Incarcerated inguinal hernia

DefinitionIrreducible/ 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.

Risk Matrix: Indirect inguinal hernia repair

Severity / Frequency matrix.

Applies to open and laparoscopic approaches

    Clavien  Dindo     
 II IIIa IIIb IVa IVb 
Rare   Wound infection  Injury to vas
Testis ascent
Testis retraction
Bowel injury
   
     Recurrence   
Common Pain
Scar 
      

Laparoscopic versus open inguinal hernia repair

Considerations when counselling parent:

  1. Age+ metachronous hernia risk : Chances of a metachronous hernia reduce with increasing age
  2. Age + recurrence risk : laparoscopic recurrence rate may be higher in older patients
  3. Sex of patient: consider laparoscopic for bilateral inguinal hernia in female patient
  4. Cost : Open surgery is more cost effective
  5. 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%)   
Categories
General

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 historyPatent 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 
  SurgicalOptions  
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-upIndicated, 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
Categories
General

Direct inguinal hernia

Direct inguinal hernias are quite rare in children.

Categories
General

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.

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