Definition | Irreducible/ incarcerated hernia: a hernia that cannot be manually reduced back into the abdomen. Local signs include firmness, tenderness and erythema. The irreducible organ may be compromised i.e. Bowel = obstruction causing reduced feeding, passage of stools and flatus, vomiting, bilious vomiting. Ovary/testis/omentum= ischaemia causing tenderness and erythema. Strangulated hernia : An irreducible/ incarcerated hernia progresses to strangulation as vascular compromise becomes established. Local signs include pain and tenderness out or proportion, spreading cellulitis. Systemic signs include pyrexia, tachycardia, hypotension. In infants and neonates, this can mimic the appearance of sepsis. If in doubt, assume strangulation and treat with concommitant speed. |
Typical presentation | A firm, tender, irreducible lump in the groin. |
Age | Tufts series: 85% of incarceration when age <1 year |
Incidence | Tufts series: Retrospective review of consecutive herniorrhaphy, 85/908 incarcerated. Within the incarcerated subgroup (n=85): -35% with known hernia present with incarceration. – 65% had a first presentation with incarceration -85% of incarceration when age <1 year |
Sex | |
Aetiology/ natural history | Tufts series: Retrospective review of consecutive herniorrhaphy, 85/908 incarcerated. Within the incarcerated subgroup (n=85): – 84% had successful manual reduction -16% had unsuccessful manual reduction, associated with a increased average length of stay (4 days) -31% significant complications ( infarction of the testis or ovary, bowel obstruction, intestinal necrosis, wound infection, and recurrent hernia) |
Differentials | Encysted hydroecoele |
Examination | Give analgesia A firm, tender, irreducible lump in the groin. Hernia vs hydrocoele |
Investigations | |
Bedside | Vital signs |
Blds | Hb check for neonates. XMatch anticipating need for laparotomy. |
Imaging | XRay : air in the groin , signs of bowel obstuction USS: useful when diagnosis is in doubt, but should not delay exploraton |
Special tests | Nuclear: |
Treatment | |
Goals/ Principles | 1. Reduction: Reduce hernia to prevent further ischaemia to bowel or testis/ ovary 2. Hernia repair: Allow oedema at the deep ring to reduce before attempting herniorrhapy |
Conservative | None. |
Medical | Analgesia, analgesia, analgesia Good analgesia is essential to improve the chance of successful manual reduction. |
Surgical | Indications |
1. Reduction: Manual reduction of incarcerated inguinal hernia 2. Hernia repair options after successful manual reduction If the patient is haemodynamically stable with no evidence of bowel ischaemia/ necrosis, expectant hernia repair can be done. Admit the patient and observe closely. Once groin oedema is reduced (typically 24-48 hours), proceed with hernia repair . A. Groin exploration and open herniotomy B. Laparoscopy and herniorrhaphy Options for failed manual reduction: Proceed immediately with 1. Laparoscopic reduction and hernia repair 2. Groin exploration and reduction and hernia repair 3. Laparotomy, reduction and hernia repair | |
Op note | |
Complications / Consent | REPERFUSION INJURY Failed reduction / reduction en mass Bowel obstruction Bowel necrosis Laparotomy Infarction of the testis/ ovary, bowel obstruction Wound infection Recurrent hernia |
Outcome measures | Rate of manual reduction Bowel resection |
Follow-up | Indicated, surveillance for hernia recurrence and testis atrophy. Circa 6m. |
Key evidence | 1. Stylianos et al (Tufts, Boston) retrospective series of 908 consecutive herniorrhaphy. |
Tag: hernia
Considerations when counselling parent:
- Age+ metachronous hernia risk : Chances of a metachronous hernia reduce with increasing age
- Age + recurrence risk : laparoscopic recurrence rate may be higher in older patients
- Sex of patient: consider laparoscopic for bilateral inguinal hernia in female patient
- Cost : Open surgery is more cost effective
- Surgeon learning curve
Laparoscopic inguinal hernia
Benefits of laparoscopic approach:
1. Detection of metachronous hernia
2. Reduced pain
3. Better cosmesis
Limitations
1. Longer operative time
2. Greater Cost
Complication data available from some large series:
Large series data available from Oyetunji lab, Children’s Mercy Kansas. https://pubmed.ncbi.nlm.nih.gov/33741178/
- 791 patients
- Age: median age at operation =1.9 years (IQR 0.37, 5.82).
- Time: median operative time= unilateral 21 min (IQR 16, 28), bilateral 30.5 min (IQR 23, 41).
- Complications
- Intra-op:
- Conversion to open = 3/ 791 (0.4%)
- Post-op:
- Bleeding: 4/791 (0.6%)
- Wound infection : 9/791 (1.2%) developed a wound infection
- Recurrence: 20/791 (2.5%)
- Iatrogenic ascent of testis = 10 (1.3%)
- Intra-op:
Inguinal hernia
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 hernia
Direct inguinal hernias are quite rare in children.
Groin Hernia
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 fat or 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 fat or bowel from the abdomen to pop into the groin (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 is moving freely 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 inflamed and tender. The operation should be done as an emergency. The operation is even more urgent 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. This is an emergency. The child needs to be reviewed in A+E for stabilisation before emergent surgery.
Does an ovarian hernia need an operation?
Yes. The timing of this operation depends on the status of the ovary.
- If the ovary is moving freely and is not stuck within the hernia, inflamed 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 direct inguinal hernia.
This type of hernia is quite rare in children. Here is some more information on direct inguinal hernias.
“Your child needs an operation.”
No parent or caregiver ever wants to hear these words.
However, when you find yourself in this circumstance, you want information from a trust source. That’s what the network of PSION collaborators provides.
We are particularly interested in narrowing the Global Health divide have dedicated ourselves to addressing this in the Sub-Saharan Africa region.