Pediatrics and Neonatology (2017) 58, 376e377

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BRIEF COMMUNICATION

Inguinal Hernia in a Preterm Neonate

Complicated by Strangulation and
Subcutaneous Hernia Sac Rupture
Jessica A. Naiditch*, David T. Schindel

Division of Pediatric Surgery, Children’s Medical Center Dallas, Dallas, TX, USA

Received Oct 20, 2015; received in revised form Jan 22, 2016; accepted Feb 26, 2016
Available online 21 August 2016

1. Introduction birth, diagnosed with a Grade 1 intraventricular hemor-

rhage, and treated for Staphylococcus aureus bacteremia
Inguinal hernias are common among preterm neonates, and pneumonia. The infant also required an oscillator for
with a relatively high rate of incarceration. We report a adequate oxygenation and ventilation. On the 18th day of
unique case of an extremely premature neonate with an life, the baby developed abdominal distension and feeding
enlarging right inguinal hernia that progressed to incar- intolerance with a new right inguinal bulge. Over the
ceration, bowel strangulation with necrosis, and subcu- following few days, the bulge became progressively larger
taneous rupture of the hernia sac on the 21st day of life and developed an overlying blue discoloration. The infant
requiring urgent laparotomy for reduction and resection of was transferred to our institution in this condition for sur-
the necrotic small bowel and ostomy creation. The poten- gical evaluation. Upon arrival in the neonatal intensive care
tial morbidity of a missed incarcerated inguinal hernia is unit, physical examination revealed a soft, mobile, tubular
high. Neonatologists and pediatricians should consider a mass with overlying erythema in the right lower quadrant
low threshold for early surgical referral and evaluation in (Figure 1). A supine X-ray of the abdomen and chest
all pediatric patients. Although incarcerated inguinal her- demonstrated a soft tissue mass in the right lower quadrant
nias are relatively common in preterm neonates, we with gas in the right hemiscrotum. An orogastric tube was
believe that this is the first report of an inguinal hernia with placed. A brief attempt at bedside reduction of a suspected
bowel strangulation and subcutaneous rupture of the hernia right inguinal hernia failed, thus prompting surgical explo-
sac in a preterm neonate in the literature. ration. At laparotomy, a transverse incision made over the
right lower quadrant revealed necrotic bowel in the sub-
cutaneous tissues without an overlying hernia sac. The
bowel was traced back to the right external inguinal ring
2. Case Report
from which it was emanating. An attempt was made to
reduce the bowel through the inguinal ring, but in vain. A
A baby boy was born with a birth weight of 700 g at 25 3/
transverse counterincision was made in the abdominal wall
7 weeks of gestation due to premature rupture of mem-
cephalad to the external inguinal ring revealing small bowel
branes at 20 weeks of gestation. The baby was intubated at
herniated through the internal and external inguinal rings.
Additional attempts were made to reduce the small bowel
into the abdomen through the inguinal canal without suc-
* Corresponding author. Division of Pediatric Surgery, Children’s
cess. Because of the necrotic changes and the inability to
Medical Center Dallas, 1935 Medical District Drive, Suite D2000,
Dallas, TX 75235, USA.
reduce the bowel, the bowel was then divided proximally
E-mail address: Jessica.naiditch@gmail.com (J.A. Naiditch). and distally to the area of necrosis. The remaining bowel

http://dx.doi.org/10.1016/j.pedneo.2016.02.012
1875-9572/Copyright ª 2016, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Rupture of incarcerated inguinal hernia 377

resection, recurrence of the hernia, or testicular atrophy,

when compared with those undergoing elective repair
(18.2% vs. 4.1%, p Z 0.009).
The optimal timing of elective repair in the premature
infant population is debated and varies between in-
stitutions. A study on 2030 neonates with inguinal hernia
identified in the Pediatric Health Information System
database demonstrated significant institutional variability
in the timing of repair. Delayed repair, defined as repair
occurring in an encounter subsequent to when the diagnosis
was made, was performed in between 3% and 74% of neo-
nates across 25 hospitals.2 Overall, 67.1% of patients un-
derwent early inguinal hernia repair and 32.9% underwent
delayed inguinal hernia repair. Patients undergoing delayed
repair had a higher incarceration rate (9.4% vs. 2.3%). Pa-
tients undergoing early repair had a longer postoperative
Figure 1 Subcutaneous, serpiginous, somewhat mobile mass
length of stay, required more critical care interventions,
in the right lower quadrant operatively found to be necrotic
and had higher rates of readmission within 30 days and a
bowel in the subcutaneous space emanating from the right
higher rate of hernia reoperation at 1 year. These data
external inguinal ring with a ruptured inguinal hernia sac.
were not stratified by birth weight category. Elective repair
for these patients would never have been undertaken early
enough in their life to have averted incarceration, given the
could then be reduced into the abdomen. The hernia defect patients’ acuity and size. However, earlier diagnosis may
and external ring were closed. End-ileostomy and mucus have prevented progression to strangulation and loss of
fistula were created. The baby has undergone ostomy bowel.
reversal and is now aged 7 months, without recurrence of These data suggest that early repair of inguinal hernia
the right inguinal hernia or the development of a contra- during the initial diagnostic encounter in the premature
lateral hernia. population, particularly very-low-birth-weight premature
infants, is prudent. Perhaps, had the child in the present
3. Discussion case been referred earlier in his course, the incarceration
may have been diagnosed and intervened upon earlier to
prevent progression to strangulation and hernia sac
Approximately 4% of the pediatric population is diagnosed
rupture, thereby avoiding the morbidity of a bowel resec-
with an inguinal hernia,1 with the majority of the cases
tion and ostomy. Early referral for surgical evaluation al-
occurring in boys.2 Inguinal hernias are common in prema-
lows for risk stratification and optimal timing of repair.
ture infants, occurring in up to 30% of infants born with a
weight of <1 kg. The risk of inguinal hernia incarceration in
pediatric patients is high, between 5% and 15%, but it is
even higher in premature infants, occurring in up to 39%.3 Conflicts of interest
Observation complicated by incarceration can result in
bowel ischemia and ovarian or testicular atrophy, necessi- The authors have no conflicts of interest relevant to this
tating emergency intervention with a greater risk of post- article.
operative complications compared with elective repair.4 To
our knowledge, this is the first report of a strangulated
inguinal hernia with rupture of the hernia sac in a prema- References
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