Inguinal, Incisional, Epigastric Hernias Flashcards

Question

What are the relative indications for exploration of the contralateral side?

Answer 1

Contralateral exploration was previously common practice, however this has declined in recent years based on large prospective studies that demonstrated children with unilateral inguinal hernias had an overall risk of metachronous hernia of 5–12% [4]. It was therefore concluded that the low incidence of contralateral hernia did not justify the routine exploration. Contralateral exploration therefore is only warranted for children at particular risk for metachronous inguinal hernias including those with increased intraabdominal pressure, connective tissue disease, ventriculoperitoneal shunts, or chronic pulmonary disease, or in patients with an underlying medical condition, which increases their risk of anesthetic complications. In the setting of a laparoscopic repair, the contralateral side is always inspected for possible contralateral hernia. This is a highly sensitive and specific means of exploring the contralateral inguinal region.

Answer 2

Epigastric hernias can be congenital or acquired defects in the anterior abdominal wall. Congenital epigastric hernias arise from defects in the linea alba or in an abnormally wide orifice for a blood vessel. Other studies have suggested epigastric hernias are acquired defects from a unique pattern of aponeurotic decussation in the upper abdominal wall. Which may be related to traction from fibers originating from the diaphragm that insert on the linea alba between the umbilicus and xiphoid. — Epigastric hernias are also reasonably common in children, although their exact incidence is not known. These hernias present as small midline or just off midline masses anywhere between the xiphoid and the umbilicus. The mass is not reducible because it represents chronically incarcerated preperitoneal fat through a defect in the linea alba. Epigastric hernias do not contain a peritoneal sac. Therefore, there is virtually no risk of omental or intestinal incarceration. Many are needlessly imaged by referring physicians because of the impression that they represent a soft tissue mass. These hernias are typically asymptomatic when seen in young children. They are repaired because they do not resolve spontaneously and can increase in size as the child gains adipose tissue with increased herniation. They can eventually produce abdominal wall pain. The surgeon must remember that the hernia defect is usually very small and can be easily missed during the operation. A number of pearls can assure a successful operation. Very small hernias that are difficult to palpate with the child relaxed can be observed. Repair actually becomes easier as the hernia size increases to a small palpable mass at rest. The hernia site should be marked with the child standing and straining prior to induction of general anesthesia, as it may be very hard to find with the child relaxed. A 1-cm horizontal or vertical incision is made over the hernia. The herniated preperitoneal fat, which is smooth and lipoma-like, is located and dissected from the more granular subcutaneous fat. This fat nodule or mass leads to the hernia defect. Excision of the herniated fat at the level of the defect allows its closure with a single or figure-of-eight suture in most cases. Although the incision is usually short, it is in a very visible part of the abdominal wall. This has led some to use laparoscopic-assisted percutaneous suturing techniques. The parents should be warned that a hard lump will be palpable in the surgical area for a few months. This represents the healing fascial closure, not a recurrence. Sherif

Answer 3

Epigastric hernias typically present with a circumscribed midline epigastric abdominal mass that may be painful or tender.

Answer 4

Epigastric hernias represent about 4% of all abdominal hernias operated on in children.

Answer 5

All symptomatic or enlarging epigastric hernias should be surgically corrected. Smaller or asymptomatic epigastric hernias can be observed until they either present with complications secondary to their hernia, or for cosmetic reasons, the patient would like surgical correction. The timing of the non-symptomatic repairs is a decision made in balancing the risks associated with anesthesia if general anesthesia is required.

Answer 6

Epigastric hernias have been traditionally repaired with an open surgical approach with incision over the fascial defect and primary closure. However, more recently, some are employing a laparoscopic technique.

Answer 7

The risk factors for an incisional hernia in the pediatric population overlap some- what with the adult population, but there are also specific pediatric incisional hernia risk factors. Risk factors for pediatric patients of developing an incisional hernia include: malnutrition, immunosuppression (due to medical conditions or immunosuppressive therapy), connective tissue disorders, obesity and operation in the neonatal period. Procedures that carry a higher risk of incisional hernia post operatively in pediatric patients include: laparotomy for necrotizing enterocolitis, stoma closure, and pyloromyotomy.

Answer 8

The incidence of incisional hernia in adults has been reported as 10–50% following any type of abdominal wall incision, with the highest being following midline incisions. There is a paucity of data relating to the pediatric population, however recent single institution based studies have reported incidence as low as 1–3% [6]. This is likely secondary to pediatric patients having fewer patient risk factors including smoking and higher incidences of obesity.

Answer 9

An incisional hernia should be suspected in a patient with a prior abdominal surgery who presents with abdominal pain or discomfort, skin changes overlying a prior incision, or symptoms of bowel obstruction or strangulation. This will often be associated with a palpable abdominal mass in the location of their prior incision sites.

Answer 10

Generally a physical examination is all that is required to diagnose an incisional hernia. However, if there is no palpable mass appreciated, symptoms not entirely in keeping with an incisional hernia, or a complex surgical history and complex possible incisional hernia based on history or examination, an ultrasound or CT scan may be indicated to confirm diagnosis and delineate the abdominal anatomy.

Answer 11

Symptomatic incisional hernias, particularly in the setting of incarcerated or strangulated bowel, require immediate operative management. Discomfort and cosmetic complaints are also valid indications for surgical repair in the pediatric setting, but the timing and ultimate decision to operate is balanced with the patient’s overall health and risks of anesthesia or recurrence.

Answer 12

Incisional hernias are repaired with either an open or laparoscopic approach. In pediatrics, the repair is a primary repair unless the abdominal wall defect precludes this requiring a mesh repair, however this is much less common than in the adult patient population.

Answer 13

D. Ligation of sac at internal ring

Answer 14

A. Testicular atrophy has been reported in 3-5 percent of boys following incarceration. (2-3%)

Answer 15

The overall lifetime incidence of an inguinal hernia is estimated to be approximately 5% for males. Inguinal hernias in males are 5–10 times more common than in females. The age at presentation of an inguinal hernia also varies by gender. A database review of nearly 80,000 children from Taiwan found the peak incidence of an inguinal hernia in males to be under 1 year of age and 4.7 years in females. In that study, hernias were much more common under 1 year of age, with a decreasing incidence thereafter. Incarceration was found to be equally common in males and females. Hernias are about twice as common on the right and are bilateral in about 10% of patients. Bilateral hernias are nearly twice as common in girls. A Swedish population-based study found that there was a twofold increase in the odds of developing an inguinal hernia when a sibling was found to have an inguinal hernia. A family history of inguinal hernia is found in 10–25% of children with an inguinal hernia. There is an increased incidence in twins, more frequently in male twins. The term inguinal hernia includes indirect inguinal hernias, direct hernias, and femoral hernias. Indirect inguinal hernias, lateral to the inferior epigastric vessels, are by far the most common in children. Even in young adults (16–18 years of age), direct inguinal hernias are uncommon. Femoral hernias (inferior to the inguinal ligament) account for less than 1% of pediatric inguinal hernias. Sliding hernias are those in which viscera (bowel, bladder, reproductive structures) compose part of the hernia sac. Pantaloon (the term is derived from baggy trousers gathered at the ankles) hernias consist of direct and indirect inguinal hernias and are more common in neonates. Eponymous inguinal hernias include: Amyand (appendix in the hernia sac) Littre (Meckel diverticulum in the sac), and Richter (ischemic antimesenteric bowel border in the hernia) hernias. [H&A]

Answer 16

The abdominal cavity is lined by the parietal peritoneum. 2 - 3 weeks AOG: An outpouching in front of the testis and gubernaculum in boys, known as the processus vaginalis, is first seen during the 2nd or 3rd month of gestation. 6 weeks AOG: Germ cells are found in the urogenital ridge by the 6th week of gestation. 7 weeks AOG: By the 7th week, the testes have begun to differentiate. Testicular descent occurs in two stages: 1) 8 -15 weeks AOG: Abdominal Phase The first is an abdominal phase with swelling and strengthening of the distal gubernaculum under the influence of insulin-like hormone 3 (Insl3). The swelling causes the gubernaculum to maintain a fixed length in males. At the same time, fetal testosterone causes regression of the cranial suspensory ligament. The testis is thus anchored to the internal ring while the abdominal cavity increases in size. 2) 25–35 weeks AOG: Inguinoscrotal phase The gubernaculum extends down to the base of the scrotum. Androgenic hormones lead to release of neurotrophins that regulate the sensory branches of the genitofemoral nerve. Calcitonin gene-related peptide (CGRP) release provides a local chemotactic gradient to guide the gubernaculum. The testis then passes through the inguinal canal and eventually reaches the base of the scrotum. The female anlage of the processus vaginalis is the canal of Nuck, a structure that leads to the labia majora. This also closes by about 7 months of fetal life, and ovarian descent is arrested in the pelvis. Once testicular descent is complete, obliteration of the patent processus vaginalis (PPV) usually occurs. Initial closure of the internal inguinal ring is followed by obliteration of the part of the processus vaginalis superior to the testis. The residual space between the cranial and caudal portions (funicular process) is normally the last to obliterate. Failure of obliteration results in an indirect inguinal hernia or hydrocele. Factors driving PPV closure are incompletely understood. Disorders with increased abdominal pressure/fluid (e.g., ascites, chronic cough) are associated with an increased incidence of indirect inguinal hernias as well as bilaterality. Prematurity results in delivery prior to completion of normal descent and obliteration, and is associated with an increased incidence of inguinal hernia ranging from 10–30%, depending on the degree of prematurity. The layers of the abdominal wall contribute to the layers of the testis and spermatic cord as the gonad descends. The internal spermatic fascia is a continuation of the transversalis fascia. The cremaster muscle derives from the internal oblique. The external spermatic fascia originates from the external oblique aponeurosis. The processus vaginalis envelops the testis as the visceral and parietal layers of the tunica vaginalis. [H&A]

Answer 17

Apart from the risk factors of male gender and family history, a number of conditions are associated with an inguinal hernia: Prematurity Cystic fibrosis and meconium peritonitis Hydrocephalus (ventriculoperitoneal shunt) Peritoneal dialysis Ascites Genitourinary abnormalities Connective tissue disorders Mucopolysaccharidoses Glycogen storage diseases Abdominal wall defects Chronic lung disease The most common association is prematurity due to interruption of the normal process of testicular descent as well as comorbidities (e.g., chronic lung disease) in this population. Cystic fibrosis (CF) carries an increased incidence (15%) of inguinal hernia. An increased risk of inguinal hernia in unaffected fathers and siblings of these children suggests genetic factors may be involved in addition to the mechanical effects of chronic lung disease and increased intra-abdominal pressure. The well-recognized vasal abnormalities in children with CF support an embryologic component. CF is also a risk factor for bilaterality and recurrence. Occasionally, a small or absent vas is found during inguinal hernia repair in males. Renal ultrasound (US) should be electively obtained to evaluate for associated ipsilateral renal agenesis. Abnormalities of the vas should also prompt an evaluation for CF. Congenital absence (bilateral or unilateral) of the vas is a heterogeneous disorder, largely due to mutations in the CF gene. Differing genotypes are noted with congenital absence of the vas as an isolated entity versus congenital absence of the vas in association with renal anomalies. Ventriculoperitoneal shunts (VPSs) for hydrocephalus are associated with an increased incidence of inguinal hernia (15–25%) and higher rates of bilaterality, incarceration, and recurrence. Inguinal hernias are more likely to develop in neonates than in older children who undergo VPS and are more common in boys than girls. The average time from placement of a VPS to inguinal hernia repair is around 5–12 months. Other conditions in which excess intra-abdominal fluid is present (peritoneal dialysis, ascites, hydrops) have similar associations. H&A — Of those associations, male gender and prematurity are by far the most prominent. Hernias in male children are 7–10 times more common than in female children. The incidence of inguinal hernia is inversely related to birth weight and approaches 40% in extremely low birth weight (<1,000 g) babies. The later descent of the right testicle is thought to explain the higher incidence of right-sided hernias, which are twice as common (60%) versus the left side (30%). Ten percent of inguinal hernias are bilateral on presentation. Some reports have shown a higher incidence of bilaterality in girls, particularly infants, but this finding has not been consistent between studies. Sherif

Answer 18

The diagnosis of an inguinal hernia is clinical and rests on the history and physical examination. The usual presentation of a hernia in a child is an asymptomatic, intermittent, unilateral inguinal bulge. On occasion, an infant or young child can present with bilateral inguinal hernias. Activities that increase intra-abdominal pressure (crying, coughing, straining, etc.) can elicit the hernia. Most are found by the parents or the pediatrician on routine physical examination. Because the inguinal bulging is intermittent, it is common to have a normal examination and a suggestive history. Cell phone picture documentation by the parents has become commonplace. A convincing history is acceptable as an indication for operation, particularly when diagnostic laparoscopy in questionable cases enables definitive diagnosis and repair. Pertinent elements of the history include prior prematurity, family history, prior genitourinary anomalies (undescended testis, hypospadias, hydrocele), and the presence or absence of the associated factors. The differential diagnosis includes retractile testis, lymphadenopathy, hydrocele, varicocele, and prepubertal fat. A frequent referral is a child with inguinal pain, no history of bulging or swelling, and a normal physical examination. Other sources such as musculoskeletal strain, gastrointestinal, or genitourinary causes should be excluded before operative intervention. Diagnostic laparoscopy is useful in those with equivocal examinations or persistent symptoms and no other apparent cause. The most common examination finding is a reducible inguinal or scrotal bulge, more prominent during Valsalva maneuvers. Having the child raise the head while supine, or “blowing up a balloon” with a thumb in the mouth, may be helpful in small children. Standing the child upright also may help demonstrate the hernia. The “silk glove sign’” (feeling the thickened peritoneum of the patent processus as the cord is palpated) is examiner-dependent but can have more than 90% sensitivity in experienced hands. In girls, a hard mass may sometimes be felt if the ovary protrudes into the sac. Radiologic assessment is not usually necessary or helpful. US can be used to identify a PPV indirectly via widening of the internal inguinal ring (more than 4–5 mm is positive), but the technique is highly operator dependent and not widely used in children. In a few reports, US has been used to identify a contralateral PPV. H&A

Answer 19

The presence of fluid in the scrotum or inguinal canal in boys or in the inguinal/labial area in girls is indicative of a hydrocele. These are commonly seen in infancy, with a secondary peak in adolescent boys. Hydroceles in infants are usually managed expectantly in the absence of evidence of communication indicating a PPV. Factors indicating communication include development of a new hydrocele after birth, waxing and waning in the size of the fluid collection, and failure to resolve by 1–2 years of age. Most surgeons observe non-communicating hydroceles until the child reaches 1–2 years of age. Communicating hydroceles in infants are treated as a hernia and repaired electively after diagnosis by some surgeons, whereas others advocate observation and expectant management. Resolution of apparently communicating, asymptomatic hydroceles is reported in 60–90% of cases. Hydrocele of the cord is due to obliteration of the proximal and distal processus, with retention of a fluid-filled sac along the spermatic cord. On examination, a smooth sausage-link mobile mass is palpable in the inguinal canal. It can sometimes be difficult to distinguish cord hydroceles from an incarcerated inguinal hernia, particularly in an irritable baby who has undergone attempted reduction by other examiners. US may be helpful in this situation. As with communicating hydroceles in infants, management of cord hydroceles is controversial, with some favoring operation and others observation. Giant hydroceles (there is no objective definition) are considered an indication for operation by some surgeons, even without evidence of communication. Abdominoscrotal hydrocele is an unusual entity. These are large scrotal masses with inguinoscrotal and abdominal components in a dumbbell configuration. The diagnosis is suggested by the “springing back ball” sign: cross-fluctuation in which compression of the scrotal component causes protrusion of the abdominal component and vice versa. Laparoscopy can be confirmatory. Treatment ranges from aspiration/observation to inguinal exploration to a combined inguinoscrotal and laparoscopic approach. Most adolescent hydroceles are noncommunicating. A history and physical examination can reasonably reliably exclude communication. If no clear cause is identified, US can be performed. A transscrotal hydrocelectomy is appropriate in adolescents in the absence of signs of a PPV or tumor. H&A

Answer 20

The incidence of incarceration in an inguinal hernia is variable and age-dependent (peaking in the first year of life), and ranges from 3–16%. Most studies show a relatively equal gender distribution in proportion to the gender distribution of hernias in general. Prematurity, although a risk factor for the presence of a hernia, may or may not be associated with an increased risk of incarceration. Increasing the wait time for elective hernia repair in infancy increases the risk of incarceration. Many series of incarcerated hernias note a prior history of an unrepaired inguinal hernia, some even with a history of incarceration. In some patients, incarceration may be the presenting sign of the inguinal hernia. As previously mentioned, it can be difficult to distinguish a hydrocele of the cord from an incarcerated hernia. A happy infant with no tenderness suggests the former diagnosis, but if several examiners have vigorously attempted to reduce the hydrocele, the distinction can be difficult and US may be helpful. If a torsed testicle is in the differential, US is indicated as well. Symptoms of incarceration frequently manifest as a fussy or inconsolable infant with intermittent abdominal pain and vomiting. Older, verbal patients will complain of severe pain and tenderness. A tender and sometimes erythematous irreducible mass is noted in the groin. Abdominal distention, bowel obstruction, and bloody stools are late signs. Peritoneal signs suggest strangulated intestine. Gasfilled bowel loops may be seen in the scrotum on plain films. It is sometimes stated that gangrenous or ischemic bowel cannot be reduced, but exceptions make this a dangerous rule to rely on. The presence of peritonitis, hemodynamic instability, or septic shock is an absolute contraindication to attempted reduction. Symptoms of bowel obstruction are a relative contraindication. Monitored conscious sedation is used after intravenous access and rehydration. Firm and continuous pressure is applied around the incarceration. Successful reduction is usually confirmed by a sudden “pop” of the contents back into the peritoneal cavity. Questionable or incomplete reductions should be explored. Reduction en mass, in which the hernia contents are reduced into the peritoneal cavity but the bowel remains incarcerated internally in the hernia sac, is a very rare occurrence, but the surgeon should be aware of this possibility. After reduction of an incarcerated hernia, a delay of 24–48 hours to allow resolution of the edema prior to open repair has historically been recommended. Delay is less important if the laparoscopic approach is planned. Reliability of the family as well as the clinical history (very difficult reduction) and geographic considerations may dictate the need for admission and observation before definitive repair. It is estimated that 70–95% of incarcerated hernias can be successfully reduced. An urgent operation is necessary if reduction of the hernia contents is unsuccessful or incomplete. We prefer the laparoscopic approach for incarcerated hernias, and there is evidence that the laparoscopic approach is associated with fewer complications. Using laparoscopic traction and manual external pressure, it is usually possible to reduce the hernia contents. The intestine or appendix can be exteriorized through the umbilicus for examination or to perform a bowel resection or appendectomy in the rare event resection is needed. On occasion, the hernia may spontaneously reduce with induction of general anesthesia. If laparoscopy is planned, it should proceed. Once the hernia contents are reduced, the repair is as described elsewhere in this chapter. In an open repair, bloody fluid or enteric contents from the open sac mandate additional investigation. A laparoscope can be inserted through the sac or via the umbilicus to evaluate for intestinal injury. Alternatively, a separate incision or La Roque maneuver (incision in the transversalis through the same inguinal skin incision, above the internal inguinal ring) will allow inspection of the peritoneal contents. With an open repair, if the bowel is still incarcerated after anesthesia has been induced, the sac is opened and viable bowel is reduced, after which a standard repair (high ligation) is done. The hernia sac is often quite edematous and friable, and repair of the hernia can be quite difficult. It may be necessary to open the internal inguinal ring laterally in order to reduce the bowel. A sliding hernia is more frequent in incarcerated hernias, particularly in girls. Ischemic intestine can be resected via the inguinal incision and an anastomosis performed, or a laparoscopic or open abdominal approach can be utilized as well. Even with incarceration, intestinal injury requiring resection is rare (1–2%). Postoperative complications are significantly increased in incarcerated hernias compared with elective repairs. The risk of recurrence is significantly increased in the presence of incarceration. Wound infections are increased, as are inadvertent injuries to the vas deferens and other organs. The parents of a boy with an incarcerated hernia should be counseled preoperatively about the possibility of testicular loss or injury because of the incarceration impinging on the blood supply to this end organ. The testis on the incarcerated side in males is often edematous and somewhat cyanotic. Even a threatened, ischemic testis should be preserved unless it is clearly necrotic. The incidence of testicular atrophy is 2–3%. In girls who have an incarcerated hernia, the ovary and/or fallopian tube are more commonly involved than is intestine. If the ovary is incarcerated on examination in an otherwise asymptomatic infant, its blood supply is usually unaffected. However, most pediatric surgeons will promptly (but not emergently) repair the hernia in a girl with an asymptomatic, nontender ovarian incarceration. The ovary is more likely to be compromised from torsion, as opposed to compression of the vessels with incarceration. H&A

Answer 21

The presence of an inguinal hernia is an indication for elective repair. It is not necessary to restrict an asymptomatic child’s activities preoperatively. Prompt repair may decrease incarceration, particularly in the very young. Inguinal hernias are common in the neonatal intensive care unit (NICU), but the timing of repair is widely variable among surgeons and between institutions and is controversial in premature infants. Repair of an inguinal hernia shortly prior to neonatal discharge (“early”) can be more technically demanding, has higher recurrence and complication rates, may prolong mechanical ventilation and length of stay in the NICU, and is associated with an increased risk of apnea and bradycardia. In contrast, “late” repair (after 55 weeks postconceptual age) carries an increased risk of incarceration (10–30%), more frequent emergency department and clinic visits and readmissions, and potential failure of the family to follow-up. Concerns about the long-term neurodevelopmental risks of anesthesia in premature infants, if substantiated, would favor the late approach. H&A — There has been significant controversy regarding the timing of repair of inguinal hernias diagnosed in the neonatal intensive care unit (NICU). These patients are under constant observation in the NICU, and therefore the risk of incarceration during the hospital stay is low. Many also have chronic lung disease, representing a significant comorbidity that may be exacerbated by re-intubation and general anesthesia. Finally, there have been concerns about possible neurodevelopmental effects of general anesthesia in neonates. The advantages of repair prior to discharge are avoidance of incarceration after discharge and avoidance of a second hospital admission. The disadvantages are potential increases in respiratory morbidity, difficulty of repair, risk of recurrence, and adverse neurodevelopmental effects. There have been a number of retrospective series that have looked at this question with divergent results. A randomized controlled trial, funded by the US National Institutes of Health, is currently underway to address this question and attempt to generate high-grade evidence. In the meantime, the surgeon should use the best judgment and make decisions regarding timing of repair in conjunction with the neonatologist and family. For example, a baby with minimal or no lung disease, who has an intermittent hernia requiring multiple reductions in the NICU, is best repaired before discharge, whereas an oxygen-dependent baby with significant chronic lung disease and a large inguinoscrotal hernia with the bowel always residing in the scrotum may be best repaired in a delayed manner. Sherif

Answer 22

The open repair of an indirect inguinal hernia (OHR) in children centers on high (internal inguinal ring) ligation of the hernia sac. A transverse inguinal crease incision is used. The inguinal canal is more lateral than one might expect, a finding made apparent with laparoscopic hernia repairs. The Scarpa fascia is opened, and the external oblique aponeurosis identified. This aponeurosis is opened along the direction of its fibers. Care is taken to identify and preserve the ilioinguinal nerve, which supplies cutaneous sensation to the skin of the anterior thigh. The anteromedial hernia sac is carefully separated from the cord structures in boys. In girls, it is simply mobilized up to the internal inguinal ring. The sac may extend down into the scrotum in boys. It is clamped after ensuring the absence of the vas and testicular vessels, divided, and followed proximally to the internal inguinal ring, where it is doubly ligated with absorbable suture. The distal sac should be widely opened but need not be removed. If a hydrocele is present, it is evacuated, but excision of the hydrocele sac is not necessary. Large or thick sacs may be everted behind the cord (Bottle procedure). In the case of a blind-ending sac, the entire sac can be resected after high ligation. Formal repair of the floor is rarely necessary in children. If a sliding hernia is present, inversion ligation after placing a proximal pursestring suture is relatively straightforward. H&A — The inguinal approach involves exposure of the cord structures, separation of the patent processus vaginalis from the vas deferens and testicular vessels, division of the sac, high ligation of the sac at the deep ring or above, and excision of the proximal sac distal to the ligature. The procedure can be carried out through a small 2–3 cm groin incision and usually necessitates opening the external oblique aponeurosis. In children less than 6–12 month of age, the superficial and deep inguinal rings are almost superimposed, and the external oblique does not have to be opened to reach the deep ring. This is referred to as a Mitchell-Banks approach. The groin incision has been considered the classic, time-honored approach for decades, and is still being used by the majority of pediatric surgeons around the world. The procedure is associated with a low complication profile, a recurrence rate in the 1%–3% range, fast recovery, and a good cosmetic result. It can be used throughout the entire pediatric age range, including adolescence. However, senior surgeons will attest to the fact that it can be extremely challenging in small premature babies, where the hernia sac is often described as “wet toilet paper” and often has to be incrementally lifted piecemeal off the vas and vessels, a procedure referred to as a Clatworthy dissection. Injuries to the vas or testicular vessels represent the immediate intraoperative complications of the open technique but should be rare events when pediatric inguinal hernias are repaired by well-trained pediatric surgeons. Postoperative scrotal hematomas in neonates and infants are quite common with this approach. Sherif

Answer 23

Historically, contralateral open inguinal exploration was common for unilateral inguinal hernias, particularly in younger infants and children. Over the past 20 years, there have been reports describing the use of laparoscopy to evaluate the contralateral inguinal ring at the time of open inguinal hernia repair. A small 70-degree scope can be inserted through a 2-mm port placed through the ipsilateral hernia sac (after insufflation) to look for a contralateral PPV. There is a small, but definite (1–2%), incidence of developing a contralateral hernia even after a negative evaluation. The indications (or lack thereof) for contralateral evaluation are controversial, but with the increasing use of transumbilical laparoscopic repair, this may be fast becoming a moot point. More recent studies and meta-analyses tend toward the opinion that contralateral evaluation may not be necessary (overtreatment). At the same time, in one study, when given the options of unilateral repair alone versus unilateral repair with contralateral evaluation, parents overwhelmingly chose contralateral evaluation with laparoscopy. H&A

Answer 24

The advent of minimal access techniques has changed the conventional approach for treatment of inguinal hernias in many infants and children. An accurate description of the current state of pediatric laparoscopic inguinal hernia repair (LIHR) is a moving target. LIHR in children was first introduced as an alternative to conventional OHR by Montupet in 1993. The proposed advantages of the laparoscopic approach include visualization of a contralateral PPV, identification of less common (direct, femoral, pantaloon) hernias, diminished postoperative pain, more rapid return to normal function, and improved cosmesis. Potential disadvantages include a possible increase in length of operative time and costs, a definite learning curve, and the need for orotracheal intubation for anesthesia. Most studies of inguinal hernia repair published in the last 20 years are focused on the laparoscopic approach, with many different techniques now used for LIHR. The different repair options can be categorized as either intracorporeal or extracorporeal/percutaneous. Montupet’s 1993 report described an intracorporeal technique, with a purse-string suture placed in the periorificial peritoneum at the level of the internal inguinal ring. In 1998, Schier reported using an N-shape suture on the peri-orificial peritoneum. In 1999, Montupet and Esposito modified two important aspects of the technique: before closing the defect, the periorificial peritoneum around the internal inguinal ring is cut, and a nonabsorbable suture is used to repair the hernia defect. The extracorporeal approach involves the placement of a suture circumferentially around the internal ring and tying the knot using percutaneous techniques. Many variations of this approach have been described. Recently, Ostlie and Ponsky reviewed the literature and stated that there was insufficient evidence to support one approach over another. We prefer the transperitoneal approach for LIHR using three ports. The surgeon is positioned at the head of the patient, and the camera operator is contralateral to the side of pathology. The video column is positioned at the patient’s feet. The patient is placed in a supine position with a 15°20° Trendelenburg inclination of the operative table to reduce the abdominal contents. The average intra-abdominal pressure is 6–8 mmHg in patients under 1 year of age and 8–10 mmHg in older children. The bladder should be emptied before beginning the operation. A 0°, 5- to 10-mm telescope is inserted through the umbilical port, allowing good visualization of the deep (internal) inguinal rings. The use of a 5- or 10-mm telescope leaves nearly the same invisible scar in the umbilicus. Selection of a 5- or 10-mm optic depends on the surgeon’s preference. Two 3-mm ports are then placed in triangulation for good ergonomics. Some surgeons prefer to use screw-type cannulas for the 3-mm ports. The advantage of using screw ports is most evident in infants under 10 kg in whom the skin and the underlying tissues are very thin and the smooth cannulas are often displaced, which can result in subcutaneous emphysema. Screw ports are more stable and allow for changing instruments rapidly, without dislodgement of the cannulas or gas leak. If only smooth ports are available, a piece of Nelaton catheter can be placed around the cannula, which is then fixed the skin to stabilize the port. Some surgeons prefer to use instruments without ports via stab incisions. The laparoscopic approach allows confirmation of the diagnosis. The first step of the laparoscopic procedure consists of checking the patency of the known hernia as well as inspection of the contralateral side for the presence of a contralateral PPV (CPPV). If there is an incarcerated hernia, the incarcerated contents can be released before closing the defect. The next step is circumferentially cutting the periorificial peritoneum, distal to the internal inguinal ring, by using monopolar hook cautery. Section of the peri-orificial peritoneum is a key part of the technique because it allows collapse of the distal sac and consequently no tension on the suture line when closing the defect with purse-string suture. Also, in a rabbit study, it was shown that inducing trauma and scarring at the internal ring may lead to a more durable laparoscopic repair. It is also important to close the medial part of the ring well, in particular the peritoneum between the inner spermatic vessels and the vas, because this is the most frequent location for recurrence. The internal ring is then closed with either an absorbable or nonabsorbable suture, performing either a pursestring suture as described by Montupet, or an N-shaped suture as described by Schier. In general, if the diameter of the inguinal orifice is 10 mm or larger, a purse-string suture is preferable. For internal openings of about 5 mm or smaller, an N-shaped suture and a purse-string suture are equally efficacious. The needle is introduced transperitoneally into the abdominal cavity and then removed transperitoneally or through the umbilical port. The preferred needle is 3/8 of a circle with a 20- to 22-mm needle. For unilateral closure, the length of suture should be 13–15 cm. For bilateral repair, it should be 15–20 cm, but this may vary according to surgeon preference. The cannula sites are closed with fine suture, adhesive strips, or glue. In the preperitoneal approach (needlescopic approach), a small hook or awl loaded with a suture is passed around the deep ring after making a small inguinal skin incision. The passage of the suture is observed via an endoscope through the umbilical port. The ligature is then brought extracorporeally and tied, thus closing the hernia orifice. The currently preferred technique for management of an isolated hydrocele without a hernia is to treat it via the open inguinal approach. In the case of a communicating hydrocele, the LIHR approach can be used. In these patients, fluid is aspirated and the PPV is closed with either an intracorporeal or extracorporeal technique. H&A

Answer 25

Laparoscopy has several advantages when compared with open repair in the treatment of an inguinal hernia in infants. First, with laparoscopy, there is a reduction in postoperative infections. This may result because laparoscopic scars are located higher compared with the inguinal incisions (inside the diaper area), which are subject to urine or fecal contamination. Recent reports have found fewer wound infections following laparoscopic repair versus open repair in infants of similar ages (0 vs 2.3%). The major technical challenge of the LIHR in infants is the very limited working space that can result from bowel distention. It can be helpful to perform a bowel prep with simethicone and one or two enemas the day before the operation to empty the intestinal loops to create a larger working space. In small infants, there is no true triangulation between the telescope and cannulas because the two operative port sites are located higher than usual and are positioned on the umbilical plane at the same level as the telescope to establish an adequate working distance from the internal inguinal ring. In infants it is sometimes preferable to insert the working ports through the cannula of the umbilical optic port—“trocar in trocar” to prevent injury to the bowel. Also, the length of the needle should be a maximum of about 17–20 mm because bigger needles are difficult to manipulate in infants and may have a higher risk of complications. Advocates of the LIHR technique cite better visualization of the vital cord structures, thereby making dissection of these structures safer. There is no dissection of the abdominal wall or spermatic cord structures, thus theoretically reducing the risk of testicular atrophy, secondary cryptorchidism, or other complications. Serious intraoperative complications such as bladder injury or rupture, which can occur with the open repair with excessive mobilization of the sac, are less likely with the laparoscopic technique due to improved visualization of the anatomy. Another advantage of laparoscopy is identification and treatment of a CPPV, present in up to half the patients, particularly the younger ones. Repair of a CPPV, if needed, should be offered to all families, because 90% desire to have the CPPV repaired at the same operative setting. Whether the laparoscopic technique is superior to the OHR is currently widely debated in the literature. It should be noted that the recent inguinal hernia literature describing outcomes following OHR is scanty, and the real incidence of complications of OHR may be underestimated. To clarify the real impact of laparoscopy in pediatric inguinal hernia repair, 90 studies were reviewed. Thirty-eight papers focused on operative time (Table 50.2). The operative time varied widely, depending on the technique and operative experience. The average operative time for OHR of a unilateral inguinal hernia was 30.1 minutes, versus 23.7 minutes via laparoscopy. In most laparoscopic studies, there were no conversions. In our review, the mean recurrence rates were similar between the OHR and LIHR, both ranging from 0–6%. In infants, the recurrence rate seems to be higher after OHR compared with LIHR. Wound infection, postoperative hydrocele, iatrogenic cryptorchidism, and testicular atrophy were significantly higher after OHR than LIHR. Rare hernias were identified in the LIHR studies, with an incidence ranging from 0.3–7.2%. The most common “rare” hernia was a direct hernia (81.5%), followed in order of frequency by femoral hernia (10%), pantaloon hernia (4.3%), a combination of indirect hernia with femoral hernia (1.4%), indirect hernia with direct and femoral hernia (1.4%), and Amyand/Littre hernia (1.4%). No rare hernias were reported in the OHR studies. Twenty-three studies reported the coexistence of a unilateral inguinal hernia with a CPPV, for a highly variable incidence of contralateral patency of between 19.9% and 66%. More CPPVs were reported in the smaller infants. In summary, there is no definitive conclusion in the current literature about which technique is preferable for inguinal hernia repair in infants and children. The surgeon should inform the parents of a child with an inguinal hernia that two different approaches exist, and be aware of the advantages and disadvantages of each option. H&A

Answer 26

Direct inguinal hernias are rare in children, even in older teenagers. The incidence ranges from 2–4% in large laparoscopic series (where they are more readily detected). Direct and femoral hernias are often unrecognized preoperatively. Some recurrences after indirect inguinal hernia repair are direct inguinal hernias. Direct inguinal hernias in children and adolescents can be managed with an open McVay repair (approximation of the transversalis aponeurotic arch and internal oblique aponeurosis to the anterior ileopubic tract and shelving edge of the inguinal ligament), a Bassini approach, or with mesh. The laparoscopic repair of a direct inguinal hernia is also an attractive option. However, the laparoscopic technique is different for a direct inguinal hernia repair as there is a large lipoma adherent to the hernia sac with a direct hernia. Reduction of the lipoma into the abdominal cavity followed by excision using a hook cautery is important and easy to perform laparoscopically. The key points of the direct repair are excision of the lipoma, closure of the defect using several interrupted nonabsorbable sutures, and the use of the vesical ligament to reinforce the closure of the defect without tension. Combinations of direct and indirect hernias, the so-called pantaloon hernias or even combinations of all three hernia forms (indirect plus direct plus femoral) can be rarely found in children, and the laparoscopic approach is the optimal way to identify and treat them. H&A

Answer 27

Femoral hernias are relatively equally distributed by gender, with a mean age at diagnosis of about 5–7 years. They are rare, constituting about 0.2% of pediatric hernias. Most are not suspected before operation. They are often not identified with an open approach and can be incorrectly treated as an indirect inguinal hernia. A mass medial to the femoral vessels and below the inguinal ligament should alert the clinician to this possibility. Femoral hernias are bilateral in 10–20% of cases. A Danish series evaluated 3970 adult femoral hernia repairs and found that the laparoscopic repair had a lower risk of reoperation compared with the open repair. Small pediatric series have documented low recurrence rates as well. Open repairs with mesh or a mesh plug or a Cooper ligament (McVay) repair are alternatives to the laparoscopic repair. H&A

Answer 28

Complete androgen insensitivity syndrome (normal female appearance and external genitalia, with an XY karyotype) is rare (1 in 20,000–60,000 live births). It is commonly associated with an inguinal hernia. The incidence of this abnormality in premenstrual girls with inguinal hernias (particularly when bilateral) may approach 1–2%. Abnormal gonads in a hernia sac should undergo biopsy (and be preserved). Phenotyping, androgen receptor (AR) gene determination, and abdominal US may be helpful adjunctive tests. Laparoscopic hernia repair allows identification of intersex abnormalities, and identification of the presence or absence of the fallopian tube, ovary, and uterus. H&A

Answer 29

Often an incidental PPV is discovered in a child undergoing laparoscopy for an unrelated problem (e.g., appendectomy). In a series of 1548 infants and children, the incidence of PPV was 20% (72% male, with a mean age of 4.8 months; most were younger than 1 year of age). Only 13% of those found to have a PPV developed a clinical hernia and at a median of 9 months from the original laparoscopy. The surgeon should inform the family of the findings, but most pediatric surgeons recommend observation for incidental asymptomatic PPVs. H&A — Both the open and laparoscopic techniques have their enthusiastic proponents, and many debates have occurred in the literature and in scientific meetings regarding the outcomes of both approaches and whether one should be considered superior. The proponents of the laparoscopic approach cite the following potential advantages: decreased pain, improved cosmesis, more rapid recovery, visualization of the contralateral ring, identification of rare hernias (direct, femoral), and less risk of complications, including injury to the vas deferens, injury to testicular vessels, and acquired cryptorchidism. Unfortunately, this has been more of a wish list rather than a proven list of advantages, as randomized trials and meta-analyses have failed to produce evidence to support them. However, of that list, visualization of the contralateral ring and decreased risk of injury to the cord structures deserve further comment. In laparoscopy, a contralateral patent processus vaginalis is repaired with the assumption that a future indirect hernia will be prevented. Some studies comparing laparoscopic and open surgery have in fact shown a decreased risk of a metachronous hernia after laparoscopic repair. However, it is not clear what proportion of patent processes will in fact become inguinal hernias. Large, single-surgeon studies with good follow-up have shown the incidence of metachronous hernia following unilateral repair and the incidence of inguinal hernia following documentation of a patent processus vaginalis to be 5% and 13%, respectively. A recent meta-analysis of prospective studies showed a 6% overall incidence of metachronous inguinal hernia, with risk factors being a left-sided hernia and an open contralateral processus vaginalis. Therefore, one can conclude that 18-20 asymptomatic patent processes have to be closed to prevent one metachronous hernia. Perhaps the one major advantage of the laparoscopic procedure is avoiding the dissection of the vas and vessels from the hernia sac. Technical failure at this step in the open repair can result in injury to these important structures. This step can also be quite difficult in premature babies and during repair of an incarcerated hernia. While this advantage is hard to argue, I do have concerns about placing a permanent braided suture essentially in contact with the vas deferens in the laparoscopic repair. This has not been at all addressed in the literature. The major argument against the laparoscopic repair, however, has been the increased risk of recurrence in most series and at least a trend toward higher recurrence rates in comparative studies. With open repairs, recurrence rates below 2% have been consistently reported. Many laparoscopic series have reported rates in the 4%–5% range. Many pediatric surgeons have seen their first inguinal hernia recurrences after switching to laparoscopy. Several modifications of the laparoscopic procedure have addressed this heightened recurrence risk, and more recent published series are showing recurrence rates within the range of those reported after open repair. Given these arguments for and against laparoscopic inguinal hernia repair, it is reasonable to conclude that both approaches are acceptable and within the standard of care. Each surgeon, based on his or her experience and training, can choose to use laparoscopy for all pediatric inguinal hernias or use it in a selective manner. For example, I now use laparoscopy for bilateral inguinal hernias, ex-premature infants, repair of incarcerated hernias, a recurrence after an open procedure, suspicion of a rare type of inguinal hernia (direct, femoral), and in any patient in whom I plan to explore and repair a contralateral patent processus vaginalis (premature infants, high intra-abdominal pressure, ventriculoperitoneal shunt, peritoneal dialysis catheter, other risk factors). I still perform a routine open hernia repair in the majority of patients. Sherif — A number of studies have shown that the incidence of CPPV is 50–70%2,3, and the incidence of IH and CPPV is age dependent. https://www.nature.com/articles/s41598-022-15435-9

Answer 30

Incidentally discovered yellow nodules along the spermatic cord or testis are due to adrenal rests. In one study, the incidence was 1.7% in 1862 pediatric hernia repairs. These should be removed if possible. Splenogonadal fusion is a very rare entity that may be difficult to distinguish preoperatively from a neoplasm. It may be continuous (cryptorchid testis, when the band attaches the gonad to the spleen) or discontinuous (usually in the scrotum). The left side is usually affected. Frozen section confirmation can be useful. Gonadal preservation is important. The presence of an acutely inflamed appendix in an inguinal hernia sac is an extremely rare entity. Patients often complain of crampy, dull, lower abdominal pain combined with an irreducible, tender mass in or near the inguinal canal. Because of the nonspecific presentation of the pain, the diagnosis of appendicitis is rarely considered. The exact mechanism is unknown. Some think it may begin upon entry of the appendix into the inguinal canal that compromises the blood supply to the appendix and increases its vulnerability to trauma (external or internal), resulting in inflammation and bacterial overgrowth. The laparoscopic approach is a safe and effective option for the treatment of this rare finding. H&A — Several relatively rare findings during repair of an inguinal hernia deserve mention. A small brownish or beige nodule attached to the cord structures is ectopic adrenal tissue of no significance. An absence of the vas deferens raises suspicion for cystic fibrosis and should lead to screening with sweat chloride test, if the patient has not been already diagnosed. Inability to identify an indirect hernia sac despite adequate cord dissection in a patient with a documented inguinal hernia on examination should raise the possibility of the rare direct or femoral hernia. If a direct hernia is obvious during an open operation, a simple Bassini repair in most children suffices. If a direct component is not readily obvious, laparoscopy is warranted and is quite accurate in identifying alternative inguinal hernias. Laparoscopic repairs of direct and femoral hernias in children have been described. A sliding hernia is described if an abdominal organ forms a wall of the sac. The most common organs involved are the bladder medially on either side or the cecum on the right side. In girls, the fallopian tube is not infrequently adherent to the medial sac. In most of these scenarios, the organ can be dissected from the wall of the sac and reduced, followed by the typical high ligation. In girls, another option is to divide and ligate the sac distal to the tube, invert it into the abdomen, and close the deep ring. Sherif

Answer 31

Most infants and children undergo inguinal hernia repair under general anesthesia. Regional anesthesia is an alternative, attracting resurgent interest due to neurodevelopmental concerns about general anesthesia in newborns and children up to age 4 years. A 2015 Cochrane metaanalysis found moderate-quality evidence that the administration of spinal, when compared with general, anesthesia without preoperative or intraoperative sedative administration may reduce the risk of postoperative apnea by nearly half in preterm infants undergoing inguinal herniorrhaphy at a postmature age. Combinations of caudal analgesia, dexmedetomidine (potentially neuroprotective), and other agents have been used as an alternative to general or spinal anesthesia. Inguinal hernia repair for healthy children or term infants is an outpatient procedure. However, the lower the postconceptual age at the time of operation, the higher the risk of postoperative apnea in premature infants (inverse correlation). Also, infants with complex comorbidities, anemia, history of apnea, or lower birth weight and infants who need supplemental oxygen or have chronic lung disease have an increased risk of postoperative apnea as well. Overnight monitoring may be necessary in high-risk patients, but the overall risk of significant apnea appears to be low (2–5%). The postconceptual age prior to which admission and monitoring is required varies among institutions, typically between 50–60 weeks. H&A — In an effort to mitigate the potential cardiorespiratory and neurodevelopmental effect of general anesthesia for hernia repair in small infants, regional anesthesia, in the form of a spinal anesthetic, has been advanced as a potential alternative. This option has been used quite successfully in many centers, but experience with this is not available at all centers. In addition, regional anesthesia is limited by duration and compatibility with laparoscopic surgery. Therefore, an anticipated difficult open repair or a laparoscopic repair may be a relative contraindication. A Cochrane review of this subject concluded that regional anesthesia may significantly decrease postoperative apnea only if no sedatives are given during the preoperative period. However, this may come at the cost an increased chance of failure of the regional anesthetic and conversion to general anesthesia. From the neurodevelopmental point of view, the GAS study, an international, multicenter, randomized trial that compared regional and spinal anesthesia in young infants undergoing hernia repair, showed no difference in outcomes at 2 years of age. The results at 5 years of age are pending. Given these data, the surgeon and anesthesiologist should make a joint decision to use regional anesthesia based on the availability of expertise, the likelihood of the procedure to be completed under regional anesthesia, and the likelihood of the patient to benefit from this approach. Sherif

Answer 32

Complications are relatively infrequent after inguinal hernia repair. Parents are often concerned about bruising and swelling in the scrotum or labial region, but this is usually transient and minor. Large scrotal hematomas/seromas can compromise the blood flow to the testis, and Doppler US may be useful to define the nature of the swelling and evaluate for ischemia. The hematoma should be promptly evacuated if there is evidence of impaired blood flow to the testis. Residual asymptomatic hydroceles are common, especially if a large hydrocele was present preoperatively. Most will eventually reabsorb, but if persistent for 6–12 months, aspiration may be indicated. Only rarely is formal hydrocelectomy required. A recurrent hernia is seen in less than 2% of repairs in the absence of predisposing factors, such as prematurity, incarceration, disease processes that increase the intra-abdominal pressure (CF, VPSs, ascites), connective tissue disorders, and teenage patients. Many authors advocate a laparoscopic approach for recurrent hernias because the technical difficulty and risk of injury to cord structures is likely increased in the scarred, previously operated inguinal canal. Operative times are reduced with a laparoscopic approach for the recurrence, and complications have been minimal in several small series. Finally, for recurrence of an inguinal hernia after an open inguinal approach, laparoscopy is likely the best approach to identify and treat the cause of the recurrence. Injury to the vas or testis is a rare complication, both under 1%. In Ein’s personal series of 6361 open inguinal hernia repairs, vasal injuries were found in 0.6 per thousand and testicular atrophy was noted in 0.3%. Similar numbers are found in other reports. The incidence of vasal injury may be underestimated as instrument manipulation of the cord causes microscopic injury and scarring in animal models. Long-term follow-up after laparoscopic repairs is not yet available. In the open era, a review of 7314 male pediatric hernia specimens found either vas deferens or epididymis in 0.53% of specimens. However some of these may represent remnants rather than true injuries. As discussed, ischemic injury to the testis or ovary is increased dramatically by incarceration, but gonadal preservation should be the rule. In an adult meta-analysis, there was no evidence of an association between prior inguinal hernia repair (without mesh) and male infertility or obstructive azoospermia. Conversely, in series of adults who have obstructive azoospermia, pediatric inguinal hernia repairs are a common cause. The success of vasal repairs in adulthood is variable, with vas patency rates of about 60–65% and pregnancy rates of 25–40%. Iatrogenic cryptorchidism, or ascending testis, is another infrequent complication of inguinal hernia repair. In a recent report, Wang et al. reviewed over 17,000 pediatric inguinal hernia repairs (approximately equally divided between open and laparoscopic repairs) and found an incidence of 0.058%. This was attributed to adhesion of the cord that fixes the testis in position. Reoperative orchidopexy is usually required. Small infants with very large inguinal hernias may have respiratory insufficiency from loss of abdominal domain after the bowel is reduced. Although uncommon, this concern needs to be taken into consideration, particularly in NICU infants with large hernias who are already oxygen or ventilator dependent. Staged repair of bilateral hernias may be necessary in such patients. Chronic pain after inguinal hernia repair is widely recognized in adults (10–15%), but less so in children. Few studies have assessed inguinodynia in children, but in two studies, the incidence was about 5%, which is half of the incidence in adults. Mortality directly related to an inguinal hernia or its repair is exceedingly rare (<1%). H&A

Answer 33

Direct and femoral inguinal hernias are rare in children. However, they have to be considered if an indirect hernia is not identified during surgery, in recurrent hernias, and in certain patient populations, such as those with connective tissue disorders. Sherif

Answer 34

Laparoscopic repair of pediatric inguinal hernias is not new, being first reported in 1993. However, the procedure gained wider acceptance after laparoscopic-assisted transcutaneous techniques were introduced, decreasing the need for multiple trocar sites and intracorporeal suturing. A number of such transcutaneous techniques using different instruments and different suture materials have been described, with the common denominator being ligation of the peritoneum at the deep ring, taking care to avoid the inclusion of the vas and testicular vessels in the ligature. One of the more commonly employed transcutaneous techniques, SEAL, used in the index case, involves introducing a permanent braided suture on a curved needle through the abdominal wall, bisecting the ring with the suture, exiting at the opposite margin of the deep ring, reversing the swage of the needle back through the entry incision, repeating the cycle by passing the needle around the full circumference of the defect while avoiding the vas and vessels, and tying the knot in the subcutaneous tissue. These steps are shown in Figure 18.4, in a 3-kg ex-premature baby boy. Insufflation immediately demonstrates the bilateral hernia by resulting in scrotal distention with air. In girls, an alternative technique is to introduce a grasper into the sac, grab its apex, invert the sac into the abdomen, ligate it using a pre-tied knot, and excise the excess. Sherif

Answer 35

Recurrence, although rare, is probably the most common adverse outcome of a pediatric inguinal hernia repair and has been discussed above in the context of open and laparoscopic procedures. It should be noted that the mechanism of recurrence is likely to be quite different between the two procedures. Recurrences after laparoscopic repairs are almost exclusively a reopening of the deep ring due to failed ligation. A recurrent hernia after laparoscopy, therefore, is almost always an indirect hernia. Recurrences after open surgery can also be due to failed identification or excision of the sac and persistence of an indirect hernia. However, they can also be missed direct or femoral hernias, an unappreciated pantaloon hernia during the initial repair, or new direct hernias due to damage of the inguinal floor during the initial repair. Recurrences after laparoscopy therefore may be best approached by an open procedure, while the reverse is true for open procedures. Laparoscopy after a failed open inguinal hernia is likely to accurately identify the etiology and allow repair in a previously undisturbed plane. Sherif

Answer 36

Umbilical hernias are by far the most common abdominal wall hernias encountered in children, present at birth in up to one-quarter of white children and up to three-quarters of children of African descent. However, a minority of umbilical hernias present at birth will progress to surgical repair. The long-held surgical dictum to wait until 4 years of age before repair of an asymptomatic umbilical hernia continues to be observed by most pediatric surgeons and is currently based on four principles. 1) The first principle is the high likelihood of spontaneous closure. Most hernias that close spontaneously do so in the first year of life, but spontaneous closure has been documented well into adolescence. However, with increasing age, the chances of spontaneous closure diminish, especially if the defect size is more than 1 cm in diameter. 2) The second principle is the very low risk of complications such as incarceration, strangulation, or skin necrosis with bowel evisceration. One of the few large, long-term studies showed that only 7% of all umbilical hernias required an urgent repair due to acute complications. This proportion is probably well above that seen by most pediatric surgeons, since an acute complication of an umbilical hernia requiring surgical intervention is a rare event in most practices. However, incarceration can indeed occur in umbilical hernias. 3) The third principle is repair of the cosmetic defect prior to start of school to prevent the child from experiencing potential negative social consequences. 4) The fourth principle is to delay purely elective surgery until after age 3 years to decrease potential negative neurodevelopmental effects. This recommendation was recently formally issued by the US Food and Drug Administration. Symptomatic umbilical hernias should be repaired expeditiously regardless of age. In addition, repair of an asymptomatic umbilical hernia should be considered in a patient younger than 4 years of age who is undergoing a general anesthetic for another outpatient procedure. In the age of laparoscopy, many umbilical hernias in babies and children are repaired at the termination of the laparoscopic procedure. With the exception of patients of African descent, most umbilical hernia defects are 1–2 cm in diameter with a small degree of protrusion. These hernias are repaired through an infra-umbilical incision. The umbilical stump, which also forms the sac, is encircled and divided. Any excess sac at the level of the defect is either excised or inverted into the abdomen to clearly delineate the muscle edges. The defect is then closed with interrupted or running slow absorbable suture. No attempt is made to excise the portion of the sac attached to the umbilicus. A large umbilical hernia is often associated with a large amount of excess redundant skin, referred to as a proboscis. The challenge in these cases is to produce a reasonable umbilicus. Many techniques, some relatively complex, have been described to address this issue. I have repaired many of these large hernias on multiple missions to Africa and have settled on a technique that involves a supra-umbilical incision, near complete excision of the sac from the muscle edges, continuous closure of the fascial defect with a slow, absorbable monofilament suture, excision of a crescent of excess skin, and closure of the wound in a frown configuration around the umbilicus. Complication rates after umbilical hernia repair are quite low. Postoperative wound complications such as seroma and hematoma are best managed non-operatively and almost always improve spontaneously. Recurrence rates should be less than 2%. A normal-appearing umbilicus can be achieved in most routine cases, and a reasonable umbilical appearance can be obtained by one of the many types of umbilicoplasties described for larger hernias. Sherif

Answer 37

A hernia that is rarely mentioned in the literature or in surgical textbooks is the supra-umbilical hernia. In this condition, the umbilical ring is closed and the umbilicus is normally attached to the underlying fascia. A separate full-thickness defect, usually measuring 1–2 cm in diameter, is seen 1–2 cm above the umbilical ring. It can be approached through a supra-umbilical incision and raising a skin and subcutaneous tissue flap superiorly. Sherif

Answer 38

Another common condition referred to pediatric surgeons is diastasis recti, a non-pathologic condition that results from more lateral insertion of the rectus muscles, creating a wider linea alba. Classically, the child’s abdomen looks normal when relaxed, with a ridge developing upon sitting up from a recumbent position (sit-up test). A gap can often be palpated between the rectus borders. The condition may gradually improve in children, but it is also present in many adults. Reassurance suffices and no follow-up is necessary. Epigastric hernia can exist along with diastasis recti and should be ruled out by physical examination. Sherif

Answer 39

A Spigelian hernia is exceedingly uncommon in children and can also be exceedingly difficult to confirm on physical examination or imaging. The hernia occurs at the junction of the linea semilunaris (lateral border of rectus muscle) with the linea semicircularis (level of absence of posterior rectus sheath approximately halfway between umbilicus and pubis). The term traumatic Spigelian hernia has been used in the literature, but should be avoided in order to prevent confusion. In boys, Spigelian hernias have been reported to contain a cryptorchid testicle in approximately half of cases. Interestingly, in about two-thirds of such patients, there is an absent inguinal canal, offering a potential etiology of these hernias related to testicular maldescent. Spigelian hernias may be suspected if a patient presents with intermittent pain and the impression of a mass at the appropriate spot. Unfortunately, they are rarely elicited by straining in such patients. Imaging with ultrasound or CT is often employed, but frequently unhelpful. If suspicion persists, a diagnostic laparoscopy may be performed, proceeding to laparoscopic or open repair if a Spigelian hernia is confirmed. Sherif

Answer 40

Incisional hernias are far less common in children than adults, occurring in 1%–2% of children after laparoscopy or laparotomy. They are mostly seen after laparotomies in neonates and infants, especially if a wound infection has occurred. The peri-umbilical incision is a versatile one in pediatric surgery and allows a number of gastrointestinal procedures to be performed. One of the most common procedures performed through a peri-umbilical incision is pyloromyotomy, which is also one of the most common sources of incisional hernias. Trocar site hernias can occur after laparoscopy in small infants. An attempt should therefore be made to close all trocar sites, including 3-mm incisions, as well as any stab incisions that were dilated in neonates, infants, and toddlers. Most incisional hernias will be identified within several weeks of the primary operation. Immediate repair is not necessary as many do decrease in size and may even close completely as the child grows. Incarceration through an incisional hernia is quite rare in children. Incisional hernias that persist can typically be repaired using primary closure without mesh. Sherif

Answer 41

Exceedingly rare lateral abdominal wall hernias can be seen in children. Congenital subcostal hernias have been reported and seen either as isolated defects or in association with other anomalies. A subcostal bulge that occurs after a low thoracotomy or a subcostal incision is usually an eventration rather than a hernia and may be observed, as gradual improvement often ensues. They can be seen after open repair of a congenital diaphragmatic hernia. Lumbar hernias are also rare. These occur in the region bordered superiorly by the 12th rib, inferiorly by the iliac crest, anteriorly by the posterior border of the external oblique, and posteriorly by the erector spinae muscle. Superior and inferior lumbar hernias referred to as Grynfelt and Petit hernias, respectively, have been described but this classification is of uncertain significance. In young children, a good muscle rim can be dissected from the sac and primary closure can be obtained. A lumbar hernia in adolescence typically requires a mesh repair. Lumbar hernia can also be seen in association with lumbo-costo-vertebral syndrome, which includes rib and vertebral anomalies. The syndrome has a wide phenotype spectrum, from asymptomatic variants to lethal forms. Sherif

Answer 42

One of the most impressive abdominal wall anomalies is prune belly syndrome. This syndrome results in a classic triad of deficient or absent abdominal wall musculature, urinary tract abnormalities, and bilateral intra-abdominal undescended testicles. Multiple associated anomalies have also been described, including several gastrointestinal anomalies such as malrotation, bowel atresia, and imperforate anus that need to be addressed by the pediatric surgeon. The deficiency of abdominal wall musculature disproportionately affects the anterior musculature below the umbilicus. A number of abdominal wall reconstruction techniques have been used to advance the better-developed peripheral musculature in order to replace the deficient central musculature. This is done with the goal of improving abdominal tone, which may in turn lead to improved functions of the urinary and gastrointestinal tracts. Sherif

Answer 43

Abdominoscrotal hydrocele, as depicted in the index case, is the rarest type of hydrocele, but is being increasingly reported. The leading theory for its etiology is extension of a hypersecreting scrotal hydrocele back into the preperitoneal space. The hydrocele therefore extends from the scrotum proximally, eventually insinuating itself into the abdominal cavity extraperitoneally, creating the classic dumbbell shape. A persistent processus vaginalis adjacent to the abdominal component may or may not exist. This theory is well-supported by surgical findings. Abdominoscrotal hydrocele is an evolving lesion and should be suspected if a hydrocele diagnosed at birth, or during the first few months of life, is increasing in size and tension or manifesting the spring-back ball sign, as described earlier. Unlike other types of hydroceles, spontaneous resolution was rarely reported, prompting earlier treatment. However, a recent experience demonstrated resolution of the abdominal component or the entire hydrocele in almost two-thirds of patients. Repair of these lesions can be challenging and is associated with a significant rate of postoperative complications. A period of observation is a reasonable alternative. Sherif

Answer 44

The timing of hydrocele repair in general has also been controversial. Several facts are known. At least two-thirds of hydroceles diagnosed during infancy will resolve spontaneously. Of those hydroceles that do resolve, the great majority will resolve by 18–24 months of age, but resolution after that age has been reported. The concern for a concomitant inguinal hernia is not substantiated, as only about 5% of patients with a hydrocele will develop an inguinal hernia. There is no good reason to repair a typical hydrocele, including a hydrocele of the cord, before the age of 2 years if the patient is otherwise asymptomatic and there are no other concerns. However, the two-year cutoff is not an absolute. The decision to repair the hydrocele at that age should take into account the size and evolution of the lesion, and the parents’ preferences. Repair of pediatric hydroceles, other than abdominoscrotal hydroceles, is identical to inguinal hernia repairs, with excision of the processus vaginalis, high ligation, and wide opening with or without partial excision of the distal sac. A hydrocele of the cord is simply excised after high ligation of the proximal sac. Sherif

Answer 45

Hydroceles may present acutely. The most common etiology of an acute hydrocele is a viral syndrome, such as an upper respiratory tract infection or gastroenteritis, which causes both reactive peritoneal fluid formation and excess secretion by the tunica vaginalis. In fact, first presentation during a viral infection is not rare and should not trigger a decision to repair. An acute hydrocele may also be a reaction to a scrotal or abdominal process. Torsion of the testicle or appendix testes is usually accompanied by a reactive hydrocele. In a premature baby boy, an acute dark-colored hydrocele may result from intestinal perforation. Since up to 40% of males may have silent patency of the processus vaginalis, an acute hydrocele in an older child or adolescent should raise suspicion for an abdominal processus leading to perforation or ascites.

Answer 46

1) At least two-thirds of hydroceles diagnosed during infancy will resolve spontaneously. Of those hydroceles that do resolve, the great majority will resolve by 18–24 months of age, but resolution after that age has been reported. The concern for a concomitant inguinal hernia is not substantiated, as only about 5% of patients with a hydrocele will develop an inguinal hernia. There is no good reason to repair a typical hydrocele, including a hydrocele of the cord, before the age of 2 years if the patient is otherwise asymptomatic and there are no other concerns. However, the two-year cutoff is not an absolute. The decision to repair the hydrocele at that age should take into account the size and evolution of the lesion, and the parents’ preferences. Repair of pediatric hydroceles, other than abdominoscrotal hydroceles, is identical to inguinal hernia repairs, with excision of the processus vaginalis, high ligation, and wide opening with or without partial excision of the distal sac. A hydrocele of the cord is simply excised after high ligation of the proximal sac. 2) Hydroceles may present acutely. The most common etiology of an acute hydrocele is a viral syndrome, such as an upper respiratory tract infection or gastroenteritis, which causes both reactive peritoneal fluid formation and excess secretion by the tunica vaginalis. In fact, first presentation during a viral infection is not rare and should not trigger a decision to repair. An acute hydrocele may also be a reaction to a scrotal or abdominal process. Torsion of the testicle or appendix testes is usually accompanied by a reactive hydrocele. In a premature baby boy, an acute dark-colored hydrocele may result from intestinal perforation. Since up to 40% of males may have silent patency of the processus vaginalis, an acute hydrocele in an older child or adolescent should raise suspicion for an abdominal processus leading to perforation or ascites. 3) The surgeon must remember that a testicular mass in an infant can mimic a hydrocele. 4) Hydroceles that start in late childhood or adolescence are usually non-communicating and often quite large. It may be difficult to palpate the testicle due to the size of the hydrocele. But regardless of whether the testicle is palpable, an ultrasound should be done to exclude scrotal pathology prior to intervention. A hydrocelectomy through a scrotal approach is preferred. Patients should be counseled that they may continue to have residual fluid and testicular involvement for weeks to months after surgery. 5) Finally, hydrocele is not exclusively found in males. A hydrocele of the canal of Nuck is the female equivalent and may be found in the inguinal canal or labia majora of a young girl. It is treated by excision and high ligation of the patent processus vaginalis. Sherif

Answer 47

B Left-sided hernia in girls under two years of age is an indication of contralateral exploration, not the right sided hernia. Syed/MCQ

Answer 48

D It is called Litter’s hernia when Meckel’s is the content. Irreducible hernia is called incarcerated hernia. Hernia with features of obstruction is called obstructed hernia. Hernia with compromised blood supply is called strangulated hernia. Hernia with double loops of bowel is called Maydl’s hernia, and when a portion of bowel is strangulated, it is called Richter’s hernia. Syed/MCQ

Answer 49

D Failure of ligation of sac at internal ring is the cause of recurrence. Syed/MCQ

Answer 50

E About 21 percent of hernia sac contains salpinx. Syed/MCQ

Answer 51

E Transillumination is not definitive because thin walled infants intestine may be transilluminated as nearly as hydrocele sac. The criteria for postoperative in hospital monitoring is the infant’s post-conceptual age (gestational age + age in weeks). After 45–50 weeks of postconceptual age, the probability of life-threatening apnea is minimal; thus, infants with postconceptual age of 55 do not require in-hospital monitoring. Syed/MCQ

Answer 52

B The inguinal canal is an oblique passage in the lower abdominal wall that passes from deep to superficial inguinal rings. It transmits the spermatic cord and ilioinguinal nerve in the male and the round ligament of the uterus and ilioinguinal nerve in the female. Its relations are: ● anteriorly – skin, Camper’s fascia, Scarpa’s fascia, external oblique aponeurosis, internal oblique in lateral third of canal ● posteriorly – conjoint tendon (medially), transversalis fascia (laterally) ● above – lower arching fibres of internal oblique and transversus ● below – lower recurved edge of external oblique (inguinal ligament). The deep inguinal ring is a defect in the transversalis fascia 1 cm above the midpoint of the inguinal ligament, lateral to inferior epigastric vessels. The superficial inguinal ring is a defect in the inguinal ligament, which lies above and medial to the pubic tubercle. An indirect hernia passes through the deep inguinal ring along the inguinal canal into the scrotum, while a direct hernia bulges through the posterior wall of the canal medial to the inferior epigastric artery through the Hasselbach’s triangle. The boundaries of the Hesselbach’s triangle are: inferior epigastric artery (laterally), inguinal ligament (inferiorly) and lateral border of rectus abdominis (medially). An indirect hernia in a child is due to a PPV, which is a peritoneal diverticulum extending through the internal inguinal ring into the canal. The female anlage of the PPV is the canal of Nuck, a structure that leads to the labia majora. The mid-inguinal point is halfway between the anterior superior iliac spine and the pubic symphysis and is the location of the femoral artery. SPSE 1

Answer 53

B The overall incidence of inguinal hernia in a term newborn is 3%–5%, whereas in a premature infant this increases to 10%–30%. other conditions associated with an increased incidence of inguinal hernia include cryptorchidism, abdominal wall defects, connective tissue disorders (Ehlers–Danlos’s syndrome), mucopolysaccharidoses such as Hunter’s or Hurler’s syndrome, cystic fibrosis, ascites, peritoneal dialysis, ventriculoperitoneal shunts, congenital hip dislocation and myelomeningocele. Approximately 60% of hernias are right sided, and 10% are bilateral. Approximately 11.5% have a family history of hernia, and there is an increased incidence in twins (10.6% in male twins vs. 4.1% in female twins). The overall incidence of metachronous contralateral inguinal hernia (MCIH) is 7.2%, 6.9% in boys and 7.3% in girls. Children with a left-sided inguinal hernia had a significantly higher risk of developing an MCIH than those with a right-sided hernia (10.2% vs. 6.3%). SPSE 1

Answer 54

A most hernias are asymptomatic, except for an inguinal bulge while straining. Incarcerated hernias result from entrapment of bowel or other viscera within the hernia sac. The risk of incarceration ranges from 12% to 17%, and is similar in boys and girls. Younger age and prematurity are risk factors for incarceration. on clinical examination, a bulge can be provoked using Valsalva’s manoeuvre, and at times a thickened spermatic cord can be palpated (silk glove sign). occasionally other structures can be found within a hernia sac, such as the appendix (Amyand’s hernia) or a meckel’s diverticulum (littre’s hernia). SPSE 1

Answer 55

D most surgeons recommend repair of the hernia soon after diagnosis. In premature infants, there is an increased risk of incarceration and the recurrence rate is higher in smaller infants. Hence many institutions recommend repair prior to discharge from the neonatal unit, after the child has attained a weight of 2 kg in asymptomatic and otherwise relatively healthy newborns. overnight stay is not necessary after inguinal hernia repair for healthy children or term infants. However, the risk of postoperative apnoea and bradycardia is increased in premature infants and hence overnight monitoring is essential. This risk decreases to less than 1% in premature infants more than 56 weeks’ post-conceptual age (gestational age + chronological age). Hence many institutions will recommend overnight stay for patients under 60 weeks’ post-conceptual age. The overall incidence of mCIH is 7.2%, 6.9% in boys and 7.3% in girls. Although contralateral exploration for unilateral inguinal hernia has been controversial, there is no evidence from the literature that routine contralateral exploration is justified. SPSE 1

Answer 56

D The male-to-female ratio of inguinal hernia is between 3 : 1 and 10 : 1. Sliding hernias are more common in girls, where a fallopian tube or mesosalpinx is frequently found in the wall of the hernia sac in girls and is at risk for injury. The finding of a testis during repair of a female hernia should raise the suspicion of congenital androgen insensitivity syndrome (CAIS) or true hermaphroditism. The reported incidence is 1.6% of female infants with inguinal hernias will have CAIS, while as many as 75% of CAIS patients present with a hernia. Bilateral hernias in girls are not associated with a higher risk of CAIS than is a unilateral hernia. If a testis is discovered at operation, most surgeons advocate repairing the hernia and leaving the gonads for the time being. Karyotyping and pelvic ultrasonography is then performed. The gonads would eventually need to be removed, although the timing is controversial. SPSE 1

Answer 57

C Testicular vessels are vulnerable to operative injury, especially in small infants. However, testicular atrophy after routine hernia repair is rare (1%). With incarcerated hernia, the blood supply to the testis may be compromised leading to testicular atrophy (2%–3%). These cases are often operated on as an emergency procedure. The risk of recurrence in an elective inguinal hernia repair is less than 1%. It is higher in premature infants, children with incarcerated hernias and children with associated diseases (mucopolysaccharidoses such as Hurler’s and Hunter’s diseases and connective tissue disorders such as Ehlers–Danlos’s and marfan’s syndromes). Hence in these disorders some surgeons recommend a high ligation and a formal herniorrhaphy to prevent recurrences. Postoperative infection rates range from 1% to 3%. After hernia repair, scrotal swelling may develop as a result of fluid accumulating in the distal sac, forming a hydrocele. This does not always indicate a recurrence and most of these resolve spontaneously. SPSE 1

Answer 58

E A hydrocele is a collection of fluid in the space surrounding the testicle between the layers of the tunica vaginalis. Hydroceles may be communicating (patent processus vaginalis with free flow of fluid) or non-communicating (usually scrotal in males). Hydroceles are usually bilateral, with a higher rate of occurrence on the right side. If a hydrocele was not present at birth, or dramatically changes in size or shows daily fluctuation in size (communicating hydrocele), this is suggestive of a PPV. A hydrocele may be secondary to torsion of the testis or its appendages. Alternatively, an acute hydrocele may be seen concurrently with or following an acute upper respiratory tract infection or diarrhoeal disease. most cases of congenital hydrocele resolve by 2 years of age. Hence most surgeons would observe these children in the first 1–2 years of life, and operate on those that persist. If a hydrocele is communicating (which indicates a PPV), or a hernia cannot be ruled out, early operation is indicated. SPSE 1

Answer 59

B A femoral hernia occurs through the femoral canal, which is the medial compartment of the femoral sheath, and is entered via the femoral ring. It contains fat and lymph nodes (Cloquet’s node). The relations of the femoral ring are: inguinal ligament (anteriorly), lacunar ligament (medially), pectineal ligament (posteriorly) and femoral vein (laterally). Femoral hernias lie below and lateral to the pubic tubercle (unlike inguinal hernias, which lie above and medial), and are inferior and posterior to the inguinal ligament. Because the femoral ring is narrow and the lacunar ligament forms a sharp medial border, irreducibility and strangulation are more common in a femoral hernia. Femoral hernias can be repaired via either the open or the minimally invasive route. Three approaches have been described for open surgery. ● lockwood’s infrainguinal approach ● lotheissen’s transinguinal approach ● mcEvedy’s high approach. The infrainguinal approach is the preferred method for elective repair. The transinguinal approach involves dissecting through the inguinal canal and carries the risk of weakening the inguinal canal. mcEvedy’s approach is preferred in the emergency setting when strangulation is suspected. This allows better access to, and visualisation of, bowel for possible resection. Repair is either performed by suturing the inguinal ligament to the pectineal ligament (Cooper’s ligament repair) using strong non-absorbable sutures or by placing a mesh plug in the femoral ring. With either technique care should be taken to avoid any pressure on the femoral vein. Bassini’s repair (conjoint tendon is approximated to the inguinal ligament) is a type of tension herniorrhaphy for the management of direct inguinal hernia. SPSE 1

Answer 60

D Umbilical hernias in childhood occur with an equal frequency in boys and girls. Premature and low-birthweight infants have a higher incidence than full-term infants. Similarly, infants with other conditions such as Beckwith–Wiedemann’s syndrome; Hurler’s syndrome; various chromosomal disorders such as trisomy 13, 18 and 21; congenital hypothyroidism and children requiring peritoneal dialysis. The umbilical hernia of childhood is distinguished from a ‘hernia of the umbilical cord’, in which there is a defect in the peritoneum, as well as an open fascial defect at the umbilicus – intestines herniate into the substance of the umbilical cord itself and are covered only by amnion. A hernia of the umbilical cord is in effect a small omphalocele. The majority of umbilical hernias will close spontaneously by 3–4 years of age. Those persisting beyond that period can be repaired through an infraumbilical approach. SPSE 1

Answer 61

C Epigastric hernias are hernias through the midline linea alba. They present as a small mass, usually with incarcerated properitoneal fat, between the umbilicus and xiphoid process. They have no communication with the peritoneal cavity and do not resolve and hence should be repaired. A spigelian hernia occurs through a defect at the intersection of the linea semicircularis and the lateral border of the rectus abdominis muscle. These hernias are more frequent in girls and more commonly occur on the right side below the umbilicus. Pain in that area and fullness or an actual mass are most common symptoms. These are difficult to detect and diagnose, and an ultrasonography or computed tomography may be needed. Repair is usually done with a tension-free closure through a transverse incision over the defect. lumbar hernias are usually visible shortly after birth as a bulge (properitoneal fat) in the area bordered by the 12th rib, sacrospinalis muscle, and internal oblique muscle. These hernias tend to develop at the site of penetration of the intercostal nerves and vessels or of the ilioinguinal, iliohypogastric and lumbar nerves. Although they are asymptomatic, repair is advisable because the defect never resolves spontaneously and incarceration is possible. Repair may sometimes require a prosthetic mesh. SPSE 1

Inguinal, Incisional, Epigastric Hernias Flashcards

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