Paediatric

Inguinal hernia and weeks or months of life. An inguinal hernia is usually only inter-
mittently detectable, becoming most obvious on straining or

hydrocele ­crying.
Examination of a reduced hernia may reveal thickening and
silkiness of the spermatic cord (‘silk glove’ sign). The mass is
Nicola P Smith usually non-tender and easily reducible. Signs of incarceration
Simon E Kenny include tenderness and later erythema, along with the signs and
symptoms of intestinal obstruction.

Congenital hydrocele presents as a mass in the scrotum shortly

after birth and is commonly bilateral. Hydroceles transillumi-
nate brilliantly and examination usually reveals a normal sper-
Abstract matic cord palpable in the groin and upper scrotum; although
Inguinal hernia and hydrocele are common paediatric surgical condi- this may sometimes be difficult to detect in the infant with
tions, affecting approximately 2% of children. This article discusses the a tense swelling that can extend up to the external inguinal
presentation and differential diagnosis of children with a lump in the ring.
groin. In addition, we summarise the aetiology, embryology, surgical
management and outcomes for these conditions.
Differential diagnosis
Keywords children; hydrocele; inguinal hernia; neonate; paediatric It is crucial to distinguish between hernia and hydrocele because
­surgery; Patent processus vaginalis; processus vaginais the management differs markedly. Other causes of a groin lump
in a child include:
• an incompletely descended testis (which may co-exist with an
In infants, inguinal hernias and hydroceles result from incom- inguinal hernia)
plete closure of the processus vaginalis (the normal developmen- • inguinal lymphadenopathy
tal communication between the abdominal cavity and the groin). • femoral hernia
The distinction between an inguinal hernia and a hydrocele • direct inguinal hernia (rare).
depends on the width of the patent channel (Figure 1). Factors It is usually possible to establish the diagnosis by careful
influencing the development of a hernia include: examination (though an ultrasound scan may be helpful). A
• mechanical ventilation direct inguinal hernia is often recognized only intraoperatively.
• peritoneal dialysis
• connective tissue disorders.
Management
Indications for surgery
Incidence
Inguinal hernia: early surgery is usually recommended follow-
The incidence of patent processus vaginalis at post mortem is: ing diagnosis due to the high risk of incarceration. This risk is
• up 94% in neonates thought to be higher in neonates and therefore younger babies
• 57% in babies up to 1 year are treated as semi-urgent cases. Some studies suggest the risk
• 37% in adults. of incarceration is lower in pre-term infants. This finding may be
Clinically detectable lesions are rarer, occurring in about 2% due to anatomical differences in the pre-term infant or may result
of children. In pre-term infants, a hernia may be detected in from the closer clinical observation enjoyed by many infants in
about 20%. neonatal units in the UK. The policy in many centres in the UK
Boys are more commonly affected than girls (male to female is to repair the inguinal hernia before discharge from hospital,
ratio is 5:1). Right-sided hernias are more common, accounting for when the baby is medically stable.
about 60%, with left–sided defects in 30%, and 10% are bilateral. Incarcerated inguinal hernia (Figure 2) – the infant should
be treated by a clinician with experience in reduction of inguinal
hernias and may need to be transferred to another hospital. The
Presentation
infant should be transferred in a calm, warm environment with
An inguinal hernia presents as a mass in the groin, extend- full resuscitation facilities.
ing towards the scrotum. They usually present in the first few Intravenous access should be obtained and morphine given,
together with appropriate fluid resuscitation (20 ml/kg of 0.9%
saline initially). Monitoring should include continuous pulse
Nicola P Smith MB BChir MA(Cantab) MD MRCS(Eng) Specialist Registrar in oximetry with supplemental oxygen given as needed.
Paediatric Surgery Royal Liverpool Children’s NHS Trust, Liverpool, UK. Reduction should be attempted by gentle constant taxis on the
Conflicts of interest: none declared. incarcerated hernia with simultaneous pressure on the external
ring. Excessive force and prolonged attempts at reduction should
Simon E Kenny BSc MD FRCS(Paed Surg) FAAP is a Consultant Paediatric be avoided because it will cause pain and there is a concomi-
Surgeon / Urologist at the Royal Liverpool Children’s Hospital tant risk of reduction of ischaemic bowel that may lead to severe
(Alder Hey), Liverpool, UK. Conflicts of interest: none declared. ­illness and sometimes death.

SURGERY 26:7 307 © 2008 Published by Elsevier Ltd.

 Paediatric

Differing widths of patent processus vaginalis result in variable pathologies

Normal Inguinal hernia Inguinoscrotal hernia Hydrocele of the cord Communicating hydrocele

Figure 1

If reduction is unsuccessful (or there is doubt as to whether Hydrocele: spontaneous resolution of congenital hydrocele
the hernia has been reduced), the infant should be transferred to is common during the first years of life. Thus, boys should be
a paediatric surgical unit for immediate evaluation and explora- observed until at least three years of age. This avoids unneces-
tion. Surgery for irrreducible hernias in infants can be technically sary surgery in the majority, whilst allowing treatment in the
very demanding and should be performed only by an experi- pre-school period in those requiring an operation. The benefit
enced surgeon. If reduction is successful, the child should remain of repair in potentially reducing testicular temperature (thus
in hospital for 24–48 hours to allow inguinoscrotal swelling to improving fertility) is supported by some surgeons, but remains
subside before performing an inguinal herniotomy. unproven.
Female infants may present with an incarcerated ovary that
can often be mistaken for an inguinal lymph node. Delays in Surgical technique
treatment may result in ovarian loss and so girls with palpable Inguinal hernia: the procedure is commonly performed under
ovaries merit urgent exploration. general anaesthesia with local (ilioinguinal or caudal) blockade.
Spinal anaesthesia is sometimes used in pre-term neonates with
chronic lung disease.
A small incision is made in the groin (following a natural skin
crease) above and lateral to the pubic tubercle. Subcutaneous fat
and Scarpa’s fascia are divided. The external oblique is opened
by splitting along the line of the fibres to enter the inguinal canal.
The cord is identified lying within the inguinal canal, fibres of the
cremaster muscle are separated to allow the cord to be lifted into
the wound. The vas deferens and spermatic vessels should be
identified and preserved by gently sweeping them away from the
sac. Care should be taken not to grasp the vas deferens because
of the risk of injury. Dissection should preserve the hernial sac
and free it from surrounding structures.
Once dissected free, the sac is secured with a haemostat across
its width and divided distally. If required, the sac may be opened
proximally to allow inspection of any suspected contents and
the diagnosis of a sliding hernia. The empty sac should be freed
from surrounding cord structures to the level of the internal ring,
Figure 2 Infant with incarcerated inguinoscrotal hernia. It has not been twisted to ensure reduction of contents, and transfixed.
possible to reduce preoperatively the left-sided inguinoscrotal swelling The external oblique is closed with interrupted absorbable
(distinct from the testis). sutures (e.g. 4/0 vicryl), followed by subcutaneous tissue (as

SURGERY 26:7 308 © 2008 Published by Elsevier Ltd.

 Paediatric

required) and skin closure. In children <18 months, it is often The major structures at risk during surgery are the vas defer-
possible to perform herniotomy without opening the external ens and vessels in males and the Fallopian tube in girls. Rates of
oblique aponeurosis. The testis is then gently pulled into the operative damage are difficult to assess accurately. The vas defer-
scrotum, to ensure adequate descent is possible and iatrogenic ens was found in the excised sac in 0.6% of histologically exam-
maldescent is avoided. ined specimens in one study; in another study, 27% of subfertile
There is no difference in surgical approach between males and adults with a history of childhood inguinal hernia were found to
females. The Fallopian tube is commonly found in the hernial sac have vasal obstruction. Testicular atrophy resulting from damage
and should be actively sought during herniotomy to avoid iatro- to the testicular vessels and/or vessel occlusion in incarceration
genic ligation. is about 6%. This risk is highest in the pre-term infant and during
repair of incarcerated herniae. Damage may also occur to hernial
Hydrocele: the operative procedure for a congenital hydrocele contents including bowel, bladder, ovary and Fallopian tube.
is similar to the repair of an inguinal hernia. However, the distal
sac should be opened to expel the scrotal fluid. If this is difficult Postoperative
to achieve (particularly in the case of an encysted hydrocele), Recurrence of indirect inguinal hernia in children is uncommon
scrotal aspiration may be performed or the fluid may be left to (4%) and is usually ascribed to failure to transfix the hernial sac
absorb. at the internal ring. Neonates appear to be at increased risk of
recurrence, particularly those with chronic lung disease.
Complications
Contralateral exploration: repair of one inguinal hernia does
Preoperative not preclude the metachronous development of a contralateral
If an inguinal hernia is diagnosed, parents should be warned of hernia. Contralateral exploration during unilateral inguinal her-
the symptoms and signs of strangulation (pain and tenderness, niotomy is controversial. This has been advocated due to the
erythema, irreducibility, vomiting), and advised to attend the high (30%) incidence of patent processus vaginalis contralateral
surgical centre immediately if such symptoms occur. to a clinically evident inguinal hernia. However, after unilateral
herniotomy, the incidence of metachronous contralateral hernia
Operative is <10%, and exploration may not be warranted. A reasonable
Care should be taken to identify the sliding hernia. This is more approach is to reserve contralateral exploration for:
common in large hernias in pre-term infants. Opening the sac • premature neonates with severe concurrent disease (e.g. lung
reveals bowel (commonly appendix) or Fallopian tube in the wall disease)
of the sac. These structures should not be dissected free because • children <18 months who are geographically isolated from
of the risk of damage. The hernia is reduced into the abdominal the treatment centre
cavity through the internal ring and the peritoneum closed distal • children who have lost a gonad due to strangulation.
to the contents. The internal ring is tightened to prevent recur- Another approach is laparoscopic contralateral inspection
rence of the hernia. with repair where necessary. ◆

SURGERY 26:7 309 © 2008 Published by Elsevier Ltd.