| 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 |
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