INTRODUCTION
Inguinal hernia is one of the most common surgical conditions in infancy, with a peak incidence during the first 3 months of life. The diagnosis of inguinal hernia is made with increasing frequency in new- borns; this period carried a particularly high risk of incarceration. On the other hand, the incidence of hernia is much higher in premature infants who sur- vive in growing numbers after sophisticated inten- sive care management. Direct hernia is exceedingly rare at this age and practically all congenital indirect inguinal hernias develop because the processus va- ginalis remains patent after birth. The most common presentation of inguinal hernia in a child is a groin bulge, extending towards the top of the scrotum. The treatment of inguinal hernia is always surgical. In in- fants and toddlers, herniotomy can be performed through the external inguinal orifice without any at- tempt at parietal reinforcement. In older children, however, the length of the canal makes it advisable to open the external oblique aponeurosis in order to achieve a high ligation of the sac. The incidence of congenital indirect inguinal hernia in full-term neo- nates is 3.5–5%. The incidence of inguinal hernia in preterm infants is considerably higher and ranges from 9–11%. The incidence approaches 60% as birth weight decreases from 500 to 750 g. Inguinal hernia is more common in males than in females. Most series report a male preponderance over females ranging from 5:1 to 10:1. Of all inguinal hernias, 60% occur on the right side, 25–30% on the left, and 10–15% are bi- lateral.
The anatomy of the inguinal canal varies slightly with age. In adults and children, the internal and ex- ternal inguinal orifices are widely separated, whereas in young infants they practically overlap. In girls, the anatomy is similar except for the absence of spermat- ic elements which are replaced by the round liga- ment.
A hydrocele of the tunica vaginalis usually presents as a soft, nontender fluid filled sac that may transilluminate. Most hydroceles usually involute spontaneously during the first 12 months of life.
Those that persist beyond 1 year of age are associated with a patent processus vaginalis and require opera- tive intervention, the same as for an inguinal hernia.
Femoral hernias are rare in children. The diagno- sis is based on the observation of a groin swelling lo- cated underneath the external inguinal orifice, al- though this location is easily missed because, unless the bulge is visible upon examination, relatives and doctors will first interpret its appearance as the ex- pression of an inguinal hernia. This explains why 50% of these patient are mistakenly operated upon for inguinal hernia and why, only when the sac is not found, exploration of the femoral area allows diagno- sis and repair. The femoral orifice, located below the inguinal ligament, allows passage of the femoral vein, artery and nerve from the pelvis to the thigh. The hernial orifice is always medial and the sac is there- fore in close contact with the femoral vein.
Umbilical hernia is as a result of failure of closure of the umbilical ring. The hernial sac protrudes through the defect. Most umbilical hernias have a tendency to resolve spontaneously. In view of the fa- vourable natural history of umbilical hernias, surgi- cal indications are limited to those hernias located above the umbilicus, to those that persist beyond the age of 4 years and to those occurring in children with connective tissue disorders.
Epigastric hernia (fatty hernia of linea alba) usu- ally occurs in the midline of the anterior abdominal wall. It is usually a small defect through which pre- peritoneal fat protrudes and may cause pain.
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General anaesthesia with endotracheal intubation is preferred in small infants. Premature infants under- going surgery have an increased risk of life-threaten- ing post-operative apnea. The use of spinal anaesthe- sia in low birth-weight infants undergoing inguinal
hernia repair is associated with a lower incidence of post-operative apnea. The infant is placed in the su- pine position on a heating blanket. A 1.5-cm trans- verse inguinal skin crease incision is placed above and lateral to the pubic tubercle.
Figure 15.2, 15.3
The subcutaneous fat and the fascia of Scarpa (which is surprisingly dense in infants) are opened, grasping them with small-toothed Adson forceps. Using blunt scissors or cautery, the external oblique aponeurosis
and external ring are exposed. The external inguinal ring is not opened except in older children and ado- lescents.
Figure 15.2 Figure 15.3
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The external spermatic fascia and cremaster are sep- arated along the length of the cord by blunt dissec- tion. The hernial sac is seen and gently separated
Figure 15.5
The sac is divided between the clamps and twisted so as to reduce its content into the abdominal cavity.
The spoon can be used to keep vas and vessels away from the neck of the sac. The sac is transfixed with a 4/0 stitch at the level of internal ring, which is marked by an extraperitoneal pad of fat. The part of
Figure 15.6, 15.7
Subcutaneous tissues are approximated using two or three 4/0 absorbable interrupted stitches and the skin is closed with a 5/0 absorbable continuous sub- cuticular suture. A small dressing can be applied over
the wound if necessary. At the end of the operation, the testis, always tractioned upwards during opera- tive manoeuvres, must be routinely pulled back into the scrotum to avoid iatrogenic ascent.
from the vas and vessels. A haemostat is placed on the fundus of the sac.
the sac beyond the stitch is usually excised. In the case of hydrocele, the distal part of the sac is widely slit allowing adequate drainage of fluid. In girls, the operation is even more straightforward since there is no risk for the vas or the vessels and the external ori- fice can be closed after excising the sac.
Figure 15.5
Figure 15.6 Figure 15.7
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The operative approach for femoral hernia is initially identical to the more commonly used approach for inguinal hernia. An inguinal skin crease incision is made and the subcutaneous layers and Scarpa’s fas- cia are opened in order to expose the external oblique aponeurosis at the level of the external ingui- nal ring. The aponeurosis is incised longitudinally taking care to preserve the ilio-inguinal nerve. The inguinal canal is open dorsally sectioning with caut- ery the conjoined tendon and the fascia transversalis.
The spermatic cord is retracted in order to obtain ac- cess to the femoral region. The sac is identified and delivered into the wound avoiding damage to the fe- moral vein which is in close contact with the sac lat- erally. It may be convenient to ligate and divide the inferior epigastric vessels in order to better expose the femoral area from behind.
Figure 15.10
The sac is then opened to ensure that it has no con- tents and it is subsequently suture-ligated with a fine stitch flush with the peritoneum. The femoral defect is then narrowed by approximating the internal in- sertions of the Cooper ligament and the inguinal lig- ament with two or three fine non-absorbable stitches
taking care of not compressing the femoral vessels.
The inguinal canal is reconstructed and the superfi- cial layers and the skin are closed like those in ingui- nal hernias. Femoral hernia repair can also be ac- complished by an infra-inguinal approach.
Ilioinguinal n.
External inguinal ring
External oblique aponeurosis
Femoral artery, vein
Femoral sac Inferior epigastric
artery and vein
Figure 15.10
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Umbilical hernia repair is carried out under general anaesthesia. A semicircular incision is made in the skin crease immediately below the umbilicus. The subcutaneous layers are dissected in order to expose
the hernial sac. By blunt dissection with a mosquito clamp, a plane is developed on both sides of the sac and the sac is encircled with a haemostat and is di- vided.
Figure 15.12
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A clamp is placed on either side of the umbilical de- fect for traction. The defect is closed by interrupted 2/0 absorbable sutures. A stitch is used to invaginate the umbilical scar, tractioning it downwards and fix-
ing it to the subcutaneous layer in the midline. The wound is closed with several interrupted sutures placed in the subcuticular plane. A slightly compres- sive dressing is maintained for 24 h.
Figure 15.15
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Epigastric hernias are repaired when they are prom- inent or when they are symptomatic. It is important to mark the location of the defect before anaesthesia, because in the recumbent position they are often im- possible to palpate along the widened linea alba. A transverse incision is made directly over the previ-
ously marked location of the hernia. The fatty mass protruding through the linea alba defect is excised after a transfixation stitch. The defect in the linea al- ba is closed with interrupted 3/0 absorbable sutures.
The skin is approximated using subcuticular sutures.
Figure 15.18
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The overall complication rates after elective hernia repair are low at about 2%, whereas these are in- creased to 8–33% for the incarcerated hernias requir- ing emergency operations. Complications of inguinal hernia repair include:
쐽 Haematoma – can be avoided with meticulous at- tention to haemostasis. It is rarely necessary to evacuate wound, cord or scrotal hematoma.
쐽 Wound infection – low risk and should not exceed 1%.
쐽 Gonadal complications – occur due to compres- sion of the vessels by incarcerated viscera. Though large numbers of testes look nonviable in patients with incarcerated hernia, the actual incidence of testicular atrophy is low and therefore, unless the testis is frankly necrotic, it should not be re- moved.
쐽 Intestinal resection. This is necessary in about 3–7% of patients in whom the hernia is not re- duced and it may cause some additional morbid- ity corresponding to resection itself and contami- nation of the field.
쐽 Iatrogenic ascent of the testes. This event is rela- tively rare since slightly more than 1% of patients operated upon for inguinal hernia during infancy required subsequently orchidopexy. This compli- cation is probably due to entrapment of the testis in the scar tissue or failure to pull it down into the scrotum at the end of the operation and to main- tain it there.
쐽 Recurrence. The acceptable recurrence rate for in- guinal hernia repair is less than 1% but when op- eration is performed in the neonatal period this complication can occur in up to 8%. The factors that predispose to recurrence are ventriculoperit- oneal shunts, sliding hernia, incarceration and connective tissue disorders. Recurrence may be indirect or direct. Indirect recurrence is due to ei- ther failure to ligate the sac at high level, tearing of a friable sac, a slipped ligature at the neck of the sac, missed sac, or wound infection. Direct hernia may be due to inherent muscle weakness or to in- jury to the posterior wall of the inguinal canal.
쐽 Mortality. In the present-day situation, the mor- tality rate of inguinal hernia operation should be zero.
SELECTED BIBLIOGRAPHY
Coats RD, Helikson MA, Burd RS (2000) Presentation and management of epigastric hernias in children. J Pediatr Surg 35 : 1754–1756
De Caluwe D, Chertin B, Puri P (2003) Childhood femoral her- nia: a commonly misdiagnosed condition. Pediatr Surg Int 19 : 608–609
Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, Caty MG, Glick PL (2002) Variability of inguinal hernia surgical
technique: a survey of North America pediatric surgeons. J Pediatr Surg 37 : 439–449
Skinner MA, Grosfeld JL (1993) Inguinal and umbilical hernia repair in infants and children. Surg Clin North Am 73 : 439–449
Tovar JA (2003) Inguinal hernia. In: Puri P (ed) Newborn sur- gery. Arnold, London, pp 561–568
