Inguinal Hernia in Children

Inguinal Hernia in Children

What is Inguinal Hernia?

Inguinal Hernia is a common pediatric surgical condition. It occurs in one in 30-50 boys(0.8-4.4%.) It can also affect girls (girl: boy = 6:1). 

Inguinal hernia is a defect of the abdominal wall. The content of the abdominal cavity, such as the small bowel, ovaries, omentum (an apron-like structure covering the bowel loop) can push out through this defect. If it gets stuck then it can cause a bowel obstruction (called an incarceration). The child often presents with tummy pain, distension of the abdomen, nausea and vomiting. If the bowel loop gets stuck for too long, the blood supply can be cut off (called strangulation). The bowel will then become black and perforate, potentially leading to fatal peritonitis.

What causes Hernia in Children?

After development of the fetus, the communication tunnel between the abdominal cavity and scrotum, known as the processus vaginalis (or labia majora in girls) is normally closed. Failure of closure leaves a defect in the abdominal wall that becomes a hernia. Inguinal hernia is therefore more common in premature babies.

How do we know when a child has a Hernia?

The most common presentation is a lump in the groin, just above the scrotum, especially after crying or when standing up. Parents can take a photo or video with their mobile phones as this helps the doctor with diagnosis. In more severe cases, the child may lose appetite, vomit and develop abdominal distension (a bloated tummy).

Below are the common symptoms of hernia in children:

Common Symptoms of Hernia in Children

Lump in the groin, just above the scrotum (especially after crying or when standing up)

Abdominal distension (bloated tummy)

Loss of appetite

Vomit

How to confirm the Hernia diagnosis?

A paediatric surgeon needs to differentiate it from other causes of the swelling in the groin, such as hydrocele, a femoral hernia, undescended testes, an enlarged lymph node, epididymitis, varicocele or even testicular tumour.
Clinical Assessment

1. Medical history

How long has the lump been there? Is the lump bigger when the child cries? Is it more prominent in the afternoon? Was the child born prematurely? Does the child have fluid in the tummy (ascietes); any tummy pain or vomiting (suggestive of intestinal obstruction)?

2. Standing up

In the standing position and when the child coughs or cries is the hernia lump easily observed?

3. Lying down

When the child lies down flat, does the hernia lump disappear by itself, or does it need to be pushed back into the abdomen (manual reduction)?

4. Hernia or hydrocele?

A hernia is typically funnel shaped, extending from the groin into the scrotum. Hydrocele is more spherical and transluminates – that is to say that light is visible when you shine a torch from behind.

5. Ultrasound examination of Inguinal Hernia

If there is any difficulty in diagnosis, an ultrasound examination is useful. Hernia at the upper end is thicker than hydrocele (1).

Treatment Choice of Hernia in Children

Inguinal hernia will not disappear by itself (2). It needs an operation. The operation for a hernia in children differs from those in adults. In children, the hernia is usually tied off (or ligated,) whereas in adults an additional patch repair is needed.

Children’s herniotomy operations can be categorised into two techniques:

Traditional open herniotomy operation
A 2-4 cm incision is made in the groin. The hernia sac is sutured outside the abdominal cavity. The traditional open operation is a safer option in a complicated situation, where the hernia is associated with a bowel obstruction, bowel necrosis (lack of blood), peritonitis or in extremely premature babies. The disadvantage compared to the laparoscopic herniotomy is that an open operation cannot deal with a potential hernia on the opposite side. This occurrence is not uncommon, and would require an additional incision or operation, if discovered at a later date.
Laparoscopic herniotomy
This is termed a “minimally invasive” technique. The most common methodology is to make an incision in the belly button for a laproscope. Two additional small incisions of about 3mm each are made in the lower abdomen on each side of the hernia for the needle holder and grasper. The hernia is oversewn inside the abdominal cavity.

Advantages of laparoscopic herniotomy

1. Hernia on the opposite side can be repaired in the same setting

If a hernia is observed on the opposite side (occurs in 10% cases) it can be repaired in the same way without an additional incision (3, 4).

2. Smaller wounds

The smaller wounds lead to less pain and faster recovery.

3. Better cosmetic result

The scar will be hidden in the navel, which is more beautiful

4. Both the complication rate (5) and recurrence rate (6, 7, 8) are low

5. Can also be performed on small babies (9, 10, 11)

What happens if the operation of Hernia is delayed?

In small babies (less than 6 months), if the hernia is not operated on immediately, in about 30% cases, the small bowel becomes stuck in the hernia sac (incarceration). When comparing whether to delay the operation for more than a month, research shows that carrying out the hernia operation within two weeks reduces bowel obstruction by 50%.

Conversely, if the herniotomy is done as an emergency operation when the bowel is obstructed, the complication rate of the operation increases four-fold (12). Early operation therefore avoids 90% of complications. If a premature baby is found to have a hernia at birth, the operation should be done before the child is discharged from hospital.

In boys, bowel loops in the hernia sac can compress the testicular blood supply, leading to shrinkage of the testis (13). In girls, ovaries stuck in the hernia sac, can leads to twisting and cutting off the blood supply to the ovaries (14).

Pre-operative routine of Hernia in Children

Pre-operative routine of Hernia in Children

Details

Other check-up
Healthy children do not need a blood test or X-ray for a herniotomy operation.
Pre-operative fasting
Pre-operative fasting is important, as all herniotomy operations in children are carried out with anaesthesia. Fasting empties the stomach of all food. This will eliminate the risk of aspiration of any gastric content if they vomit. Aspiration can cause pneumonia or even suffocation. Children should avoid all food for 8 hours before the operation but can drink water up to two hours pre-operatively.
Registration at the hospital
After registration at the hospital admission desk, the child will change into an operation gown in the ward. A name band is applied to the wrist for identification. The operating doctor will mark the side of hernia together with parents. The operation details will be explained to the guardians/parents before signing the consent form.
Operation procedure
Anaesthesia, sterilization of skin, the operation, dressing, recovery from anaesthesia and observation will take about 2-3 hours in the operation suite.

Post-operative care of Hernia in Children

Post-operative care of Hernia in Children

Details

Pain control
The wound will be infused with a local anaesthetic agent (lignocaine or bupivacaine) which suppresses pain for up to 3 hours (15). Subsequent oral pain killers like paracetamol or ibuprofen are provided on discharge.
Post-operative observation
After being fully awake in the ward, the patient can start to drink sips of water and gradually resume eating food. If there is no vomiting and the patient can pass urine spontaneously, he/she can be discharged on the same day. Premature babies or babies under 5 months of age need to be observed overnight in the ward to ensure a full recovery.
Nutrition
After the operation, the child can resume normal food intake. There is no need to avoid any foods, as normal wound healing requires adequate protein intake.
Keep the dressing dry
Avoid wetting the wound dressing in the shower or bath for two days. This reduces the possibility of contamination of the wound.
Physical Activity
Normal walking is permitted but physical education classes or other kind of sports should be avoided for three weeks.
Follow up
Follow up with the surgeon is required one week after the operation. Most wounds will be closed with dissolvable sutures and so there is no need for stitches to be removed. Additional water-proof tissue glue may be applied to the wound. This glue will usually fall off by itself within two weeks.

Herniotomy Complications

Herniotomy complications include:

Wound infection
Like all surgeries, wound infection can occur in 1% of the cases (0.9%). Because of the low risk of complication, preventative (prophylactic) antibiotics are not administered (16).
Wound bleeding, scrotal swelling or fluid collection
This can occur in about 1% patients after the operation. Most are transient and settle with time.
Elevated testicular position

After open herniotomy, for a small fraction(0.43%) of boys , the testicular position may be slightly higher in the scrotum (6).

Hernia recurrence
Hernias can reoccur in 0.35 – 1.2% of patients. Common contributing factors include an emergency herniotomy operation, premature baby, poor nutrition, fluid in the abdomen (ascites), wound infection or technical problems due to doctors’ experience.
Damage to the vas deference or testicular vessels
This is extremely unusual.
Testicular atrophy
In about 0.8% of cases, the testicular size becomes smaller after the operation (17). This is mainly due to compression of the testicular blood supply by bowel loops in the hernia sac.
Should parents notice anything unusual, contact the operating surgeon.

Paediatric laparoscopic herniotomy package price

Item

Standard Fee (HKD)

Package Fee (HKD)*

Pre-operative consultation
Laparoscopic herniotomy operation
Post-operative follow-up consultation
$40,000
$31,000
Anaethestist fee
Separate from surgeon fee, usually 1/3 of surgeon fee
Ward round (each day)
Hospitalization fee (each day)
Operation theatre fee
Operation sutures and disposables
Varies from hospital to hospital
Approximately $8,000 - $15,000 (varies from hospital to hospital) #

Remark: After uneventful operation patients can usually be discharged on the same day, or stay over for a night. If you choose a private or semi-private room, you will be charged an additional fee for the doctor's surgery and the specialist in anesthesiology.

*Patients will be seen by a physician who will determine if they are suitable for the standard package based on their condition. This package is only available for patients who are admitted to a standard bed or day room during office hours. For moderate risk patients (e.g. infants less than 6 months old), the additional charge is 20% of the standard package. (Herniotomy operations on babies younger than 5 months of age or premature babies are considered major cases and need to be observed for 12 hours in the ward. There is 20% additional operation charge.)

#The cost of surgery depends on the hospital and the ward chosen (first class, second class or general room or day surgery); there are also additional surcharges on Sundays and public holidays, so be careful when choosing the day and hospital.

Frequently Asked Questions

A: An inguinal hernia will not disappear by itself (2). There is risk of bowel obstruction, and in severe cases, even gut perforation and peritonitis, if the treatment is delayed. Therefore all inguinal hernias need operative treatment.

A: Most children present hernia under one year of age. 30% present within 6 months after birth.
A: Bilateral hernia occurs in 10% of cases. In an open operation, if a hernia on the opposite side is clinically not obvious, operation on the opposite side is not usually done (6). In a laparoscopic herniotomy, the opposite inguinal ring can be inspected and if it is open (i.e. identified as a hernia), it can then be repaired at the same setting.
A: In elective surgery, prophylactic antibiotics are not needed . In emergency surgery, some patients may need antibiotic coverage.
A: The risk of recurrence of hernia is about 1%。Factors contributing to the recurrence include a herniotomy done under an emergency situation, poor nutrition or associated medical conditions, as well as surgeon’s experience.

Reference

(1)Ultrasonography for inguinal hernias in boys. K C Chen, C C Chu, T Y Chou, C J Wu. J. Pediatr Surg. 1998. https://pubmed.ncbi.nlm.nih.gov/9869050/

(2)Inguinal hernia and hydroceles. P L Glick, S C Boulanger. Pediatric Surgery, 7th ed, 2012 edited by A Coran et al, Elsevier Saunders. 2012.

(3)Inguinal hernia in neonates and ex-preterm: complications, timing and need for routine contralateral exploration. A Pini Prato, V Rossi, M Mosconi, N Disma, L Mameli, G Montobbio, A Michelazzi, F Faranda, S Avanzini, P Buffa, L Ramenghi, P Tuo, G Mattioli. Pediatr Surg Int. 2015. https://pubmed.ncbi.nlm.nih.gov/25381589/

(4)Evidence supporting laparoscopic hernia repair in children. S Jessula, DA Davies. Curr Opin Pediatr. 2018. https://pubmed.ncbi.nlm.nih.gov/29461296/

(5)Open Versus Laparoscopic Inguinal Herniotomy in Children: A Systematic Review and Meta-Analysis Focusing on Postoperative Complications. S Feng, L Zhao, Z Liao, X Chen. Surg Laparosc Endosc Percutan Tech. 2015. https://pubmed.ncbi.nlm.nih.gov/26018053/

(6)Hernia recurrence following inguinal hernia repair in children. K Taylor, K A Sonderman, L L Wolf, W Jiang, L B Armstrong, T P Koehlmoos, B R Weil, R L Ricca Jr, C B Weldon, A H Haider, S E Rice-Townsend. J Pediatr Surg. 2018. https://pubmed.ncbi.nlm.nih.gov/29685492/

(7)Laparoscopic Hernia Repair versus Open Herniotomy in Children: A Controlled Randomized Study. R Shalaby, R Ibrahem, M Shahin, A Yehya, M Abdalrazek, I Alsayaad, M A Shouker. Minim Invasive Surg. 2012. https://pubmed.ncbi.nlm.nih.gov/23326656/

(8)Laparoscopic hernia repair in children by the hook method: a single-center series of 433 consecutive patients. Y H Tam, K H Lee, J D Y Sihoe, K W Chan, P Y Wong, S T Cheung, J W C Mou. J Pediatr Surg. 2009. https://pubmed.ncbi.nlm.nih.gov/19635295/

(9)Outcomes following laparoscopic inguinal hernia repair in infants compared with older children. W Choi, N J Hall, M Garriboli, O Ron, J I Curry, K Cross, D P Drake, E M Kiely, S Eaton, P D Coppi, A Pierro. Pediatr Surg Int. 2012. https://pubmed.ncbi.nlm.nih.gov/23069994/

(10)Neonatal laparoscopic inguinal hernia repair: a 3-year experience. V Pastore, F Bartoli. Hernia. 2015. https://pubmed.ncbi.nlm.nih.gov/24889274/

(11)Laparoscopic inguinal herniorrhaphy in babies weighing 5 kg or less. S Turial, J Enders, K Krause, F Schier. Surg Endosc. 2011. https://pubmed.ncbi.nlm.nih.gov/20532570/

(12)Inguinal hernia in Chinese Children. P K Tam, T M Tsang, H Saing. Aust N Z J Surg. 1988. https://pubmed.ncbi.nlm.nih.gov/3178596/

(13)Risk of incarceration in children with inguinal hernia: a systematic review. C S Olesen, L Q Mortensen, S Öberg 2, J Rosenberg. Hernia. 2019. https://pubmed.ncbi.nlm.nih.gov/30637615/

(14)Ovarian torsion in inguinal hernias. T E Merriman, A W Auldist. Pediatr Surg Int. 2000. https://pubmed.ncbi.nlm.nih.gov/10955568/

(15)Comparison of post operative pain relief between paracetamol and wound infiltration with levobupivacaine in inguinal hernia repair. M S Bari, N Haque, S A Talukder, L H Chowdhury, M A Islam, M K Zahid, S M Hassanuzzaman, M M Alam. Mymensingh Med J. 2012. https://pubmed.ncbi.nlm.nih.gov/22828535/

(16)Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience. D Vaze, R Samujh, K L Narasimha Rao. Afr J Paediatr Surg. 2014. https://pubmed.ncbi.nlm.nih.gov/24841018/

(17)Establishing benchmarks for the outcome of herniotomy in children. H D E Vogels, C J P Bruijnen, S W Beasley. 2010. https://pubmed.ncbi.nlm.nih.gov/20632283/

Last Update: December 2021

Please note that all medical health articles featured on our website have been reviewed by Chiron Medical doctors. The articles are for general information only and are not medical opinions nor should the contents be used to replace the need for personal consultation with a qualified health professional on the reader’s medical condition.

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