Pediatric, Adolescent Surgical Associates, P.C.
w w w. p a s a p c . c o m
Hernia and Hydroceles- What the pediatrician needs to know
PASA Surgical Staff
U P D AT E
2007 S U M M E R
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An inguinal hernia is the protrusion of an abdominal viscus into a peritoneal The diagnosis of an inguinal hernia is made by the history and the finding of a
sac in the inguinal canal. The contents of the sac are usually intestine but may reducible bulge in the groin. Other conditions that must be considered and their
be omentum or ovary and fallopian tube. Repair of inguinal hernia is the most distinguishing characteristics include the following:
common operation performed in children. Boys outnumber girls about 6:1. The
incidence of inguinal hernia is increased in premature infants and in patients with • Enlarged lymph nodes are firm, immobile and nonreducible.
Ehlers-Danlos syndrome, or who have a ventriculoperitoneal (V-P) shunt.
• An abscess is tender, firm, immobile and nonreducible.
As the testis (or round ligament in the female) descends in the last month of prenatal
life, a peritoneal pouch, the processus vaginalis, is brought down with it through the
• An undescended testis is a firm, grapelike mass that sometimes can be
“reduced” or manipulated into the scrotum.
internal inguinal ring, along the inguinal canal and through the external inguinal
ring into the scrotum or labia. The distal-most sac wraps around the testis, forming • A hydrocele is fluid in the scrotum with no mass in the groin above. It is soft
the tunica vaginalis and the proximal sac is normally obliterated. Failure of this or firm and nonreducible.
obliteration results in a patent processus vaginalis into which intestine, ovary or • A hydrocele of the cord (or canal of Nuck) is a firm, mobile, grapelike
other viscera can protrude, forming an indirect inguinal hernia. nontender mass that cannot be reduced or manipulated into the scrotum.
(Transillumination is unreliable in differentiating a hernia from a hydrocele.)
• A hernia only exits when something protrudes into the sac.
• A patent processus vaginalis (not a hernia) is present in 80% of boys at birth, Incarceration results if the intestine gets stuck in the internal inguinal ring. If the hernia is
in 40% at 2 years and in 20% of adult men. not promptly reduced, the intestine swells and becomes edematous causing compression of
the blood supply of the testis or obstruction of the bowel. Once the blood supply to the testis
Other types of groin hernias are: is cut off, infarction will occur within a few hours. An ovary may become incarcerated but
• Direct inguinal hernia – a protrusion through the posterior wall of the seldom infarcts because of the small size of the vascular pedicle.
inguinal canal, medial to the deep inferior epigastric vessels
The characteristics of an incarcerated hernia are sudden onset of severe pain or
• Femoral hernia – a protrusion through a defect that is deep to the inguinal swelling and a hard, tender, fixed mass in the groin. There may be symptoms of
ligament and medial to the femoral vessels intestinal obstruction, such as vomiting and abdominal distention. Often, there is no
prior history of a hernia. Incarceration is most likely in infants. Usually incarcerated
hernias can be manually reduced. If not, emergency surgery is necessary.
Nearly half of all inguinal hernias are noted in the first year of life, most in the
first six months. A bulge in the groin (sometimes extending into the scrotum) that An elective hernia repair is an outpatient procedure unless the patient is a premature
comes and goes is almost always an inguinal hernia. Typically, the hernia appears infant or has other medical problems requiring admission post-operatively. Full
when the child cries or strains but disappears when he relaxes. After a hernia has term infants less than 6 weeks of age and premature infants less than 55 weeks post-
been present for a long time, it may remain “out” constantly. Hernias are usually conceptual age require an overnight stay after hernia repair. Once the diagnosis is
not symptomatic except when they are incarcerated. made, surgery is scheduled. The procedure is performed under general anesthesia,
usually with a caudal epidural for post-operative pain control. Most patients return to
Physical examination reveals a soft bulge in the groin that can be made to disappear
normal activity in 1 to 2 days.
by digital pressure. The “silk glove” sign and “thickening” of the cord noted by
palpation are unreliable signs of hernia and usually cannot be relied upon to make Complications are uncommon but include a 1% to 2% risk of recurrence and a risk
the decision for surgery. A femoral hernia presents as a bulge in the groin that is of injury to the testicle or ovary. Management of the contralateral asymptomatic side
actually on the anterior thigh deep to the inguinal ligament, medial to the femoral is variable and can include exploration, laparoscopic evaluation, or observation.
vessels. A direct hernia is usually indistinguishable from an indirect one by physical Surgery for newborn or congenital hydroceles is usually not indicated since most
examination, although it will not progress into the scrotum. resolve by age one year.