Treatment
Medical Therapy
Trusses place pressure on the skin and bowel, induce related injury, and mask signs of incarceration and strangulation. The temporary use of binders or corsets can be useful in patients with large-necked hernias, during the preoperative period, or with a high risk of operation on a long-term basis.
Reduction
Sedation, analgesia, and Trendelenburg positioning may aid in the reduction of an incarcerated hernia. Ice cooling of an incarcerated hernia is counterproductive. Simple pressure over the distal sac usually is ineffective since the incarcerated viscera then mushroom over the external ring. Pressure directed medially at the external ring and maintained for several minutes, while simultaneously invaginating the distal sac, will often reduce a difficult incarcerated viscus. (See images below and Images 5-6.)
Hernia content balloons over the external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied first.
In children, pressure should be applied from the posterior and directed laterally and superiorly through the external ring. Of note, the internal ring in infants is more medial than in older children and adults. The hourglass configuration of a hernia/hydrocele complex will not reduce with pressure applied to the hydrocele portion.
Topical therapy
Cauterization with silver nitrate aids in the resolution of an umbilical granuloma. If there is a stalk, ligation of the base resolves the problem. Delaying the repair of umbilical or asymptomatic epigastric hernias until children are older than 5 years allows spontaneous closure in most children. Strapping, with or without a coin, is not indicated in the treatment of umbilical hernia because of problems with skin erosion and lack of effectiveness.
Grob introduced the use of Mercurochrome as an escharotic for scarifying the intact sac of a giant omphalocele. However, the development of mercury poisoning terminated its use. Chemical dressings using silver sulfadiazine (complication is leukopenia), povidone-iodine solution (complication is hypothyroidism), 0.5% silver nitrate solution (complication is argyrism), and gentian violet have served as agents to protect against infection while the sac epithelializes. In current practice, only life-threatening associated conditions, poor probability of survival in infants, or failure of better means of coverage warrant use of these methods. A large residual ventral hernia results, which may be problematic because of loss of domain.
Progressive compression dressing of an omphalocele sac with an inner layer of saline moistened dressings and an outer dressing of Coban can reduce viscera over 5-10 days, after which delayed primary fascial and skin closure is accomplished.
For children with an omphalocele and life-threatening associated conditions, a poor probability of survival, or a very large omphalocele, the combination of topical escharotic agents and daily abdominal wrapping with an ACE bandage has produced successful closure in many patients. As the child grows, the defect remains the same size and becomes smaller relative to the increasing abdominal wall. Delayed closure following epithelialization can allow primary fascial closure with no prosthesis, which eliminates the need for multiple operations. External coverage with pigskin, skinlike polymer membrane, or human amniotic membrane can be used adjunctively in the treatment of giant omphalocele or after failed primary therapy.
Surgical Therapy
Inguinal hernia
Treatment for adult inguinal hernia is described as follows:
After a diagnosis is established, the signs, symptoms, and risks of incarceration, as well as the timing, conduct, and risk of the repair procedure, should be explained to the patient or to the parents of the child. Most repairs proceed within several weeks and are dependent on multiple factors (eg, employment, insurance).
Massive hernias need prosthetic material to aid closure in most patients, and appropriate materials should be available in the operating room prior to incision. Progressive pneumoperitoneum, using increasing volumes of air over time, may allow accommodation to increased intra-abdominal pressure but probably does little to increase the size of the abdominal cavity.
Adults with very large chronic hernias should be admitted postoperatively because of the combination of ileus from extensive manipulation and the loss of domain with the attendant problems of increased pressure on the diaphragm, vena cava, kidneys, and hernia closure. The adult who presents with bilateral hernias without the need for formal reconstruction can have simultaneous repair, whereas more complex procedures should be metachronous by a month or more.
Local anesthesia is sufficient for most repairs in adults; however, prolonged procedures, repair of hernias with a large intraperitoneal component, including laparoscopy, and repair of recurrent hernias are best managed with spinal, epidural, or general anesthesia.
The use of routine preoperative antibiotics in low-risk adults undergoing a standard tension-free repair with mesh is not currently recommended, as multiple studies have shown no benefit in decreasing postoperative wound infection.
Pediatric surgeons repair soon after diagnosis, regardless of age or weight, in healthy full-term infant boys with asymptomatic reducible inguinal hernias.9 In full-term girls with a reducible ovary, most surgeons operate at a close elective date, but, if the ovary is not reducible but asymptomatic, more urgent timing of surgery is preferred. Premature infants with inguinal hernias are usually repaired prior to discharge from the neonatal intensive care unit (NICU), but this practice is changing, as infants are now being discharged home at much lower weights. Some surgeons prefer to postpone the surgery in these very small babies for 1-2 months to allow further growth. Apnea is common in postoperative infants. These young infants should have an apnea monitor during the postoperative period.
All children with bilateral presentation should undergo bilateral inguinal hernia repair under a single anesthesia. However, potential damage to the spermatic cord structures in boys argues against routine contralateral exploration. Controversy exists over the routine exploration of the opposite side in children with unilateral inguinal hernias.10 Previous practices of routinely exploring the opposite side in all boys younger than 2 years and all girls younger than 4-5 years are no longer popular.
Most surgeons do not routinely perform open exploration of the contralateral groin, except in cases of high anesthetic risk (eg, congenital heart disease, premature infants), risk for developing contralateral hernia secondary to increased intra-abdominal pressure (eg, peritoneal dialysis, ventriculoperitoneal shunt, ascites), or limited access of the child to appropriate medical care should an incarceration occur on the opposite side. Current practice in many pediatric centers uses peritoneoscopy through the ipsilateral inguinal sac to identify contralateral patent processes and hernias. Long-term follow-up is needed because only 20% of the patent processes identified become clinically apparent hernias in the short term.
A surgeon who is unfamiliar with the tissue characteristics and metabolic and psychological needs of children or who does not have a skilled pediatric anesthesiologist available should not attempt a hernia operation in a young child. Older children usually have general inhalation anesthesia, whereas some anesthesia providers use spinal or continuous caudal anesthesia with preterm infants. Preemptive regional anesthesia, by ilioinguinal and iliohypogastric nerve block or by caudal block, decreases postoperative discomfort. The routine use of perioperative antibiotics for uncomplicated inguinal hernia repairs in children is not generally indicated. Some cardiologists advise prophylactic antibiotic use to lower the risk of endocarditis in children with associated cardiac defects; patients with ventriculoperitoneal shunts may also benefit.
Postoperative apnea is common in premature infants.11 Premature infants younger than 50 weeks’ gestational age should be admitted for 24 hours postoperatively and placed on a cardiorespiratory monitor.
Patients undergoing a neurectomy have a significantly lower prevalence of neuralgia without increased paresthesia. Antibiotic prophylaxis is not indicated in low-risk adult patients undergoing open mesh inguinal repair.
Gastroschisis and omphaloceleThe morbidity and mortality associated with infants with omphalocele or gastroschisis over the past 35 years has greatly decreased because of better preoperative and postoperative care. Specifically, these improved outcomes are secondary to advances in neonatal ventilator care and the development and use of total parental nutrition during the period of transition to normal bowel function. Syndromic omphaloceles have had only modest increases in mortality secondary to the unchanged severity of their associated defects. The improvement in this population results from prenatal recognition, earlier prenatal transport to pediatric surgical referral centers, and enhanced perioperative care.
Perioperative treatment is described as follows:
The greatest loss of contractility and mucosal function of the bowel and the fibrous coating of the bowel in gastroschisis occurs late in gestation. Delivery of infants with prenatally diagnosed abdominal wall defects can be via vaginal or cesarean delivery, as there is no clear advantage of one method over the other. Preterm induction after ensuring lung maturity may be advantageous in cases of gastroschisis in which serial imaging of the bowel reveals increasing dilation suggestive of a restrictive defect. Elective preterm cesarean section is no longer recommended for infants with large omphaloceles, to avoid damage to the sac from labor and delivery.
Placing the infant up to the axillae in a sterile plastic bag maintains sterility, prevents evaporative water loss, and decreases heat loss. Infants with gastroschisis can be placed on their right side until silo placement is complete to prevent vascular compromise by twisting or kinking of the fascial edge. Although the recommendations in the literature vary, the trend is toward universal silo placement and gradual reduction. Broad-spectrum antibiotics should be given, most commonly ampicillin and gentamicin.
The inflamed peritoneal and intestinal capillary membranes stabilize in 12-18 hours after surgery, and the fluid requirements then markedly decrease. When the capillary membrane stabilizes, exogenous albumin may be administered to elevate serum levels to 2.5-3 g/dL. The testes may be extracorporeal and should be placed near the processus vaginalis, because testicular proximity is a critical factor in the formation of the gubernaculum.
Preoperative Details
A full preoperative assessment and adequate fluid resuscitation precede early operation. The fluid requirements for an infant with gastroschisis are 2-8 times the usual requirements for the first 24 hours of life because of the visceral inflammation. Maintenance of urinary output of 1-2 cm3/kg/h by closely monitored administration of crystalloids keeps the infant properly hydrated. A sump type nasogastric tube should be passed through the mouth and into the stomach and placed on suction to negate the effects of the ileus.
Intraoperative Details
Surgical options depend on type and location of hernia.
Basic repair techniques
The fundamentals of indirect inguinal hernia repair are basically the same regardless of the age at presentation. Reduction or excision of the sac and closure of the defect with minimal tension are the essential steps in any hernia repair. If tissue is sufficiently attenuated as to preclude following these precepts, many techniques involving the release of tension by flaps, prosthetic materials, or a simple relaxing incision in adjacent tissue will fulfill the requirements. Overlay, underlay, and sandwiching of the edges with plastic meshes constitute most techniques today. Return to work is dictated by the approach and the amount of physical activity involved with the job. Accurate postoperative instruction and easy access to care (if problems arise) are as effective as a full postoperative visit following routine inguinal hernia repairs.
The Bassini repair
The essence of the Bassini repair is apposition of the transversus abdominis, transversalis fascia, and lateral rectus sheath to the inguinal ligament. This is usually performed by imbrication. The Shouldice technique uses 2 layers of running suture in a similar fashion. (See image below and Image 14.)
Bassini-type repair approximating transversus abdominis aponeurosis and transversalis fascia to iliopubic tract and inguinal ligament.
The Cooper repair
The greatest proponent of the Cooper repair is McVay. This repair approximates the conjoint area, transversus abdominis, and transversalis fascia to the pectineal ligament. Overlying the vein, these structures are sewn to the iliopubic tract. It also provides a good approach for the repair of femoral hernias.
The standard adult hernia repair now uses prostheses to reinforce the floor, usually polypropylene mesh. The material can overlay, underlay, or sandwich the area or be used as a plug. This provides a tension-free repair and excellent results, but it carries a slightly increased risk of wound infection.
The preperitoneal approach has advocates who claim ease in identifying the sac, reducing the contents, and dissecting the cord structures. Mechanical advantages include the use of natural intra-abdominal pressure to keep the mesh in place over all potential hernia sites. The best uses are in the incidental repair of a hernia during other abdominal procedures, recurrent hernias, and femoral hernias. A Pfannenstiel, lower midline, or other incision is used to reach the preperitoneal plane. The internal inguinal ring and the hernia sac are identified lateral to the inferior epigastric vessels. After dissecting the sac from the testicular vessels and vas deferens, it is divided and the peritoneum is closed. The repair follows the pectineal approach and often has mesh applied.
The laparoscopic approach is being increasingly used for both primary hernias and recurrent hernias. The endoscopic totally extraperitoneal approach (TEP) is usually favored over the transabdominal preperitoneal operation (TAPP) because of the complications that arise from exposed intraperitoneal mesh in the TAPP repair. Postoperative pain, time to full recovery, and return to work are improved with the laparoscopic approach, but it is more expensive. Short-term recurrence data are similar, but there has been insufficient length of follow-up to completely compare it to the more conventional approaches.
Pediatric hernias
A simple inguinal hernia repair is possible in children because of the smaller size, better muscle tone in the canal, and rapid recuperation. Excision of the hernial sac (processus vaginalis) is usually sufficient, with little need for prosthetic repair of an attenuated internal ring or posterior wall of the inguinal canal. Preincisional injection of the incision or a caudal block are preferable to no preincisional therapy.12
A small incision is performed just superior and lateral to the pubic tubercle in the suprapubic skin crease. This centers the operative field near the internal ring. The aponeurosis of the external oblique muscle is incised in the direction of its fibers, or the internal ring and the external ring are transposed by laterally retracting the external ring. Tugging on the testis can help visualize the cord structures. The glistening white hernia sac frequently bulges up amidst the cord. The sac, which is located anteromedially with respect to the cord, is elevated from the floor and carefully dissected free from the vas deferens and testicular vessels.
Short hernia sacs are freed to the internal ring, but hemisecting a long sac can be helpful. Proximal dissection to the internal ring should extend until preperitoneal fat is visible circumferentially. Twisting the sac prior to ligation provides strength and narrows the internal ring. The sac is ligated at its base. Because of occasional postoperative “spitting” of a nonabsorbable suture, such as silk, synthetic sutures are used for sac ligation. If fascial repair seems necessary, the transversalis fascia is sutured to the shelving margin of the ilioinguinal ligament. The incision is closed in layers, and a single adhesive strip is placed. The testis must be pulled into the scrotum to prevent iatrogenic cryptorchidism. (See image below and Image 9.)
An iatrogenic cryptorchid testis in a child. Taking care to position the testis in the scrotum is an integral part of completion of hernia repair in a boy.
Approximately 2% of girls with inguinal hernias have an intersex differentiation syndrome. Each girl should have the fallopian tubes and ovaries examined directly or by peritoneoscopy. The hernia sac of a female patient must be scrupulously examined for signs of testicular tissue if it contains an ovary. The most common cause is testicular feminization (androgen insensitivity) syndrome, which is a result of end-androgen resistance and leads to a small testis and a rudimentary vagina (persistent genitourinary sinus) without fallopian tubes or a uterus. If a girl with a hernia has testicular feminization, a gonadectomy on one side and isolation of the other gonad in a superficial position until puberty permits secondary sexual characteristics to develop. Hermaphrodites have an asymmetric ovotestis, which should not be removed.
Postoperatively, the patient is discharged when fully awake and drinking. One should provide analgesics for the subsequent few days. Bathing is not allowed for 1-2 days after the operation, and the adhesive strips are not replaced if they come off. Older children can return to school after 3 days; physical education and recess activities are interdicted for 2-3 weeks.
An incarcerated object within an inguinal hernia in a girl, especially in an infant, is usually an ovary. An incarcerated ovary is not usually reducible, but strangulation is infrequent making surgical reduction of the irreducible ovary less urgent than reduction of an incarcerated intestine. A child with an incarcerated hernia containing the intestine that successfully is reduced should be admitted for a day to allow resolution of edema prior to repair.
A child with tachycardia, fever, or signs of obstruction must have immediate operation. Fluid and electrolyte correction and antibiotic administration precede the operation. Testicular atrophy occurs with incarcerated pediatric hernias, and the parents should be warned of the possibility.
Exposure and opening of the sac prior to dividing the external ring permits the contained intestine to be controlled with a clamp, prohibiting unintentional release of the bowel into the abdomen. Once viability of the incarcerated intestine is ensured, dividing the external ring and sometimes the internal oblique muscles laterally will reduce it.
Laparoscopy through the hernia sac can be used to assess visceral viability if incarcerated intestinal contents reduce before visualization. The gangrenous bowel is resected, an end-to-end anastomosis is performed, and the intestine is returned to the abdomen. Repair of a contralateral side is deferred. An apparently infarcted testis is left in place after performing a capsulotomy.
Sliding hernias
In about 40% of girls with an inguinal hernia, the fallopian tube or occasionally the ovary or uterus is a sliding component of the hernia that does not easily reduce into the abdominal cavity. The sac wall may seem too thick in the medial or lateral quadrants, or the contained viscus (particularly the fallopian tube and ovary) may not reduce into the peritoneum. The walls must then be inspected for a sliding component. The hernia sac is ligated distal to the fallopian tube and divided. The proximal sac is ligated and then invaginated into the peritoneal cavity. A purse-string suture inside the opened hernia sac may be used to aid in visualization during sac closure. The internal ring is closed with sutures from the transversalis fascia to the iliopubic tract.
Masses in the femoral canal
Atypical tuberculous adenitis is best treated with local excision. Repeated trauma may cause painful reactive inguinal or femoral lymph nodes. Excision of the involved node relieves the symptoms. The potential for malignancy in a persistent mass in the femoral canal despite antibiotic therapy warrants biopsy. Any enlarged lymph node that is excised should be divided, with one half sent fresh for lymphoma protocol and the other half sent to microbiology. A suspected femoral hernia, usually after a missed inguinal hernia repair, also warrants exploration. The best approach for both adenopathy and femoral hernia is a preperitoneal approach. Reduction of an incarcerated intestine is easy, and there is clear access to the lymph node. A pectineal ligament repair or laparoscopic mesh placement closes the opening into the femoral canal. Groin incisions usually heal better than thigh incisions, particularly with lymph channel disruption.
Umbilical hernias
Umbilical hernia repair is best performed under general anesthesia in children, whereas regional or local anesthesia can be used in adults. A semicircular incision in the infraumbilical skin crease exposes the umbilical sac. A plane that is created to encircle the sac at the level of the fascial ring expedites repair. The defect is closed primarily in a transverse direction with a single layer of interrupted sutures. If the defect is very large, mesh is occasionally required. Although excessively wrinkled skin can appear cosmetically troublesome, elasticity and growth usually corrects it since the skin incision is within the umbilical fold. In cases with severe redundant skin, removal of a circle of skin and peritoneum to access the hernia followed by a purse sting closure provides an excellent cosmetic result. A pressure dressing is applied for several days after repair.
Epigastric hernias
Immediately prior to operation, the defect should be marked with the patient in the standing position. After anesthetic induction, a small vertical incision directly overlying the defect is carried to the linea alba. Incarcerated preperitoneal fat may be either excised or returned to the properitoneum. The edges of the fascial defect are approximated transversely with interrupted sutures. Recurrence is rare, although a second epigastric hernia may develop elsewhere as another defect.
Spigelian hernias
Despite their rarity and difficulty in diagnosis, spigelian hernias have an easy approach. A transverse incision over the hernia to the sac allows dissection to the neck, and clean approximation of the internal oblique and transversus abdominis muscles completes the repair. Laparoscopic repair allows accurate delineation of the anatomy and helps establish the diagnosis in suspect instances.
Interparietal hernias
As most interparietal hernias have an associated undescended testis, the spermatic cord should be identified. In a young child, an orchiopexy is performed if the testis is not gangrenous. The older child or adult should have the testicle removed. In the usual presentation of bowel incarceration, a properitoneal indirect inguinal hernia repair is the best approach.
Supravesical hernias
Supravesical hernias are repaired with the standard techniques used for inguinal and femoral hernias, usually by way of a paramedian or midline incision. The internal supravesical hernia repair should include division and closure of the neck of the sac.
Lumbar hernias
A lumbar hernia is best approached with the patient in the lateral decubitus position and a lumbar roll or kidney rest. A skin line oblique incision extends from the 12th rib to the iliac crest. A layered closure or mesh onlay for large defects is successful.
Pelvic hernias
Obturator hernias
Obturator hernias are approached abdominally and can be repaired laparoscopically. If the hernia content is difficult to reduce, incision of the obturator membrane at the inferior margin will lessen damage to the obturator vessel or nerve. Mesh closure is necessary for a tension-free repair. The other side must be viewed to preclude problems with a contralateral hernia.
Sciatic hernias
A transperitoneal approach is used in the event of incarceration. Avoiding neurovascular injury during reduction and repair requires careful attention posteriorly and inferolaterally for the suprapiriformis hernia, superomedially for the infrapiriformis hernia, and medially for the subspinous hernia. The defect is closed with prosthetic material.
A transgluteal repair can be used if the diagnosis is established and the intestine is clearly viable. The patient is placed prone and the incision extends from the hernia toward the greater trochanter. The fibers of the gluteus maximus are spread to expose the piriformis muscle, the gluteal neurovascular bundle, and the sciatic nerve. A prosthetic patch closes the defect between the piriformis and the iliac or ischial bone.
Perineal hernias
A transabdominal approach with prosthetic closure is the preferred approach in the repair of perineal hernias.
Gastroschisis and omphaloceles
The major challenges in gastroschisis are reduction of the inflamed viscera into the abdomen and maintenance of effective nutrition. The 2 major problems in the management of omphaloceles are closure of the defect without undue tension, and treatment of associated anomalies, particularly cardiac defects and pulmonary hypoplasia. Associated anomalies must be stabilized swiftly prior to operation.
Primary closure of fascia and skin is the best approach for omphalocele and gastroschisis. However, increased intra-abdominal pressure from immediate reduction can produce compromised ventilation and abdominal compartment syndrome with inferior vena caval compression, intestinal and renal hypoperfusion, and lower extremity edema. Enlarging the abdominal cavity by stretching the abdominal wall, decompression of the stomach and irrigation of the intestine and colon to remove meconium, and postoperative use of ventilators and muscle relaxants frequently can aid in achieving successful primary closure. The sac is removed at the fascial edge. Umbilical artery and/or vein catheters can be transposed to an extraumbilical location for postoperative monitoring and fluid delivery. Vigorous attempts to decompress can cause intestinal tears and should be avoided.
Nonoperative management of gastroschisis, also known as plastic closure, is an alternative to conventional primary operative closure or staged silo closure. Although it is considered to be safe, nonoperative management is nonetheless associated with increased development of umbilical hernias.13
Intra-abdominal pressure measurements help to avoid an intra-abdominal compartment syndrome. Excessively high pressures mandate immediate conversion to a Silon chimney sutured to the skin or the fascial rim. (See image below and Image 7.) The gradual reduction of liver and intestine is an improvement over previous methods, and most pediatric surgeons use this technique. Fascial and skin closure occurs after complete reduction of contents into the abdomen, which usually occurs over 3-7 days. An alternative technique for omphaloceles is abdominal binding. With sequential pressure, the viscera can be reduced into the abdomen in a similar period, followed by delayed primary closure. During final abdominal closure, a prosthetic patch of GORE-TEX or biosynthetic mesh can bridge the gap between the rectus muscles. Tissue expanders can facilitate this stage.14 Orchiopexy can be performed for cryptorchid testes at the time of final closure.
Infant with a Silon chimney placed in the treatment of gastroschisis.
Intestinal atresia is common. Anastomosis at the closure operation is sometimes possible, depending on the bowel thickening. Repair after a 4- to 6-week period of bowel decompression and parenteral nutrition is preferable, but this is contraindicated in the face of a large proximal-distal discrepancy or necrotic intestine. The combination of stomas and prosthetic material can be avoided in almost all patients.
Syndrome omphaloceles
Beckwith-Wiedemann syndrome
The diagnosis of Beckwith-Wiedemann syndrome should be suspect in a large neonate with macroglossia. As these infants are at risk for severe hypoglycemia, close monitoring and early administration of glucose can prevent the serious sequela of hypoglycemia.
Pentalogy of Cantrell
Pentalogy of Cantrell is a malformation of the upper abdominal fold characterized by an anterior diaphragmatic and pericardial defect, a short bifid sternum, and cardiac defects associated with an epigastric omphalocele sac or hypotrophic epigastric skin. Temporary coverage of the omphalocele during evaluation of the cardiac defects will allow subsequent complete repair of cardiac, diaphragmatic, and pericardial defects.
Vesicointestinal fissure (cloacal extrophy)
Vesicointestinal fissure or cloacal extrophy is a malformation of the lower fold defined by an inferior-sited omphalocele, exstrophy of the cecum between the hemibladders, diastasis of the symphysis pubis, a short distal colon, no rectum, a shortened small bowel, and occasional meningosacral anomalies. These infants can survive following multiple corrective intestinal and urinary tract procedures.
Umbilical remnants
Mucosal biopsy provides diagnostic confirmation of the clinical suspicion. A patent omphalomesenteric duct requires prompt excision to prevent intussusception. Fifty percent of the children with external mucosal remnants will have an additional component within the abdomen. Urachal remnants should be excised locally at the umbilicus and followed caudally for a short distance toward the dome of the bladder, where it should be sutured, ligated, and divided.
Postoperative Details
Postoperatively, the patient is discharged when fully awake and drinking. Provide analgesics for the subsequent few days. Bathing is not allowed for 1-2 days after operation, and the adhesive strips are not replaced if they come off. Older children can return to school after 3 days; physical education and recess activities are interdicted for 2-3 weeks. Return to work is dictated by the approach and the amount of physical activity involved with the job.
Follow-up
Accurate postoperative instruction and easy access to care (if problems arise) are as effective as a full postoperative visit following routine inguinal hernia repairs.
Complications
Inguinal hernias
Hernia recurrence, infarcted testis or ovary with subsequent atrophy, wound infection, bladder injury, iatrogenic orchiectomy or vasectomy, and intestinal injury are complications of hernia repair. (See image below and Image 8.) Postoperative death is usually related to complications, such as strangulated bowel, or to preexisting risk factors.15 A postoperative hydrocele results from fluid accumulation in the distal sac. This usually resolves spontaneously but sometimes requires aspiration.
Atrophy of the right testis after hernia repair. Note the adult-type incision.
A femoral hernia as a sequela of inguinal hernia repair may have been primarily overlooked. Unilateral transection of the vas deferens can cause infertility through antibody production. Iatrogenic cryptorchidism can occur in children (1.3%) if the testicle is not placed in the scrotum at the end of the operation and requires orchiopexy for correction. Iliohypogastric and ilioinguinal neuralgia usually will regress within months. Nerve blocks or neurectomy can be used in refractory cases.
Most recurrences happen within 5 years of operation and are often associated with incarcerated hernias, concurrent orchidopexy, sliding hernias in girls, and emergency operations. The recurrence rate is higher in children younger than 1 year and in the elderly. Recurrence is more common in patients with ongoing increased intra-abdominal pressure, growth failure and malnutrition, prematurity, seizure disorder, and chronic respiratory problems. Technical factors increasing recurrence include an unrecognized tear in the sac, failure to repair a large internal inguinal ring, damage to the floor of the inguinal canal, and infection or other postoperative complications. A direct hernia sometimes results from vigorous dissection or may have been a simultaneous hernia unrecognized initially.
Other hernias
Recurrence, bleeding, infection, and persisting pain are potential complications for the other abdominal wall hernias. Incisional hernias may have a 30% rate of recurrence. The addition of mesh to most abdominal wall hernia repairs is decreasing the incidence of recurrence.
Gastroschisis and omphaloceles
Complications arising from the prolonged time required to reduce the contents into the abdomen include infection, dislodgment of the prosthesis, prolonged mechanical ventilation, intestinal obstruction, and Budd-Chiari syndrome (due to kinking of the suprahepatic inferior vena cava).
Intestinal atresias occur in about 20% of infants with gastroschisis. Massive atresias present infrequently with their attendant sequela of short gut syndrome. Maximal bowel preservation by “second look” operations 24-48 hours after the initial management may be warranted. Infants with gastroschisis are at risk for necrotizing enterocolitis following initiation of feeding. This is managed by bowel rest and broad-spectrum antibiotics; surgery is seldom necessary. An increased incidence of gastroesophageal reflux following closure of gastroschisis and omphalocele often requires antireflux medication. Severe reflux and hiatal hernias require operative correction. Adhesive small bowel obstruction is a frequent occurrence in the first year following treatment of congenital abdominal wall defects, with prior sepsis and fascial dehiscence as predictive factors.16
Long-term follow-up shows function equal to age-related groups.
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Further Reading
Related eMedicine topics:
Gastroschisis
Hernia Inguinal Repair, Laparoscopic
Hernia Inguinal Repair, Open
Hernia Reduction
Hernias
Hydrocele and Hernia in Children
Omphalocele
Omphalocele and Gastroschisis
Pediatric Hernias
Clinical guidelines:
Hernia. Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 Mar 10). 43 pages. NGC:006559
Laparoscopic surgery for inguinal hernia repair. National Institute for Health and Clinical Excellence (NICE) - National Government Agency [Non-U.S.]. 2001 Jan (revised 2004 Sep). 33 pages. NGC:004522
Clinical trials:
Inguinal Hernia Study Using Surgisis IHM
Strattice in Repair of Inguinal Hernias (RING)
Study of Hernia Repair Utilizing the Bard Ventrio Hernia Patch
Trial of Laparoscopic Compared to Open Inguinal Hernia Repair in Children Younger Than 2 Years
Watchful Waiting of Incisional Hernias
Keywords
abdominal hernia, inguinal hernia, hernia surgery, umbilical hernia, repair hernia, inguinal hernia repair, hernia operation, femoral hernia, gastroschisis, omphalocele, incarcerated hernia, epigastric hernia, abdominal wall hernias, hernias of the groin, indirect inguinal hernia, direct inguinal hernia, femoral hernia, prevascular femoral hernia, femoral lymphadenopathy, spigelian hernia, supravesical hernia, obturator hernia, sciatic hernia, perineal hernia, superior lumbar hernia, Grynfeltt hernia, inferior lumbar hernia, Petit hernia, Littre hernia, Richter hernia
exomphalos, umbilical rest, umbilical granuloma, urachus, omphalomesenteric duct, ventral hernia, incisional hernia, lumbar hernia, interparietal hernias, congenital hernia, hydrocele of the canal of Nuck, hydrocele of the cord, osteogenesis imperfecta, silk sign, hydrocele, chronic hernia, hernia of Laugier, hernia of Cloquet, umbilical granuloma, umbilical polyp
