Inguinal hernia and hydrocele

Nicola P Smith is a Clinical Lecturer in Paediatric Surgery at Liverpool University, Liverpool, UK. Simon E Kenny is a Consultant Paediatric Surgeon and Urologist at Alder Hey Childrens Hospital, Liverpool, UK. In infants, inguinal hernias and hydroceles result from incomplete closure of the processus vaginalis (the normal developmental communication between the abdominal cavity and the groin). The distinction between an inguinal hernia and a hydrocele depends on the width of the patent channel (Figure 1). Factors influencing the development of a hernia include: mechanical ventilation peritoneal dialysis connective tissue disorders.
Differing widths of patent processus vaginalis result in variable pathologies

Normal

Inguinal hernia

Inguinoscrotal hernia

Hydrocele of the cord

Communicating hydrocele

Incidence

The incidence of patent processus vaginalis at post mortem is: up 94% in neonates 57% in babies up to 1 year 37% in adults. Clinically detectable lesions are rarer, occurring in about 2% of children. In pre-term infants, a hernia may be detected in about 20%. Boys are more commonly affected than girls (male to female ratio is 5:1). Right-sided hernias are more common, accounting for about 60%, with left-sided defects in 30%, and 10% are bilateral.

Presentation

An inguinal hernia presents as a mass in the groin, extending towards the scrotum. They usually present in the first few weeks or months of life. An inguinal hernia is usually only intermittently detectable, becoming most obvious on straining or crying. Examination of a reduced hernia may reveal thickening and silkiness of the spermatic cord (silk glove sign). The mass is usually non-tender and easily reducible. Signs of incarceration 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 transilluminate brilliantly and examination usually reveals a normal spermatic cord palpable in the groin and upper scrotum; although this

may sometimes be difficult to detect in the infant with a tense swelling that can extend up to the external inguinal ring.

Differential diagnosis

It is crucial to distinguish between hernia and hydrocele because the management differs markedly. Other causes of a groin lump in a child include: an incompletely descended testis (which may co-exist with an inguinal hernia) inguinal lymphadenopathy femoral hernia direct inguinal hernia (rare). It is usually possible to establish the diagnosis by careful examination (though an ultrasound scan may be helpful). A direct inguinal hernia is often recognized only intraoperatively.

Management Indications for surgery

Inguinal hernia: early surgery is usually recommended following diagnosis due to the high risk of incarceration. This risk is thought to be higher in neonates and therefore younger babies are treated as semi-urgent cases. Some studies suggest the risk of incarceration is lower in pre-term infants. This finding may be due to anatomical differences in the pre-term infant or may result from the closer clinical observation enjoyed by many infants in neonatal units in the UK. The policy in many centres in the UK is to repair the inguinal hernia before discharge from hospital, when the baby is medically stable. 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 infant should be transferred in a calm, warm environment with full resuscitation facilities.

2 Infant with incarcerated inguinoscrotal hernia. It has not been possible to reduce preoperatively the left-sided inguinoscrotal swelling (distinct from the testis). 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 oximetry with supplemental oxygen given as needed. Reduction should be attempted by gentle constant taxis on the incarcerated hernia with simultaneous pressure on the external ring. Excessive force and prolonged attempts at reduction should be avoided because it will cause pain and there is a concomitant risk of reduction of ischaemic bowel that may lead to severe illness and sometimes death. If reduction is unsuccessful (or there is doubt as to whether the hernia has been reduced), the infant should be transferred to a paediatric surgical unit for immediate evaluation and exploration. Surgery for irrreducible hernias in infants can be technically very demanding and should be performed only by an experienced surgeon. If reduction is successful, the child should remain in hospital for 2448 hours to allow inguinoscrotal swelling to subside before performing an inguinal herniotomy.

Female infants may present with an incarcerated ovary that can often be mistaken for an inguinal lymph node. Delays in treatment may result in ovarian loss and so girls with palpable ovaries merit urgent exploration. Hydrocele: spontaneous resolution of congenital hydrocele is common during the first years of life. Thus, boys should be observed until at least three years of age. This avoids unnecessary surgery in the majority, whilst allowing treatment in the pre-school period in those requiring an operation. The benefit of repair in potentially reducing testicular temperature (thus improving fertility) is supported by some surgeons, but remains unproven.

Surgical technique

Inguinal hernia: the procedure is commonly performed under 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 Scarpas 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, twisted to ensure reduction of contents, and transfixed. The external oblique is closed with interrupted absorbable sutures (e.g. 4/0 vicryl), followed by subcutaneous tissue (as required) and skin closure. In children <18 months, it is often possible to perform herniotomy without opening the external oblique aponeurosis. The testis is then gently pulled into the scrotum, to ensure adequate descent is possible and iatrogenic maldescent is avoided. There is no difference in surgical approach between males and females. The Fallopian tube is commonly found in the hernial sac and should be actively sought during herniotomy to avoid iatrogenic ligation. Hydrocele: the operative procedure for a congenital hydrocele 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 to achieve (particularly in the case of an encysted hydrocele), scrotal aspiration may be performed or the fluid may be left to absorb.

Complications Preoperative
If an inguinal hernia is diagnosed, parents should be warned of the symptoms and signs of strangulation (pain and tenderness, erythema, irreducibilty, vomiting), and advised to attend the surgical centre immediately if such symptoms occur.

Operative

Care should be taken to identify the sliding hernia. This is more common in large hernias in pre-term infants. Opening the sac reveals bowel (commonly appendix) or Fallopian tube in the wall of the sac. These structures should not be dissected free because of the risk of damage. The hernia is reduced into the abdominal cavity through the internal ring and the peritoneum closed distal to the contents. The internal ring is tightened to prevent recurrence of the hernia. The major structures at risk during surgery are the vas deferens and vessels in males and the Fallopian tube in girls. Rates of operative damage are difficult to assess accurately. The vas deferens was found in the excised sac in 0.6% of histologically examined specimens in one study; in another study, 27% of subfertile adults with a history of childhood inguinal hernia were found to have vasal obstruction. Testicular atrophy resulting from damage to the testicular vessels and/or vessel occlusion in incarceration is about 6%. This risk is highest in the pre-term infant and during repair of incarcerated herniae. Damage may also occur to hernial contents including bowel, bladder, ovary and Fallopian tube.

Postoperative

Recurrence of indirect inguinal hernia in children is uncommon (4%) and is usually ascribed to failure to transfix the hernial sac at the internal ring. Neonates appear to be at increased risk of recurrence, particularly those with chronic lung disease. Contralateral exploration: repair of one inguinal hernia does not preclude the metachronous development of a contralateral hernia. Contralateral exploration during unilateral inguinal herniotomy is controversial. This has been advocated due to the high (30%) incidence of patent processus vaginalis contralateral to a clinically evident inguinal hernia. However, after unilateral herniotomy, the incidence of metachronous contralateral hernia is <10%, and exploration may not be warranted. A reasonable approach is to reserve contralateral exploration for: premature neonates with severe concurrent disease (e.g. lung disease) children <18 months who are geographically isolated from the treatment centre children who have lost a gonad due to strangulation. Another approach is laparoscopic contralateral inspection with repair where necessary.

Copyright 2004 The Medicine Publishing Company Ltd