HERNIAS in Paediatrics

DONE BY: HUGH JACOBS

Case
A 2 year old female child, Nessa, presents with her very worried
mother to the A&E department. The mother complains that Nessa
has a bulge in her belly-button that appears sometimes, mostly
while she is crying or when she has a bad cold.
What is this bulge?
What is your next step?
How would you counsel this patients very worried mother?

Types of Hernias

Inguinal
Umbilical
Paraumbilical
Incisional
Epigastric
Spigelian

Umbilical Hernias
Failure of the umbilical ring to close results in a
central defect in the linea alba.
The resulting umbilical hernia is covered by
normal umbilical skin and subcutaneous tissue,
but the fascial defect allows protrusion of
abdominal contents.

Umbilical Hernias
Common, particularly in Afro-Caribbean children.
Most will close spontaneously during the rst few years of life,
regardless of size.
Complications are rare
If the hernia fails to close surgical repair can be performed at
around 5yrs of age.

Umbilical Hernias
Generally asymptomatic protrusions of the abdominal wall noted
by parents or physicians shortly after birth.
Families of patients with umbilical hernia should be counseled
about signs of incarceration:
-Abdominal pain, bilious emesis, and a tender, hard mass protruding
from the umbilicus.
Immediate exploration and
repair of the hernia to avoid
strangulation.

Umbilical Hernias
SURGICAL REPAIR:

A small curving incision that fits into the skin

crease of the umbilicus is made, and the sac is
dissected free from the overlying skin.

The fascial defect is repaired with permanent

or long-lasting absorbable, interrupted sutures
that are placed in a transverse plane.

The skin is closed using subcuticular sutures.

Prognosis
The postoperative recovery is typically uneventful, and recurrence
is rare, but more common in children with elevated intraabdominal pressures such as those with a ventriculoperitoneal
shunt.

Case
An 18 month old male, Rojelio, presents with a swelling in his
right groin since birth. His mother first noticed it when she was
changing little Rojelios diaper. She tells you that the swelling is
worse when he cries but disappears completely when he is
sleeping at night. She is very worried and wants to know what is
going on.
The swelling is reducible and there are no skin changes.
-What is your next step?

Inguinal Hernias
Results from a failure of closure of the processus vaginalis, a
finger-like projection of the peritoneum that accompanies the
testicle as it descends into the scrotum.
Closure of the processus vaginalis normally occurs a few months
prior to birth. (high incidence of inguinal hernias in premature
infants)
When the processus vaginalis remains completely patent, a
communication persists between the peritoneal cavity and the
groin, resulting in a hernia.

Inguinal Hernias

Inguinal Hernias

Inguinal Hernias
Indirect hernia- defect protruding through the internal or deep
inguinal ring
Direct hernia- defect protruding through the posterior wall of the
inguinal canal.
Incomplete hernia- confined to the inguinal canal.
Complete hernia- comes out of the inguinal canal through the
external or superficial ring into the scrotum.
Direct hernias are always incomplete, whereas indirect hernias
can also be complete.

Inguinal Hernias
Are congenital inguinal hernias in children
DIRECT or INDIRECT?
All congenital hernias in children are by definition indirect
inguinal hernias.

Inguinal Hernias
More commonly in
males than females
(10:1)

More common on the

right side than the
left.

15% hernias are

bilateral.

Infants are at high risk

for incarceration of an
inguinal hernia
because of the
narrow inguinal ring.

Inguinal Hernias- Clinical Presentation

Patients most commonly present with a groin bulge that is noticed
by the parents as they change the diaper.
The bulge commonly occurs after crying or straining and often
resolves during the night while the baby is sleeping.
Older children may notice the bulge themselves.
Mostly asymptomatic.

Inguinal Hernias- On Examination

A reducible swelling in the groin, often extending into the scrotum
The cord on the affected side will be thicker, and pressure on the
lower abdomen usually will display the hernia on the affected
side.
Incarcerated hernia- firm bulge that does not spontaneously
resolve; may be associated with fussiness and irritability in the
child.
Strangulated hernia- edematous, tender bulge in the groin,
occasionally with overlying skin changes.

Treatment?
ALWAYS SURGICAL!
Open vs Laproscopic

Herniotomy vs Herniorraphy vs Hernioplasty

Herniotomy
Removal/ligation
of the hernial sac
only

Herniorraphy
herniotomy plus
repair of the
posterior wall of
the inguinal
canal

Hernioplasty
herniotomy plus
reinforcement of
the posterior
wall of the
inguinal canal
with a synthetic
mesh

Herniotomy vs Herniorraphy vs Hernioplasty

Herniotomy- adequate for an indirect inguinal hernia in children with
normal abdominal wall muscles; formal repair of the posterior wall of the
inguinal canal not required
Herniorrhaphy- suitable for a small hernia in a young adult with good
abdominal wall musculature. (Bassini and Shouldice repairs)
Hernioplasty- required for large hernias and hernias in middle-aged and
elderly patients with poor abdominal wall musculature. (Lichtenstein
tension-free mesh repair)

Inguinal Hernias
Surgical herniotomy.
Infants should be repaired within a few weeks of diagnosis because
the risk of incarceration is high. The lessens after the age of 1yr.
When the hernia is very large and the patient very small,
tightening of the internal inguinal ring or even formal repair of the
inguinal floor may be necessary, (Herniorraphy) although the vast
majority of children do not require any treatment beyond high
ligation of the hernia sac.

Surgical repair
The following procedures may be used for the repair of inguinal hernias in children:
1. High ligation and excision of the processus vaginalis, the most common procedure, is
used when the hernia is small and of recent onset. In girls, confirmation that the
hernia sac does not contain the ovary, fallopian tube, or uterus is necessary before it
is ligated.
2. In addition to ligation and excision, plication of the floor of the inguinal canal (the
transversalis fascia) may be necessary when the inguinal ring has been enlarged by
repetitive herniation.
3. Complete reconstruction of the floor of the inguinal canal using the conjoint tendon
is occasionally required in small infants who have large hernias that have gone
untreated, causing progressive enlargement of the inguinal ring and total breakdown
of the transversalis fascia.

Treatment Of Incarcerated Hernias

Resuscitation of the child
Reduction of the hernia by taxis (i.e. gentle, but sustained
pressure is applied to the sac to reduce the contents).
Most hernias can be reduced safely, although it may be necessary
to give the baby morphine rst.
If the hernia cannot be reduced, emergency surgical exploration is
necessary (but this is rare).
Provided the hernia is reduced a herniotomy should be performed
after 2448hr to allow for any oedema to settle.

Hydrocele
When a hydrocele is diagnosed in infancy and there is no evidence
of a hernia, observation is proper therapy until the child is older
than 12 months.
If the hydrocele has not disappeared by 12 months, invariably
there is a patent processus vaginalis, and operative
hydrocelectomy with excision of the processus vaginalis is
indicated.

INTERNAL HERNIAS
Congenital Diaphragmatic Hernias
3 types:
Posterolateral (Bochdalek)
Left- sided (85%)
Right-sided (13%)
Bilateral, rare, often fatal
Anterior (Morgagni)
Hiatus

References
1) Schwartzs Principles of Surgery 10th Ed.
2) Oxford Handbook of Pediatrics
3) Toronto Notes 2016
4) www.Medscape.com
5) www.uptodate.com

Thank You!