Pediatric Hernias Follow-up

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• Routine follow-up care after operative repair of an inguinal hernia typically requires only one office visit or telephone consultation if the parents have reported no problems or complications. Scrotal swelling and bruising after surgery are common and may last for 1-3 weeks. Such signs do not indicate any complications; they represent normal postoperative changes.

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• Most patients who undergo elective repair of an inguinal or umbilical hernia are discharged from the hospital shortly after surgery. Overnight observation is indicated only in small premature babies who are at risk for postoperative apnea. Such patients are usually admitted for 24-hour observation and monitoring in the hospital.

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• Most patients are treated with acetaminophen for 24-48 hours after surgery. Codeine is occasionally added for pain management in older children (>1 y).

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• Transfer to a facility with pediatric surgical expertise is indicated in premature babies with inguinal hernias or in the event of inguinal hernia incarceration and/or strangulation.

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• Few complications result from operative repair of an inguinal hernia. Possible consequences of hernia repair include decreased testicular size (≤ 20% of patients), testicular atrophy (1-2%), ^[16] vas injury (< 1%), and development of sperm-agglutinating antibodies. The risk of gonadal injury in females is low. Fortunately, in the hands of pediatric surgeons, such complications are quite rare.

• The incidence of wound infection is 1-2%.

• Hernia recurrence rates are around 1% when experienced pediatric surgeons perform the operation. Factors associated with recurrence of inguinal hernia include an unrecognized tear in the sac, failure to repair an enlarged inguinal ring, damage to the canal and inguinal floor, infection, history of incarceration, connective tissue disorder, and conditions producing increased intra-abdominal pressure (eg, chronic respiratory problems, constipation). The hernia recurrence rate with the laparoscopic technique has been reported to be higher if the surgeon is still in the "learning curve." However, in the hands of an experienced surgeon, the recurrence rate for the laparoscopic technique should be similar to the one reported for the open technique. 

  A study that included data from 9,993 pediatric patients who underwent inguinal hernia repair reported a recurrence rate of 1.4% with an incidence of recurrence 3.46 per 1000 person-years. The study also found that the majority of recurrence occurred within a year and children with multiple comorbidities had a greater risk of recurrence. ^[15]

• The vas deferens and ilioinguinal nerve occasionally may be injured and should be repaired with 7-0 or 8-0 Maxon sutures. This may be technically difficult because of the extremely small vas lumen not traversed by semen. One infertility expert advises marking the ends of the vas with permanent suture and performing vasovasotomy after puberty with a 2-layer closure. It is also important to remember that the finding of vas or epididymis on the surgical pathology report does not necessarily imply injury because embryonal müllerian remnants have been recognized in 1-6% of surgical specimens. Specific histologic features of the remnant include a smaller diameter and failure to show a prominent muscular wall with Masson trichrome staining.

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• Overall prognosis is excellent; most patients do extremely well after operative repair of their inguinal hernia. Mortality is extremely rare but, unfortunately, continues to be reported as a consequence of delayed recognition of an incarcerated and strangulated inguinal hernia.

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• Instruct parents and caretakers on the signs and symptoms of inguinal hernia incarceration. Delayed recognition of incarceration is likely to result in significant morbidity and mortality for the child.

• For excellent patient education resources, visit eMedicineHealth's Digestive Disorders Center. Also, see eMedicineHealth's patient education article Hernia.