What is a Hernia?
Hernia is the bulging of a visceral organ out of a weak point around it. The commonest hernia is inguinal hernia. In addition, umbilical hernia and abdominal midline hernias (epigastric) may also develop in children.
What is a Pediatric Inguinal Hernia?
Inguinal hernias seen in children are congenital. They have to be repaired through surgery as soon as possible. This is because the visceral organs such as intestines and omentum may enter inside the hernia sac, creating life-threatening risks. If this condition is not corrected through surgery, the intestines entering the hernia sac may be squeezed and punctured to lead to gangrene, and this may threaten life. Inguinal hernia can be observed as a subcutaneous swelling arising from the bulging of the peritoneum with pressure from the visceral organs out of a weak point of inguinal canal muscles. It is easy to diagnose. It may develop immediately after birth.
Why do pediatric inguinal hernias develop?
Testicles start to develop in the low back region where the kidneys are located during the gestation. At the seventh gestational month, they start to descend to the inguinal region. Then, they push the peritoneum through the inguinal canal and started to descend to the scrotum. The peritoneum which is pushed by the testicles as they descend to the scrotum recovers after the placement of testicles in the scrotum. This recovery leaves behind a weak point which is vulnerable to hernia development. Afterwards, increased intra-abdominal pressure causes the peritoneum to bulge out of the weak point and the formation of the hernia sac starts. The organs like intestines and omentum may pass through this weak point to the inguinal region and then, to the scrotum. This is mainly attributable to the bulging of the peritoneum out of the weak point.
If the weak point is large enough for intestines and other visceral organs to pass through, then these organs bulge downward. This big weak area will not close on its own. In general, the incidence of inguinal hernia is between 1 and 5 per 100 births. 60 percent of them are on the right side. 30 percent of them are on the left side. 10 percent are on the both sides. Rarely, girls may suffer from inguinal hernia. In addition, pediatric inguinal hernia may be accompanied with undescended testicles. 30 percent of preterm infants may suffer from inguinal hernia.
What are the symptoms of pediatric inguinal hernia?
If painful swelling is observed in the inguinal region, this may indicate strangulation of intestines at the bulging section. In this case, the child is bad-tempered. He refuses to eat or drink and cries continuously. This swelling may be characterized with edema, pain and stiffness. If the intestines have bulged outside of the hernia region and got squeezed and strangled afterwards, the swelling on the skin stiffens and the pain gets worse. The child suffers from nausea, vomiting, and loss of appetite. The skin over the swelling develops edema, rash and color distortion. In girls, the ovaries and Fallopian tubes may enter into the hernia sac in addition to the intestines.
If visceral organs are strangled in the hernia region, but the overall condition of the patient is not very severe –that is, there is no nausea, vomiting and excessive tension on the abdomen– no immediate surgical operation is performed. The first thing to do is to send visceral organs back into the abdomen with hands. An operation must be conducted in 1-2 days after the organs are sent back. In medical parlance, the condition in which the intestines enter into the hernia sac and they cannot be pushed back is called incarceration.
If the overall condition of the patient is poor (vomiting, nausea, swelling in the abdomen and abnormal tension) in connection with the strangulation of visceral organs in the hernia sac, the patient is immediately taken to operation.
Diagnosis of Pediatric Inguinal Hernia
Inguinal hernia in newborn infants or children is characterized with a swelling in the inguinal region or scrotum. This swelling is visible to the naked eye. It can be easily diagnosed. This swelling may disappear when the child is lying as the intestines and omentum are pushed back into the abdomen. It may appear that there is no symptom. When the child moves or cries, the intra-abdominal pressure increases and the hernia becomes salient again. This swelling may be painful or painless. In case of doubt, ultrasonography may prove useful.
Sometimes, inguinal hernia may be wrongly diagnosed as hydrocele. For this reason, a method called transillumination may be employed on the swelling for correct diagnosis. Ultrasonography, too, is an important indicator.
Hernia and strangulation of intestines may be accompanied by torsion of testis, especially in newborn babies. Special attention should be paid to this possibility.
Diagnosis may be more complicated in babies as visceral organs may enter into and go out of the bulging section. If it is possible to communicate with the child, the child may be made to cough or strain to check whether any organ enter into the bulging region. On the other hand, it is impossible to communicate with babies. Therefore, pressure is applied to the abdomen with special movements and the bulging region is observed.
Which children are more prone to inguinal hernia?
Inguinal hernia is more common among preterm babies, the children with undescended testicles, the patients with hipospadias, bladder exstrophy and epispadias. The rate of strangulation of visceral organs is higher in right-side hernias than left-side ones. Likewise, hernia is accompanied with strangulation of intestines in the bulging section at a higher rate. 80 percent of cases of strangulation affect the infants aged below 1 year. Cases of strangulation are more prevalent in female infants. Self-healing is not possible in cases of inguinal hernia. To avoid the possibility of strangulation, surgery should be expedited. In case of hydrocele, no intervention should be made for at least 12 months as self-healing is a possibility. Likewise, no surgery is performed for umbilical hernia before the age of 5 for the possibility of self-healing.
Pediatric Inguinal Hernia Surgery
An incision of 1-2 cm is used to enter the inguinal canal. The hernia sac is located. It is tied from above so that the connection between the abdominal cavity and the scrotum is eliminated. Thus, intestines cannot enter the inguinal canal. If the weak point on the abdominal wall is large, the bottom of the inguinal canal is strengthened by weaving it after the hernia sac is tied. Inguinal hernia surgery is more critical for girls. This is because there may be ovaries or Fallopian tubes inside the hernia sac. These should be preserved. There are reports that when inguinal hernia occurs on one side, the possibility of inguinal hernia developing on the other side is 30 percent. Therefore, parents should be cautioned about future risks. If needed to eliminate this possibility, the other side is treated in the same operation.
In case of emergency procedures, surgery is complicated and challenging. The parents should be briefed about the risks of surgery. They should be particularly informed that if the intestines had become gangrenous, some portion of the intestines may be removed.