Category: General

Definition	Hernia: Passage of one organ through a musculo-aponeurotic sheath. Indirect inguinal hernia: -herniating organs = bowel, omentum, ovary – musculoaponeurotic sheath = deep inguinal ring
Typical presentation	Right > Left
Age	Neonates > Infants
Incidence	Depends on gestation and age. 1 percent at term neonate 30 percent premature neonate 10 percent bilateral in premature neonate
Sex	Male > Female
Genetics
Aetiology and natural history	Patent process vaginalis (PPV) at the deep inguinal ring communicates with groin leading to accumulation of fluid (hydrocoele) or, if large enough, herniation of bowel , omentum or ovary. Therefore, patent process vaginalis is more common in prematurity. Not all PPV results in clinically apparent hernia, with  29% patent processus vaginalis on post mortem studies  Most remain indolent till repaired. However, there is a 10-35% risk of incarceration.
Differentials	Male: Hydrocoele, undescended testis, lymph node Female : Canal of Nuck hydrocoele, lymph node
Classifications
Severity/Staging
Assessment
History : Antenatal
History : Postnatal
Examination
Investigations
Bedside	Inguinal canal is  0.5 cm in a neonate and 4cm in an adult
Blds	Hb check for neonates Xmatch not required
Urine
Solids/Swabs
Imaging	USS: may be useful to confirm diagnosis
Echo
Special tests	Nuclear:
Treatment:
Goals/ Principles	Divide/ligate processus vaginalis and close deep ring to prevent incarceration of hernia.
Conservative	Not an option due to risk of incarceration
Medical	None
Surgical	Indications
Surgical	Options   1. Open 2. Laparoscopic Timing: -Once identified, should be done as soon as feasible to prevent incarceration. – Incarcerated hernia should be treated as an emergency.
Complications/Consent	Consent for open procedure Intra-op: Injury to vas and vessels, bleeding Post op: Recurrence, testis atrophy, testis retraction/ ascent, wound infection, pain, scar Consent for laparoscopic procedure Intra-op: Conversion to open = 3/ 791 (0.4%) Post-op: Recurrence, testis atrophy, testis ascent/ retraction, bleeding, wound infection, pain, scars Severity/ Frequency Matrix
Op note	Open procedure (M): Laterality: EUA: Both right and left testes at scrotal base, equal in size. Hernia reduced. I: groin, skin crease F: PPV confirmed. Sac [is empty/ contains omentum/ bowel/ovary ] P: Vas and vessels identified and preserved throughout. Spermatic cord skeletonised, hernia sac defined to deep ring. Hernia sac divided, twisted, transected, ligated (x2 vicryl 3/0). C: 3/0 vicryl to ext oblique, Scarpas . 5/0 vicryl to skin. Steristrip dressing. Both right and left testes at scrotal base, equal in size at end. Post op: Can eat and drink, PRN analgesia, home [ later/ after overnight apnoea monitoring ]. Clinic 6/12. Laparoscopic procedure (M): Laterality: EUA: Both right and left testes at scrotal base, equal in size. Hernia reduced. I: umbilical-5mm scope, right and left flank-3mm instruments F: Hernia – deep ring is open. Sac [is empty/ contains omentum/ bowel/ovary ] Contralateral deep ring inspected- it is [closed/ open]. Procedure below to close [Right/Left/Both] deep ring. P: Hernia reduced. Vas and vessels identified and preserved throughout. 4/0 prolene purse string closure of deep ring. C: 2/0 vicryl to umbilical ring, Scarpas . Glue to skin. Steristrip dressing. Both right and left testes at scrotal base, equal in size at end. Post op: Can eat and drink, PRN analgesia, home [ later/ after overnight apnoea monitoring ]. Clinic 6/12.
Outcomes	Recurrence rate Laparoscopic/ Open rate (age subsets) Operative time Cost
Follow-up	Indicated, to monitor for recurrence and testis complications (circa 6m).
Key evidence	Laparoscopic vs open inguinal hernia Risk of metachronous/ contralateral hernia Approaches to hernioscopy Approaches to laparoscopic herniorrhaphy

Direct inguinal hernias are quite rare in children.

My child has a lump in the groin. Is it a hernia?

In boys, the lump may be a a high testicle, a bowel hernia, abdominal fat lining (omentum) or a hydrocoele. Less commonly it is a lymph node.

In girls, a lump in the groin can be a bowel hernia, an ovary or a lymph node.

The difference between these lumps is quite important. Therefore, all groin lumps in children should be properly checked by a doctor.

Why did my son have a hernia?

During development in the womb, all children have a ring-shaped gap communicating between the abdomen and the groin.

In boys, the testicle tracks through this gap on its journey from the abdomen to the testicle sac (scrotum). If this gap doesn’t close by the time of birth it can allow a trickle of fluid (hydrocoele). Sometimes the gap is large enough to allow bowel from the abdomen to follow the testicle into the scrotum (hernia).

Therefore, hernias are more common in boys because of the link to testicle development and descent. They are also more common in premature babies for the same reason.

Why does my daughter have a hernia?

Again, all children have a ring-shaped gap communicating between the abdomen and the groin. In most baby girls, this gap is closed at the time of birth. However, in some girls it remains open and becomes more obvious as the child grows.

The gap can allow a little trickle of fluid (canal of Nuck hydrocoele). The gap can allow bowel to pop into the groin (bowel hernia). The ovary lies low in the abdomen and close to the ring-shaped gap. Sometimes, a hernia contains the ovary.

Does a bowel hernia need an operation?

Yes.

If the bowel or fat within the hernia is moving greely in and out of the groin, then the operation should happen as soon as is feasible.

• If the bowel or fat is stuck within the hernia, it becomes inflammed and tender. The operatoin should be done as an emergency. The operation is even more uirgeny if there are signs of bowel blockage.

Bowel blockage or obstruction is suspected when the hernia is tender. The child deteriorates from reduced feeding to vomiting, particularly green vomiting.

Does an ovarian hernia need an operation?

Yes. The timing of this operation depends on the status of the ovary.

• If the ovary is not stuck within the hernia, inflammed or tender, then the operation should happen as soon as is feasible.
• If the ovary is stuck within the hernia, is inflammed or tender, then the operation should be done as an emergency procedure.

Are children’s hernias different to adult hernias?

Yes.

Most bowel hernias in children are properly called indirect inguinal hernias. They arise from variations in the development process. Adults tend to have direct inguinal hernias which arise from weakening of the abdominal wall.

This difference matters for two reasons.

• Firstly, the operation for children’s hernias involves closing off the ring-shaped gap. This is done with a strong stitch. No mesh is needed.
• Secondly, your surgeon should be specially trained to perform the operation in children. It can be done both keyhole (laparoscopic) and open, with good outcomes for both approaches.

The doctor thinks this lump is a femoral hernia.

This type of hernia is quite rare in children. Here is some more information on femoral hernias.

The doctor thinks this lump is a femoral hernia.

This type of hernia is quite rare in children. Here is some more information on direct inguinal hernias.