Pediatric Hydrocele and Hernia Surgery Treatment & Management

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.

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 become incarcerated 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 hydroceles in newborns 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 - A study by Kurobe et al found that one third of patients older than 2 years with asymptomatic hydrocele experienced spontaneous resolution ^[5] ; the authors accordingly recommended an initial period of conservative management before surgery in children with asymptomatic hydrocele, evan after the age of 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

Operative details

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. ^{[6, 7]} 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 has not been performed as commonly in children as 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 has not been used as commonly in children as in adults. Initial results were favorable, though recurrence rates were 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. ^[8] The authors reported no complications and no recurrences; however, the details and length of follow-up were not clearly defined. ^[8]

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. ^[9]

In a systematic review of 15 published studies (N = 2920) of laparoscopic pediatric hydrocele repair, Jin et al found that this procedure appeared to be safe and effective. ^[6] Most of the studies used an extraperitoneal approach; only a few used an intraperitoneal approach. The hydrocele sac was left alone in 10 of the studies and was resected or transected in only five. Nonabsorbable sutures were more often used to ligate the hydrocele sac than absorbable materials were. Operative complications were infrequent and were not significantly influenced by hydrocele subtype, surgical approach, suture material, or management of the hydrocele sac.

A systematic review and meta-analysis of laparoscopic and open inguinal repair in children by Kantor et al found no difference between the two approaches with respect to recurrence rate, surgical time, and length of hospitalization; however, laparoscopic repair was associated with a higher risk of wound infection and a lower risk of ascending testis. ^[10]  The laparoscopic approach also afforded the surgeon the chance to explore and repair the contralateral side if necessary.

A retrospective single-center study (N = 2018) by Duan et al found lparoscopic percutaneous extraperitoneal closure with peritoneum reinforcement (LPECPR) to be a safe and effective approach for pediatric inguinal hernia and to have a low recurrence rate (0.15%). ^[11]

Single-port laparoscopic approaches have been developed that appear to be both effective and safe. ^{[12, 13, 14, 15, 16, 17, 18, 19, 20]}

The percutaneous internal ring suturing (PIRS) technique appears to be safe and effective for laparoscopic repair of pediatric inguinal hernia. ^{[21, 22]} It may be especially useful in girls, who lack a spermatic cord and other structures that may lead to complications with this approach in boys. ^[23]

The overall operative complication rate associated with hydroceles and hernias is 1.7-8%.

Infertility may result from bilateral injury to the vas deferens or injury to the vas of a solitary testis. Presence of a vaslike structure in the pathology specimen does not necessarily indicate injury to the vas: As many as 6% of specimens contain müllerian ductal remnants with a histologic appearance very similar to that of the vas.

An incarcerated hernia may compromise blood flow to the testicle before surgery. The rate of testicular atrophy after repair of an incarcerated hernia can be as high as 19%. Testicular atrophy may also result from intraoperative injury to the testicular blood supply.

As with any surgical procedure, hematomas may occur. A hematoma usually need not be explored unless the hematoma continues to enlarge or becomes infected. Scrotal elevation is encouraged, and analgesics are administered.

Wound infections can occur.

Hypesthesia and neuropathic pain can result from nerve entrapment or injury.

Secondary cryptorchidism may result from excessive scar formation and ascent of the testicle with growth.

Cord hydrocele may occur after laparoscopic intracorporeal inrepair of inguinal hernia in male pediatric patients; removal of the hernia sac may reduce the risk of this complication. ^[24]

Recurrence of the hydrocele may be seen in fewer than 5% of cases. If the hydrocele does not disappear spontaneously after 1 year, reoperation is indicated.

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, patients may return to school as soon as their comfort level allows (usually 1-3 days postoperatively).