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Pediatric Hydrocele and Hernia Surgery Treatment & Management

  • Author: Joseph Ortenberg, MD; Chief Editor: Marc Cendron, MD  more...
 
Updated: Oct 27, 2014
 

Medical Care

No medical therapy is effective for a hernia or a communicating hydrocele. Aspiration and injection of sclerosing agents have been recommended for noncommunicating hydroceles in adults, but this therapy is relatively contraindicated in children. Because most hernias and hydroceles in children are associated with a patent processus vaginalis (PPV), sclerosing agents may damage intra-abdominal contents and are not likely to correct the underlying pathology.

Anti-inflammatory agents may be used in the setting of a reactive hydrocele. Antibiotic therapy is often prescribed for infectious epididymo-orchitis with a reactive hydrocele.

A study by Esposito et al found that hydroceles can develop in as many as 12% of children undergoing surgery for varicocele (varicocelectomy) and that the incidence varies with the type of procedure performed.[1] Preservation of the lymphatic vessels at the time of surgery reduces the risk of later hydrocele. Conservative management (observation or aspiration) results in resolution of 80% of these hydroceles. Surgical correction was required in only one third of these hydroceles that occurred after varicocelectomy.

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Surgical Care

Although hernias and hydroceles are similar, their natural histories differ. Spontaneous closure does not occur in frank hernias, and the risk of incarceration is significant. In particular, the risk of incarceration is high in premature children. As many as 60% of hernias in premature infants incarcerate within the first 6 months after birth; thus, hernias should be corrected as soon as possible in these babies. For these reasons, surgical repair is generally accepted as the appropriate treatment for an inguinal hernia in children and adults.[2, 3, 4]

Unlike hernias in infants, many newborn hydroceles resolve because of spontaneous closure of the PPV early after birth. The residual noncommunicating hydrocele does not wax and wane in volume, and no silk glove sign is present. The fluid in the hydrocele is usually reabsorbed before the infant reaches age 1 year. Because of these facts, observation is often appropriate for hydroceles in infants.

The following are indications for hydrocele repair:

  • Failure to resolve by age 2 years
  • Continued discomfort
  • Enlargement or waxing and waning in volume
  • Unsightly appearance
  • Secondary infection (very rare)

A hernia or hydrocele may protrude intermittently. Not infrequently, a bulge in the child's groin is noted by the parents or a primary care physician. Often, this bulge cannot be reproduced during a consultation, but thickening of the spermatic cord structures on the same side with a history of a bulge or a "silk glove" sign is suggestive of a PPV. Such a situation is a sufficient indication for inguinal exploration. A photograph of the area when the bulge is present may help clarify the diagnosis.

The following specific considerations apply to the timing of surgery:

  • If an incarcerated hernia cannot be reduced or signs suggest that the hernia is strangulated, schedule surgery on an emergency basis
  • In full-term infants with no history of incarceration, schedule surgery as soon as possible on an outpatient basis
  • For preterm neonatal intensive care unit (NICU) infants weighing 1800-2000 g, schedule surgery before hospital discharge
  • For formerly premature infants younger than 60 weeks’ postconceptual age, schedule surgery as soon as possible with 24-hour postoperative monitoring for apnea and other anesthesia-related complications

Procedure

Examine the child to confirm the presence of testes. Make a small inguinal incision.

Enter the inguinal canal and dissect the processus vaginalis (PV), which is the hernia sac or hydrocele sac, free of the vas deferens and vessels. Optical magnification is beneficial, especially in premature infants and small children.

If the sac contents (ie, abdominal organs, fluid) appear normal, reduce them into the abdomen. If the contents of the sac appear compromised or cannot be reduced, open the sac and enlarge the inguinal ring. Ischemic bowel may show improvement in vascularity. Necrotic contents should be resected. Ligate the sac at or above the internal ring.

If the lesion involves the testicle, the testicle is delivered into the incision, and the distal end of the sac is excised or everted around the testes (Bottle operation). These procedures are advised to avoid the later development of a postoperative noncommunicating hydrocele.

Reposition the testis in the scrotum. If the testis does not remain in the bottom of the scrotum, cryptorchidism may be present and orchiopexy should be performed at that time.

Inspect the internal ring to ensure that any abdominal contents are reduced completely. Reinforce the internal ring if it was opened or if it appears larger than normal caliber.

Local anesthesia may be injected subcutaneously, or an inguinal nerve block may be performed. Sew the fascial layers and skin closed.

Contralateral exploration with inguinal hernias is performed as indicated. When an inguinal hernia is present, some urologists and surgeons perform a contralateral groin exploration. This is intended to detect an occult PPV (5% of cases) that may lead to a hernia on the opposite side (metachronous contralateral hernia.)

The Goldstein test can be used to determine when to perform a contralateral exploration, but this may not be conclusive. In this test, the abdomen is insufflated with air or gas through the hernia sac, which is opened during surgery. Crepitus in the opposite groin is a positive test result, suggesting a contralateral PPV and warranting a contralateral exploration. Alternatively, a laparoscope can be used to detect an occult contralateral PPV.

Role of laparoscopy

Laparoscopy has an evolving role in hydrocele and hernia surgery. Exploratory laparoscopy may be carried out through a separate incision at the umbilicus or through the hernia sac, once it has been opened. This allows inspection of the contralateral inguinal ring and assessment of patency. Additional procedures may then be performed as needed.

Laparoscopic hernia repair is not performed as commonly in children as it is in adults. Several European centers have used a technique in which the hernia sac is not excised but rather simply closed at the neck with suture. Mesh is not used as commonly in children as it is in adults. Results to date are favorable, though recurrence rates are higher than with open repair.

A series by Kaya et al from Germany reported favorable results with the laparoscopic approach as compared with reduction and repair of incarcerated inguinal hernias in children.[5] The authors reported no complications and no recurrences; however, the details and length of follow-up were not clearly defined.[5]

A study by Saka et al from Japan comparing laparoscopic extraperitoneal closure with traditional open repair found that the laparoscopic technique was safe and effective for inguinal hernias and hydroceles in children, regardless of age, sex, or incarceration, and suggested that this approach could lower the incidence of metachronous contralateral hernias.[6]

Single-port laparoscopic approaches have been developed that appear to be both effective and safe.[7, 8]

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Activity

Convalescence after hernia or hydrocele surgery is usually straightforward.

For pain control, infants may be given ibuprofen 10 mg/kg every 6 hours or acetaminophen 15 mg/kg every 6 hours. Narcotics should be avoided in young babies because of the risk of apnea. Older children may be given acetaminophen with codeine (1 mg/kg of codeine) every 6 hours.

For 2 weeks after surgery, straddle positions (eg, bicycle) should be avoided to prevent displacement of the mobile testes out of the scrotum, which could become entrapped by fibrous tissue, causing secondary cryptorchidism.

In children of ambulatory age, vigorous activities should be limited as much as possible for 1 month. In children of school age, strenuous activities and active sports should be limited for 4-6 weeks. Because most surgical procedures for pediatric hernia and hydrocele are performed on an outpatient basis, the patient may return to school as soon as his or her comfort level allows (usually 1-3 days postoperatively).

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Contributor Information and Disclosures
Author

Joseph Ortenberg, MD Clinical Professor of Urology and Pediatrics, Louisiana State University School of Medicine, New Orleans; Director of Urologic Education, Children's Hospital, New Orleans;

Joseph Ortenberg, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Plastic Surgeons, American Urological Association, Society of University Urologists

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher C Roth, MD Associate Professor of Urology, Children’s Hospital of New Orleans, Louisiana State University School of Medicine in New Orleans

Christopher C Roth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association, Society for Pediatric Urology, Society for Fetal Urology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Harry P Koo, MD Chairman of Urology Division, Director of Pediatric Urology, Professor of Surgery, Virginia Commonwealth University School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond

Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston

Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, New Hampshire Medical Society, Society for Pediatric Urology, Society for Fetal Urology, Johns Hopkins Medical and Surgical Association, European Society for Paediatric Urology

Disclosure: Nothing to disclose.

Additional Contributors

Howard M Snyder, III, MD Professor, Department of Surgery, Division of Pediatric Urology, University of Pennsylvania School of Medicine and Children's Hospital of Philadelphia

Howard M Snyder, III, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, National Kidney Foundation

Disclosure: Nothing to disclose.

References
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  2. Zhou X, Song D, Miao Q, Shan W. Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children. J Pediatr Surg. 2011 Dec. 46(12):2417-20. [Medline].

  3. Naji H, Ingolfsson I, Isacson D, Svensson JF. Decision making in the management of hydroceles in infants and children. Eur J Pediatr. 2011 Nov 22. [Medline].

  4. Clarke S. Pediatric inguinal hernia and hydrocele: an evidence-based review in the era of minimal access surgery. J Laparoendosc Adv Surg Tech A. 2010 Apr. 20(3):305-9. [Medline].

  5. Kaya M, Huckstedt T, Schier F. Laparoscopic approach to incarcerated inguinal hernia in children. J Pediatr Surg. 2006 Mar. 41(3):567-9. [Medline].

  6. Saka R, Okuyama H, Sasaki T, Nose S, Yoneyama C. Safety and efficacy of laparoscopic percutaneous extraperitoneal closure for inguinal hernias and hydroceles in children: a comparison with traditional open repair. J Laparoendosc Adv Surg Tech A. 2014 Jan. 24(1):55-8. [Medline].

  7. Wang Z, Xu L, Chen Z, Yao C, Su Z. Modified single-port minilaparoscopic extraperitoneal repair for pediatric hydrocele: a single-center experience with 279 surgeries. World J Urol. 2014 Feb 13. [Medline].

  8. Liu W, Wu R, Du G. Single-port laparoscopic extraperitoneal repair of pediatric inguinal hernias and hydroceles by using modified Kirschner pin: a novel technique. Hernia. 2014 Jun. 18(3):345-9. [Medline].

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  10. Hata S, Takahashi Y, Nakamura T, et al. Preoperative sonographic evaluation is a useful method of detecting contralateral patent processus vaginalis in pediatric patients with unilateral inguinal hernia. J Pediatr Surg. 2004 Sep. 39(9):1396-9. [Medline].

  11. Hosgor M, Karaca I, Ozer E, et al. The role of smooth muscle cell differentiation in the mechanism of obliteration of processus vaginalis. J Pediatr Surg. 2004 Jul. 39(7):1018-23. [Medline].

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  14. Shirvani AR, Ortenberg J. Communicating hematocele in children following splenic rupture: diagnosis and management. Urology. 2000 Apr. 55(4):590. [Medline].

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  16. Weber T, Tracy T. Groin hernias and hydroceles. Pediatric Surgery. 2nd ed. WB Saunders Co; 1993. 562.

  17. Wiener ES, Touloukian RJ, Rodgers BM, et al. Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg. 1996 Aug. 31(8):1166-9. [Medline].

  18. Yerkes EB, Brock JW, Holcomb GW, Morgan WM 3rd. Laparoscopic evaluation for a contralateral patent processus vaginalis: part III. Urology. 1998 Mar. 51(3):480-3. [Medline].

 
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