time of surgery. Using a standard loss of resistance technique and a 4.0 cm 20 G epidural needle, the epidural space was positively identified on the first attempt in 16 (89%), and on the second attempt in 2 patients (11%). Reflux of 0.9% saline used to identify the epidural space was blood tinged in two cases. Epidural analgesia was achieved in all cases with bupivacaine 0-25% with and without 1:200,000 epinephrine, 0.75 ml · kg-1 for the first two cases, and subsequently 1.0 ml · kg-1~'. In 15 patients (83%), good operating conditions were achieved with epidural analgesia alone. Inhalational anaesthesia supplementation was necessary in three cases (17%). In the first two patients, the level of analgesia (T8) was insufficient to control the response to traction on the hernial sac. In one infant, analgesic to T4, whose surgery was inadvertently delayed for four hours, inhalation anaesthesia was needed to control restlessness rather than pain. Ten infants were analgesic to T2, four to T4, two to T6 and two to Tg. Intraoperative periodic breathing was seen in seven infants (39%), four with oxyhaemoglobin desaturation to 75%, and two to 85%. All responded to increased F1O2. No adverse haemodynamic effects were seen. Apnoeic spells in the first 24 hr after surgery occurred in three infants; one of these infants also had apnoeic spells during the previous 24 hr. Otherwise, there were no postoperative complications. We conclude that LEA was technically easy, and provided good operating conditions for most neonates in this study.
We compared surgical outcomes of mini laparoscopic and open herniorrhaphy in infants.
We enrolled 55 infants undergoing herniorrhaphy, of whom 24 underwent mini laparoscopic herniorrhaphy (bilateral in 17, unilateral in 7) and 31 open herniorrhaphy (bilateral in 9, unilateral in 22). Mean±SD patient age was 7.17±4.21 months in the mini laparoscopic and 5.39±4.11 months in the open groups (p=0.37). During laparoscopy a contralateral patent processus vaginalis of 2 cm or greater was noted and repaired simultaneously in 13 of 20 infants (65%) initially diagnosed with unilateral hernia.
Mean±SD followup was 22.9±10.5 months in the mini laparoscopic group and 20.2±10.5 months in the open group (p=0.20). Contralateral metachronous inguinal hernia manifested in 4 of 22 patients (18%) initially presenting with unilateral hernia in the open group and in no patient in the mini laparoscopic group (p<0.05). Recurrence was noted in 1 of the 40 open herniorrhaphy sites and in none of the 41 mini laparoscopic herniorrhaphy sites (p=0.49). For unilateral repair mean±SD operative time was significantly longer in the mini laparoscopic group (80.00±18.97 minutes) compared to the open group (51.15±23.27 minutes, p<0.05). For bilateral repair mean±SD operative time was comparable between the 2 groups (82.52±14.74 minutes for mini laparoscopy and 95.62±20.62 minutes for open repair, p=0.35).
Mini laparoscopic herniorrhaphy in infants may prevent contralateral metachronous inguinal hernia, and is as safe and effective as open herniorrhaphy. The drawback of mini laparoscopic repair is the longer operative time for unilateral herniorrhaphy, which may be overcome by increased experience.
Prevalence and incidence of inguinal hernia in a representative sample of low birthweight survivors were determined by tracing children at 3 years of age. Prevalence was examined in relation to perinatal factors recorded in hospital case notes, using a logistic regression model to allow for confounding variables. Of the 1074 two year survivors, 995 (93%) were assessed. Seventeen per cent of 497 boys and 2% of 498 girls had a hernia by 3 years of age, a total cumulative prevalence of 9.2%: it was significantly increased by lower birth weight, male sex, neonatal intravenous feeding, and lack of respiratory disease. Neonatal illnesses were otherwise not associated with herniation, and most infants were well when they presented. Peak incidence was at the expected full term of gestation. Bilateral hernias were increasingly more common than unilateral hernias at lower gestational ages. It is proposed that causes of increased abdominal pressure in healthy neonates are important causes of herniation during a critical period of inguinal development.
In the course of 11 years, 2,015 children were operated upon for an inguinal hernia at the Alder Hey Children's Hospital. Of these, 140 (7%) were strangulated, and 33 (1.6%) were less than one month old.
Reduction of the strangulated hernia by taxis was successful in 14 cases, unsuccessful in 6, and was not attempted in 13 because of signs of intestinal obstruction, or because the inguinal swelling was extremely tender. There was no relationship between length of history and the success or failure of taxis.
Gangrene of the intestine requiring resection occurred in only one child, in another the related testicle was infarcted, and in 5 others the testis was engorged but viable.
There were 2 deaths, neither of which was directly due to the hernia.
Several reports with conflicting results have been published describing the incidence of testicular lesions resulting from incarcerated inguinal hernia. At the Department of Pediatric Surgery of the University of Graz, 178 children were treated for 180 incarcerated inguinal hernias from 1978 to 1985; 124 infants with suspected testicular lesions were followed up in 1984. The size of the testicles was determined using the Prader of the testicles was determined using the Prader orchidometer and comparing both testicles. In 18 children (14.4%) distinct testicular lesions were found. Infants less than 2 months old showed a significantly higher incidence of testicular lesions than older children (33.3% vs. 6.8%). Children in whom operative reduction of the incarcerated hernia was necessary had a significantly higher incidence of testicular atrophy than children in whom preoperative reduction was successful (29.0% vs. 9.6%). Our study shows that risk factors such as age, time of reduction, histologically proven hemorrhagic infarction, and undescended testis are of prognostic value.
Trends are changing in the management of infants and children with indirect inguinal hernias. Advances in neonatal intensive care have resulted in the survival of many small premature infants who have a high incidence of inguinal hernia. The rate of incarceration, strangulation, and gonadal infarction in these babies is twice that of the general pediatric age group. Respiratory immaturity, apnea, bradycardia, and associated neonatal conditions require special management at the time of hernia repair, usually performed just before discharge from the neonatal intensive care unit. New information concerning volume loss and depletion of germ cells beginning at 6 months of age in boys with undescended testes has stimulated the performance of orchiopexy when the patient is 1 year of age. More than 90% of boys with cryptorchid testes at the age of 1 year have an associated hernia that requires concomitant repair at the time of orchiopexy. The use of the peritoneal cavity for fluid absorptive purposes in hydrocephalus treated by venticuloperitoneal shunts or of peritoneal dialysis for renal failure and metabolic diseases such as hyperammonemia and lactic acidosis causes increased intraabdominal pressure and results in the appearance of a previously unrecognized hernia. Recognition of these and other conditions associated with a high incidence of hernial occurrence should allow early diagnosis and treatment before the development of complications. Most elective repairs of hernias are safely performed in the outpatient setting; however, some infants and children with concurrent illnesses are best managed in a "morning admissions" program, in which hospital admission occurs postoperatively.
This retrospective review covers our experience over 5 years of 436 hernia repairs in 392 children upto the age of 15 years. The number of emergency presentations was 71 (18.1 per cent) and 66.2 per cent of these were under the age of 12 months. Most cases were initially treated conservatively and only 18 children required operation on the day of admission. There were 11 recurrences (7 elective and 4 emergency cases) giving a recurrence rate of 2.5 per cent. In all eleven cases the original operation was performed by a junior surgeon. The complication rate (excluding recurrences) was 2.8 per cent but may be an underestimate because of the limitations of a retrospective study. We suspect our results are typical of those to be found in any large British hospital and that with careful training and supervision of junior staff in the technique of inguinal herniotomy the results could be improved and approach those found in specialist paediatric units in America.
In 1955 Rothenberg and Barnett1 reported 50 infants and children with unilateral inguinal hernias who had contralateral groin explorations. They concluded that 100 per cent of infants under one year of age and 65.8 per cent of children over one year had “bilateral inguinal hernias.” Since that time there have been many reports confirming the high incidence of an open processus vaginalis on the side opposite a clinically apparent inguinal hernia. Sparkman,2 in 1962, reviewed a combined series of 918 infants and children with a unilateral inguinal hernia and contralateral groin exploration. A patent processus was found in 57 per cent of the cases. During the past several years, a controversy3–6 has centered about the significance of the high incidence of patency of the processus vaginalis on the side opposite an inguinal hernia.We have studied a large series of children with inguinal hernias (2764) operated upon by one group of surgeons, in a single hospital. Our objectives were to: (1) determine the natural history of the patent processus; (2) determine the factors that might be associated with patency of the processus; and (3) attempt to find what factors might be related to the development of a clinically apparent inguinal hernia from a patent processus vaginalis.
Contemporary neonatal intensive care has resulted in survival of many seriously ill preterm and older infants that frequently present with symptomatic inguinal hernia. Controversy exists concerning timing and safety of early repair in prematures or other neonates, especially those hospitalized with concurrent illness. This study examines this topic by evaluating predisposing factors, presentation, and postoperative complications in 100 recent consecutive hernia repairs in previously hospitalized infants less than 2 months of age. There were 85 boys and 15 girls. Thirty percent were premature (less than 36 wks gestation). Forty-two infants were hospitalized for RDS with assisted ventilation in 16 infants, hydrocephalus and ventriculoperitoneal (VP) shunt in 7 infants, and congenital heart disease (CHD) in 19 infants. Clinical presentation was on the right side in 44 infants, bilateral in 42, and on the left side in 14. Incarceration occurred in 31 cases with nine babies having overt intestinal obstruction. The incidence of cryptorchidism was 12.9%. All (VP) shunt, CHD patients, and incarcerated cases were treated with preoperative antibiotics. Following discharge, 49 preterm or previously ill infants developed a symptomatic hernia at home and were readmitted. Nine full-term infants were treated as outpatients. Bilateral inguinal exploration was performed in 92 cases with second hernia or patent processus found in 81. Seven of eight with unilateral exploration had acute incarceration with obstruction at the time of the procedure. Three subsequently required a second hernia repair. Two infants with incarceration and cryptorchid testis or ovarian slider had gonadal infarction. There were eight postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)
In the years from 1971 to 1980 inclusive, 511 infants under 1 year of age presented with inguinal hernia. Of these, 158 (31%) (149 boys and 9 girls) had incarcerated inguinal hernia. In 151 (95.5%) infants the incarcerated inguinal hernia was reduced by taxis and herniotomy performed 48 to 72 hours later. Seven infants (4.5%) required emergency operation. Of the 142 boys whose incarcerations were reduced by taxis 87 (61%) were contacted and examined. They were aged 10 months to 10 years, 9 months at the time of follow-up. Two boys had testis in the groin presumably hitched up at operation. Testicular volume was assessed in 87 boys using Prader's orchidometer. Two boys had unilateral testicular atrophy. In the remaining 85 boys testicular volume was not different from that of age-matched controls. Our data show that the danger of testicular infarction from an incarcerated inguinal hernia, although real, has been much over-emphasized.
Development of herniography as a diagnostic tool has reopened the question of whether the asymptomatic groin should be explored at the time of unilateral herniorrhaphy in infants. In an attempt to provide data toward the formulation of an answer, the authors review 32 yr of experience with 160 infant hernias. They represent a sequential, unselected series of pediatric patients whose hernias were repaired only if confirmed by examination, and whose postoperative fate has been assessed over extended periods of time. Ninety-six percent of the group were able to be evaulated over an average follow-up interval of 20 yr. It was discovered that of the total group of children with hernias, 29% developed a hernia on the opposite side at some time in their lives. The chance of contralateral occurrence was found not to vary with the child's age at time of first repair, but was found to depend on which side the original repair involved; if the first repair was on the left, the child's chance of contralateral involvement was 41%; if on the right, the risk was only 14%. Morbidity was insignificant with the notable exception of testicular atrophy, which occurred in 2% of the group. The authors conclude that despite the 29% overall risk of future contralateral development, bilateral exploration is not justified for two reasons: First, that a number of unnecessary procedures would be performed, two operations to prevent each subsequent right-sided hernia, and six operations to preclude each later left-sided occurrence; Second, that the risk of bilateral testicular trauma, though slight, is too great.
Incarcerated and strangulated hernias in children
- Rowe
Rowe MI, Clatworthy HW. Incarcerated and strangulated her-nias in children, Arch Surg 1970; 101: 136-9.
Risk of testicular lesions follow-ing incarcerated inguinal hernia in infants
- G Fasching
- Hollsworth
- Me
Fasching G, Hollsworth ME. Risk of testicular lesions follow-ing incarcerated inguinal hernia in infants. Pediatr Surg Int 1989; 4: 265-8.
Groin hernias and hydroceles. In: Textbook of pediatric surgery. Philadelphia: WB Saunders
- Holder Tm
- Ashcraft
Holder TM, Ashcraft KW. Groin hernias and hydroceles. In: Textbook of pediatric surgery. Philadelphia: WB Saunders, 1980: 594-608.
Life-threatening apnea in infants recovering from anesthesia.
- Liv LMP
- Cote CJ
- Goudsouziah NG
Liv LMP, Cote CJ, Goudsouziah NG, et al. Life-threatening apnea in infants recovering from anesthesia. Anesthesiology 1983; 59: 506-10.
Life-threatening apnea in infants recovering from anesthesia
- Liv