Congenital Inguinal HerniaCongenital Inguinal Hernia Indirect Inguinal Hernia Indirect Inguinal Hernia

Continued patency of the Processus Continued patency of the Processus Vaginalis Vaginalis

Patent PV sac is potential Patent PV sac is potential hernia/hydrocoelehernia/hydrocoele

In hernia the sac is wider & contains an In hernia the sac is wider & contains an intraabdominal structureintraabdominal structure

In hydrocoele the sac is narrow & In hydrocoele the sac is narrow & contains only peritoneal fluidcontains only peritoneal fluid

Processus VaginalisProcessus Vaginalis . . . . . . PV develops during12th wk of gestation PV develops during12th wk of gestation

Out pouching of the peritoneal cavity through Out pouching of the peritoneal cavity through the internal ringthe internal ring

PV plays an integral role in the descent of testesPV plays an integral role in the descent of testes

PV obliterates spontaneously from the deep ring PV obliterates spontaneously from the deep ring to the testisto the testis

possible role of CGRP in fusion of PVpossible role of CGRP in fusion of PV

Distal portion persists as tunica vaginalisDistal portion persists as tunica vaginalis

At birth PV is patent in up to 80% At birth PV is patent in up to 80% infants.infants.

IncidenceIncidence 0.8 – 4 %0.8 – 4 %

Highest in 1st year of lifeHighest in 1st year of life

Incidence in premature infants 16 – Incidence in premature infants 16 – 25%25%

M:F is 6:1M:F is 6:1

Right 60%, Left 30%, Bilateral 10%Right 60%, Left 30%, Bilateral 10%

Factors contributing to Factors contributing to development of herniadevelopment of hernia

Undescended testisUndescended testis Increased peritoneal fluid :Increased peritoneal fluid : Ascites, VP shuntAscites, VP shunt

Increased abdominal pressure :Increased abdominal pressure : Severe ascites, Meconium peritonitis,Severe ascites, Meconium peritonitis,

post repair of Exomphalos / CDHpost repair of Exomphalos / CDH

Chronic respiratory disease :Chronic respiratory disease : Cystic fibrosisCystic fibrosis

Connective tissue disorders:Connective tissue disorders: Ehlers –Danlos, Marfans, MucopolysaccharidosisEhlers –Danlos, Marfans, Mucopolysaccharidosis

Clinical FeaturesClinical Features Bulge in inguinal area extending towards / Bulge in inguinal area extending towards /

into scrotum with crying / straining into scrotum with crying / straining

may be present at birth or appear latermay be present at birth or appear later

reduces in size when the child is relaxed / reduces in size when the child is relaxed / asleepasleep

smooth soft-firm mass that emerges from the smooth soft-firm mass that emerges from the external ring lateral and above pubic tubercle, external ring lateral and above pubic tubercle, enlarges with increased abdominal pressureenlarges with increased abdominal pressure

Can be reduced with gentle pressure, Can be reduced with gentle pressure, may reduce with gurgling noisemay reduce with gurgling noise

Examine position of testis – Examine position of testis – undescended / retractileundescended / retractile

Reappears on crying / valsalva Reappears on crying / valsalva (blowing a balloon / coughing ) (blowing a balloon / coughing ) preferably while standingpreferably while standing

Thickening & silkiness on palpating the Thickening & silkiness on palpating the cord as it crosses pubic tubercle – cord as it crosses pubic tubercle – Silk Silk Glove signGlove sign

If in doubt re-evaluate at second visitIf in doubt re-evaluate at second visit

ManagementManagement Inguinal hernia does not resolve Inguinal hernia does not resolve

spontaneouslyspontaneously

Must be operated because of high Must be operated because of high risk of incarcerationrisk of incarceration

Operation : Operation : HerniotomyHerniotomy - High suture ligation - High suture ligation

of the sac at the internal ringof the sac at the internal ring

Open technique / LaparoscopyOpen technique / Laparoscopy

Technique Technique Anaesthesia:Anaesthesia:

In infants – ETGAIn infants – ETGA

Older children – facial or laryngeal Older children – facial or laryngeal maskmask

Transverse groin skin crease Transverse groin skin crease incision incision

Open layersOpen layers Incision in external oblique Incision in external oblique

aponeurosis lateral to external ring aponeurosis lateral to external ring

Fibres of cremasteric fascia are Fibres of cremasteric fascia are separatedseparated

Shiny glistening white hernial sac Shiny glistening white hernial sac identified & lifted with blunt forcepsidentified & lifted with blunt forceps

In males the sac lies anterior & medial In males the sac lies anterior & medial to vas & vesselsto vas & vessels

Vas & vessels are never held with Vas & vessels are never held with

forceps, dissected off the sac with forceps, dissected off the sac with overlying areolar tissueoverlying areolar tissue

In females there are no significant structures In females there are no significant structures other than round ligament of uterusother than round ligament of uterus

Ensure there are no contents in the sac, divide Ensure there are no contents in the sac, divide between clampsbetween clamps

Dissect proximally upto neck of the sacDissect proximally upto neck of the sac

Twist the proximal sac & transfix the neck at Twist the proximal sac & transfix the neck at the level of deep ringthe level of deep ring

Traction on the testis to return it to the scrotumTraction on the testis to return it to the scrotum

Closure in layers Closure in layers

Contralateral explorationContralateral exploration Selected contralateral exploration:Selected contralateral exploration: Age:Age: 40% contralateral hernias occur after unilateral 40% contralateral hernias occur after unilateral

surgery in children under 1 yrsurgery in children under 1 yr

Side of hernia:Side of hernia: Left Left

Sex:Sex: Female Female

Patency of PV sac on opposite side:Patency of PV sac on opposite side: Herniography, Herniography, intraoperative pnuemoperitoneum, Choledochoscope / intraoperative pnuemoperitoneum, Choledochoscope / laparoscopelaparoscope

Conditions predisposing to hernia on the opposite side:Conditions predisposing to hernia on the opposite side: VP Shunt, connective tissue disordersVP Shunt, connective tissue disorders

Poor risk for GAPoor risk for GA

Irreducible HerniaIrreducible Hernia

Incarcerated hernia: contents cannot be Incarcerated hernia: contents cannot be easily reduced into peritoneal cavityeasily reduced into peritoneal cavity

Irritability, pain in the groin / abdomen, Irritability, pain in the groin / abdomen, vomitingvomiting

Tense, tender, non fluctuant mass in Tense, tender, non fluctuant mass in the groin, may extend into scrotum, the groin, may extend into scrotum, not transilluminantnot transilluminant

Bilious vomiting, abdominal distension Bilious vomiting, abdominal distension indicates obstruction of bowelindicates obstruction of bowel

Strangulated hernia: Tightly Strangulated hernia: Tightly constricted at the neck resulting in constricted at the neck resulting in ischemia of contents.ischemia of contents.

Pain intensifies, vomiting becomes Pain intensifies, vomiting becomes bilious. Blood in stoolsbilious. Blood in stools

Mass is tender, edema & reddening of Mass is tender, edema & reddening of overlying skin, feveroverlying skin, fever

Management:Management:

Non operative:Non operative: only when there is only when there is no e/o ischemiano e/o ischemia

Under sedation & analgesia reduce Under sedation & analgesia reduce the hernia by gentle compressionthe hernia by gentle compression

Elective herniotomy after 48 hrs by Elective herniotomy after 48 hrs by which time there is less edemawhich time there is less edema

Operative:Operative: When hernia cannot be When hernia cannot be reduced or hernia is strangulatedreduced or hernia is strangulated

Hernial sac opened. Look for viability Hernial sac opened. Look for viability of bowelof bowel

Deep ring can be enlarged by Deep ring can be enlarged by incising the arching fibres of conjoint incising the arching fibres of conjoint tendon superiorlytendon superiorly

Tell tale e/o ischemia – bloody or foul Tell tale e/o ischemia – bloody or foul smelling fluid in the sac. Explore the smelling fluid in the sac. Explore the abdomen abdomen

Complications of Complications of herniotomyherniotomy

Ascending / trapped testisAscending / trapped testis

Recurrence – 0.8%Recurrence – 0.8%

Injury to vasInjury to vas

Testicular atrophyTesticular atrophy

Congenital HydrocoeleCongenital Hydrocoele

Usually noted in early infancy, can occur Usually noted in early infancy, can occur at anytimeat anytime

Often bilateralOften bilateral

Soft, bluish, fluctuant swelling Soft, bluish, fluctuant swelling surrounding the testissurrounding the testis

Fluctuate in size: smaller at night when Fluctuate in size: smaller at night when the child is relaxedthe child is relaxed

Neck of the hydrocoele narrows at the Neck of the hydrocoele narrows at the external ring & usually does not extend external ring & usually does not extend into the inguinal canalinto the inguinal canal

Hallmark: Brilliant transilluminationHallmark: Brilliant transillumination

In most children with congenital In most children with congenital hydrocoele the PV sac closes and hydrocoele the PV sac closes and hydrocoele resolves between 12 – 24 hydrocoele resolves between 12 – 24 monthsmonths

There is no e/o hydrocoele will evolve into There is no e/o hydrocoele will evolve into herniahernia

ManagementManagement

Observation for first 2 years unless Observation for first 2 years unless large, painfullarge, painful

Herniotomy if it persists > 2 yrsHerniotomy if it persists > 2 yrs