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Pediatric Hernias

  • Author: Andre Hebra, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Sep 09, 2015
 

Background

Approximately 400 years ago, a French surgeon named Ambroise Pare described the reduction of an incarcerated pediatric hernia and the application of trusses. He recognized that inguinal hernias in children were probably congenital in nature and that they could be cured. Unfortunately, despite the many historical descriptions of conservative medical management of inguinal hernias, no effective nonsurgical means of treating this condition is recognized. All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as inguinal hernia incarceration or strangulation.

Today, inguinal hernia repair is one of the most common pediatric operations performed. Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Most hernias that are present at birth or in childhood are indirect inguinal hernias. Other less common types of ventral hernias include umbilical, epigastric, and incisional hernias.

In this article, the embryology, clinical presentation, and management of inguinal hernias are discussed in relation to the pediatric population. Because inguinal hernias are common, every clinician must be well versed in the subject and able to provide optimal care to patients and their families, especially because hernias can be organ-threatening or life-threatening if not expeditiously managed. Examples of hernias are shown in the images below.

Typical appearance of an infant with a large right Typical appearance of an infant with a large right indirect inguinal hernia. The right scrotal sac is enlarged and contains palpable loops of bowel and fluid.
A premature baby boy with bilateral giant inguinos A premature baby boy with bilateral giant inguinoscrotal hernias. Because of the large size of the hernias, operative repair typically requires repair of the inguinal floor in addition to the high ligation of the indirect hernia sac.
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Pathophysiology

The processus vaginalis is an outpouching of peritoneum attached to the testicle that trails behind as it descends retroperitoneally into the scrotum. When obliteration of the processus vaginalis fails to occur, inguinal hernia results.[1] A review of embryonic development of the inguinal region is important to understanding the pathophysiology and surgical management of inguinal hernias.

Although the sex of the embryo is determined at fertilization, the gonads do not begin to differentiate until 7 weeks' gestation. Primordial germ cells migrate along the dorsal mesentery of the gut. They arrive at the primitive gonads early in the fifth week of development and, during the sixth week, invade the genital ridges, which lie on the medial aspect of the mesonephros. The coelomic epithelium proliferates, and the underlying mesenchyme condenses, forming the primitive sex cords.

Under the influence of the Y chromosome, the cords in the male embryo proliferate to form the testes. Near the end of the second month, the testis and mesonephros are attached by the urogenital mesentery to the posterior abdominal wall. As the mesonephros degenerates, only the testis remains suspended. At its caudal end, the attachment is ligamentous and is known as the caudal genital ligament. The gubernaculum, a mesenchymal structure rich in extracellular matrices, also extends from the caudal pole of the testis. This structure attaches in the inguinal region between the differentiating internal and external oblique muscles prior to descent of the testes. As the testes begin to descend at about 28 weeks' gestation, an outgrowth of gubernaculum from the inguinal region grows toward the scrotal area, and as the testis passes through the inguinal canal, this portion of the gubernaculum comes in contact with the scrotal floor.

During this time, the peritoneum of the coelomic cavity is forming an evagination on each side of the midline into the ventral abdominal wall. This evagination, known as the processus vaginalis, follows the path of the gubernaculum testis into the scrotal swellings and forms, along with the muscle and fascia, the inguinal canal. The descent of the testes through the inguinal canal is thought to be regulated by both androgenic hormones produced by the fetal testis and mechanical factors resulting from increased abdominal pressure.

As each testis descends, the layers of the abdominal wall contribute to the layers of the spermatic cord. The internal spermatic fascia is a reflection of the transversalis fascia, the internal oblique muscle helps form the cremaster muscle, and the external spermatic fascia results from the external oblique aponeurosis. In addition, a reflected fold of the processus vaginalis covers each testis and becomes known as the visceral and parietal layers of the tunica vaginalis.

In the female embryo, the ovaries descend into the pelvis but do not leave the abdominal cavity. The upper portion of the gubernaculum becomes the ovarian ligament, and the lower portion becomes the round ligament, which travels through the inguinal ring into the labium majus. If the processus vaginalis remains patent, it extends into the labium majus and is known as the canal of Nuck.

Before birth, the layers of the processus vaginalis normally fuse, closing off the entrance into the inguinal canal from the abdominal cavity. In some individuals, the processus vaginalis remains patent through infancy, into childhood, and possibly even into adulthood. The precise cause of the obliteration of the processus vaginalis is unknown, but some studies indicate that calcitonin gene-related peptide (CGRP), released from the genitofemoral nerve, may have a role in the fusion.

When luminal obliteration fails to occur, a ready-made sac is present where abdominal contents may herniate. Even when the processus vaginalis is patent, the entrance may be adequately covered by the internal oblique and transverse abdominal muscles, preventing escape of abdominal contents for many years. Failure of fusion can result not only in an inguinal hernia, but also in a communicating or noncommunicating hydrocele.

In infants, the most common type of hydrocele is the communicating type. A communicating hydrocele results when the proximal portion of the processus vaginalis remains patent, allowing fluid from the abdominal cavity to freely enter the scrotal sac. When closure is present proximally but fluid remains trapped within the tunica distally, a noncommunicating hydrocele results.

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Epidemiology

Frequency

United States

Although the exact incidence of indirect inguinal hernia in infants and children is unknown, the reported incidence ranges from 1-5%. Sixty percent of hernias occur on the right side. Premature infants are at increased risk for inguinal hernia, with incidence rates of 2% in females and 7-30% in males. Approximately 5% of all males develop a hernia during their lifetime.

International

International incidence rates are similar to those in the United States.

Mortality/Morbidity

An incarcerated or strangulated inguinal hernia can result in severe complications and even death. An incarcerated or strangulated inguinal and/or femoral hernia may also result in significant sequela, depending on which visceral structure is involved in the hernia sac. Such sequela can range from life-threatening complications to gonadal dysfunction, including intestinal necrosis and perforation, intestinal obstruction, intestinal stricture, testicular necrosis, testicular atrophy, ovarian necrosis, ovarian atrophy, and tubal stricture.

Race

Inguinal hernia appears to occur equally among races. Umbilical hernias, on the other hand, appear to be more common in blacks than in other races.

Sex

Inguinal hernias are much more common in males than in females. The male-to-female ratio is estimated to be 4-8:1.

Age

Premature infants are at an increased risk for inguinal hernia, with the incidence ranging from 7-30%. Moreover, the associated risk of incarceration is more than 60% in this population. Most pediatric ventral and inguinal hernias are detected in the first year of life. Occasionally, hernias may remain asymptomatic and unnoticed by the parents until later in life. Finding an adult patient with an indirect inguinal hernia that has been present since birth is not unusual.

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Contributor Information and Disclosures
Author

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, Florida Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, Children's Oncology Group, International Pediatric Endosurgery Group, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

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.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Jeffrey J Du Bois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J Du Bois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, California Medical Association

Disclosure: Nothing to disclose.

References
  1. Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb. 88(1):27-43, vii-viii. [Medline].

  2. Kaneda H, Furuya T, Sugito K, Goto S, Kawashima H, Inoue M, et al. Preoperative ultrasonographic evaluation of the contralateral patent processus vaginalis at the level of the internal inguinal ring is useful for predicting contralateral inguinal hernias in children: a prospective analysis. Hernia. 2014 Nov 4. [Medline].

  3. Skinner MA, Grosfeld JL. Inguinal and umbilical hernia repair in infants and children. Surg Clin North Am. 1993 Jun. 73(3):439-49. [Medline].

  4. Deeba S, Purkayastha S, Paraskevas P, et al. Laparoscopic approach to incarcerated and strangulated inguinal hernias. JSLS. 2009 Jul-Sep. 13(3):327-31. [Medline].

  5. Lukong CS. Surgical techniques of laparoscopic inguinal hernia repair in childhood: a critical appraisal. J Surg Tech Case Rep. 2012 Jan. 4(1):1-5. [Medline]. [Full Text].

  6. Esposito C, St Peter SD, Escolino M, Juang D, Settimi A, Holcomb GW 3rd. Laparoscopic versus open inguinal hernia repair in pediatric patients: a systematic review. J Laparoendosc Adv Surg Tech A. 2014 Nov. 24(11):811-8. [Medline].

  7. Lao OB, Fitzgibbons RJ Jr, Cusick RA. Pediatric inguinal hernias, hydroceles, and undescended testicles. Surg Clin North Am. 2012 Jun. 92(3):487-504, vii. [Medline].

  8. [Guideline] Al-Ansari K, Sulowski C, Ratnapalan S. Analgesia and sedation practices for incarcerated inguinal hernias in children. Clin Pediatr (Phila). 2008 Oct. 47(8):766-9. [Medline].

  9. Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopic evaluation of the pediatric inguinal hernia--a meta-analysis. J Pediatr Surg. 1998 Jun. 33(6):874-9. [Medline].

  10. Dutta S, Albanese C. Transcutaneous laparoscopic hernia repair in children: a prospective review of 275 hernia repairs with minimum 2-year follow-up. Surg Endosc. 2009 Jan. 23(1):103-7. [Medline].

  11. McClain L, Streck C, Lesher A, Cina R, Hebra A. Laparoscopic needle-assisted inguinal hernia repair in 495 children. Surg Endosc. 2015 Apr. 29 (4):781-6. [Medline].

  12. Timberlake MD, Herbst KW, Rasmussen S, Corbett ST. Laparoscopic percutaneous inguinal hernia repair in children: Review of technique and comparison with open surgery. J Pediatr Urol. 2015 May 13. [Medline].

  13. Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia following unilateral repair in a pediatric hospital. J Pediatr Surg. 1989 Oct. 24(10):963-5. [Medline].

  14. Gonzalez Santacruz M. Low prevalence of complications of delayed herniotomy in the extremely premature infant. Acta Paediatr. 2004. 93:94-98. [Medline].

  15. Han BK. Uncommon causes of scrotal and inguinal swelling in children: sonographic appearance. J Clin Ultrasound. 1986 Jul-Aug. 14(6):421-7. [Medline].

  16. Matsuda T, Muguruma K, Horii Y, et al. Serum antisperm antibodies in men with vas deferens obstruction caused by childhood inguinal herniorrhaphy. Fertil Steril. 1993 May. 59(5):1095-7. [Medline].

  17. Myers JB, Lovell MA, Lee RS, et al. Torsion of an indirect hernia sac causing acute scrotum. J Pediatr Surg. 2004 Jan. 39(1):122-3. [Medline].

  18. Othersen HB Jr. The pediatric inguinal hernia. Surg Clin North Am. 1993 Aug. 73(4):853-9. [Medline].

  19. Rescorla FJ, West KW, Engum SA, et al. The "other side" of pediatric hernias: the role of laparoscopy. Am Surg. 1997 Aug. 63(8):690-3. [Medline].

  20. Scherer LR 3d, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. 1993 Dec. 40(6):1121-31. [Medline].

  21. Stoppa R. About biomaterials and how they work in groin hernia repairs. Hernia: The Journal of Hernias and Abdominal Wall Surgery. 2003. 7:57-60. [Medline].

  22. Tesselaar CD, Postema RR, van Dooren MF, et al. Congenital diaphragmatic hernia and situs inversus totalis. Pediatrics. 2004 Mar. 113(3 Pt 1):e256-8. [Medline].

 
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Typical appearance of an infant with a large right indirect inguinal hernia. The right scrotal sac is enlarged and contains palpable loops of bowel and fluid.
A premature baby boy with bilateral giant inguinoscrotal hernias. Because of the large size of the hernias, operative repair typically requires repair of the inguinal floor in addition to the high ligation of the indirect hernia sac.
Illustration of the technique for intraoperative diagnostic laparoscopy to evaluate for the presence of an asymptomatic contralateral inguinal hernia at the time of elective repair of an indirect inguinal hernia.
Laparoscopic view of a left indirect inguinal hernia at the time of surgery for laparoscopic needle-assisted repair.
Laparoscopic needle-assisted repair of a left indirect inguinal hernia. Note the passage of a Prolene suture through a small 22G spinal needle; this is used for creation of the purse-string suture that closes the open inguinal ring.
Laparoscopic view of the repaired left indirect inguinal hernia with the closed Prolene purse-string suture around the internal inguinal ring.
 
 
 
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