Inguinal hernias in children occur when a part of the intestine or other abdominal contents protrude through the inguinal canal.

  • Common in boys
  • Usually congenital due to the incomplete closure of the processus vaginalis
  • Most hernias that present at birth or in childhood are indirect inguinal hernias.

All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as inguinal hernia incarceration or strangulation.

History and examination

Risk Factor: History of prematurity or low birth weight

Symptoms:

  • Visible or palpable groin bulge which gets larger when child cries and disappear when child is lying down
  • Pain or discomfort (Usually, it is painless but if there is painful bulge, think of incarcerated inguinal hernia)
  • Crying or irritability during straining (In incarcerated hernia)

Signs:

  • Reducible or non-reducible groin swelling
  • Positive cough impulse
  • Inguinal tenderness

Note: Always palpate both testicles in boys to rule out undescended or retractile testes.

Differential diagnosis (D/D) & Complication

D/DComplications
Hydrocele (transilluminates, no impulse on coughing)
Undescended testis (absent testis in scrotum)
Lymphadenopathy (firm, non-reducible, no cough impulse)
Psoas abscess
Saphenous varix
Retractile testis
Varicocele
Testicular tumor		Incarceration
Strangulation
testicular ischemia
bowel obstruction
Infarction

Investigation

  • Clinical evaluation is usually sufficient for diagnosis
  • Ultrasound (if diagnosis is uncertain or to differentiate from other conditions)

Admission criteria

  • Admission is required for irreducible or incarcerated hernias, or if there is suspicion of strangulation

Sign of strangulation and incarceration of hernia

  • Sudden pain
  • Fever
  • Nausea and vomiting
  • Server constipation
  • Color change in skin near hernia
  • Inability pass gas
  • Increased heart rate

Management

Surgical

  • Herniotomy either laproscoic or open : Children younger than 5 years are likely to recover extremely quickly from surgery; they are typically capable of returning to their normal level of activities within 24-48 hours of surgery.
  • Elective herniorrhaphy for reducible hernias (within 1-2 weeks of diagnosis)
  • Children presenting as emergency with irreducible/incarcerated hernia should have attempted reduction of hernia under sedation. Once reduced, elective herniotomy may be performed typically in 24–48 hours, by which time the swelling would have reduced. If the hernia cannot be reduced even under sedation, urgent exploration is required. Complications (recurrence and testicular atrophy) of emergency herniotomy for irreducible hernia are higher than elective herniotomy

Advices

  • Educate parents about signs of complications (incarceration, strangulation) and when to seek urgent medical attention
  • If a child has developed a unilateral hernia, there is a potential risk(10%) of developing a hernia on the opposite side-this risk is higher in premature babies and infant girls.
  • Following operative repair, avoidance of major physical activity for 1 week is recommended. After that time, the patient is allowed to participate in physical activities (eg, sports, swimming, running)
  • Recurrence of inguinal hernia after surgery occurs in 1% (0.7–3.8%) of children.
  • Children younger than 5 years are likely to recover extremely quickly from surgery; they are typically capable of returning to their normal level of activities within 24-48 hours of surgery.

Referral

  • Refer to a pediatric surgeon for evaluation and surgical management

Additional points

  • Contralateral inguinal exploration may be considered in high-risk patients (e.g., prematurity, family history) to identify and repair a possible contralateral hernia

References:

  1. Antonoff, M. B., Kreykes, N. S., Saltzman, D. A., & Acton, R. D. (2011). American Academy of Pediatrics Section on Surgery hernia survey revisited. Journal of Pediatric Surgery, 46(6), 1009-1014.
  2. Rowe, M. I., Copelson, L. W., & Clatworthy, H. W. (1978). The patent processus vaginalis and the inguinal hernia. Journal of Pediatric Surgery, 13(1), 45-50.
  3. Niyogi, A., Tahim, A. S., Sherwood, W. J., De Caluwé, D., & Giuliani, S. (2010). The incidence of complications following primary inguinal herniotomy in babies weighing 5 kg or less. Pediatric Surgery International, 26(3), 289-293.