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Pediatric Surgical Procedures – An Updated Guide – Volume I
71
Hippocrates said that those who suffered from hernia were not apt to live long.
Hippocrates also mentioned inguinal hernias in children and established the difference between hernia and hydrocele, as the hydrocele could be diagnosed with a
transillumination technique [3].
Guy de Chauliac was one of the most prominent surgeons of the late Middle
Ages and advocated advanced treatment of hernia in the era of barber surgeons.
Guy de Chauliac proposed a manual reduction of the hernia with the patient in the
Trendelenburg position or even hanging by the feet if necessary. He used laxatives,
rest, and rigorous diets to facilitate the reduction of the hernia. In the book Chirurgia
Magna, he described six surgical techniques for inguinal hernia surgery [1].
Sir William Mitchell Banks in 1882 described the technique of herniotomy that was
often used in children, performed without incision of the oblique muscle and external
ring but rather isolating the hernia sac outside the external ring. The technique of
Mitchelle Banks is the most favored procedure and suitable for newborns and infants,
where the inguinal canal is short and inguinal rings are almost superimposed. In older
children, with growth, the inguinal canal is extended, and the Mitchelle-Banks technique
would be less effective in achieving a high ligation from an anatomical point of view [1].
. Inguinal hernia in children
. Embriology
According to Ramachandran et al. [4] the processus vaginalis is described as
a tongue of the peritoneal membrane present in both males and females, which
establishes and perforates the muscle layer of the abdominal wall. In males, the testis
precedes the Processus vaginalis’s descent through the tunnel. Initially, the gonad is
located near the diaphragm, where it is attached to the craniosuspensory ligament.
However, as the abdominal cavity extends and the developing intestines return to
the coelomic cavity, the testis drops between 8 and 15weeks after fertilization. The
second stage occurs in males in whom the inguinal canal is a restored passage. The
gubernaculum connects to the lower pole of the testis and the processus vaginalis,
facilitating the movement of both structures via the inguinal canal.
Literature and evidence have shown that the testes remain undescended until the
scrotum has fully formed, often occurring between 25 and 35weeks of gestation.
Some authors claim that a calcitonin gene-related peptide plays a role in this process.
After that, the last relevant step is the closure of the processus vaginalis. It has also
been shown that the thickening of the peritoneal membrane has been linked to smooth
muscle differentiation at the neck of the hernial sac, where it has been suggested that
the hepatocyte growth factor is involved. However, embryologic changes seem to be an
important factor in the predisposition to developing hernias. As proof of this, evidence
shows that the premature closure of the processus vaginalis on the left side, compared
to the right side, increases the likelihood of right-sided inguinal hernias [4].
. Epidemiology
Inguinal hernias represent a prevalent concern in pediatric surgery. It is undeniable
that this condition is becoming more frequent in the field [4, 5]. According to Khan
et al. [6], its incidence is approximately 8 to 50 per 1000 live births in term newborns,
reaching nearly 20% in extremely low-birth-weight (<1000g) neonates. Glick et al. [7]
Inguinal Hernia in Children: A Literature Review
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reported evidence that shows differences in the appearance of hernias between males
and females, as the reported ratios are around 3:1 and 10:1. Approximately 60% of hernias are right-sided. This is true for both males and females. In males, this is possibly
the result of a later descent of the right testicle than the left, but this does not explain
the observation in females. The presentation of bilateral hernias occurs approximately
10% of the time. In accordance with multiple authors, patients with left-sided hernias
are more likely to develop a right-sided hernia than vice versa [7]. Other differences are
related to hernia content. While in boys, the most commonly herniated intra-abdominal content is the small intestines, in female infants, it is the ovaries; nevertheless, after
1 year of age, the bowel becomes more common in both sexes, and a herniated ovary in
an adolescent is a rare finding [8].
According to Yeap et al. [5], around 99% of inguinal hernias in children are
indirect. It seems to be that direct hernias are more frequent findings in adults.
However, they can also be present in children as a bulging in the Hesselbach’s triangle.
Furthermore, several authors have found a correlation between the incidence of
inguinal and gestational age. It seems to be an indirect proportion, as age decreases,
the incidence of inguinal hernias increases. The risk of developing an inguinal hernia
in a male infant born at 24weeks of gestation is 40%. In contrast, the incidence of
male infants born after 32weeks of gestation falls to 4% [4].
The incidence of inguinal hernias is indirectly proportional to birthweight, as
it gradually decreases as birthweight increases. Neonates with a birthweight under
1000g had an incidence of inguinal hernia between 30% and 42%. In contrast, neonates with a birthweight of around 1500g had a lower incidence of inguinal hernia,
being just about 3% [4].
The same association has been found between inguinal hernia occurrence and
birthweight. Neonates with a birthweight under 1000g presented 30 and 42% frequency of inguinal hernia. In contrast, neonates with a birthweight of around 1500g
had a lower incidence of inguinal hernia, being just about 3% [4].
. Associations and risk factors
Inguinal hernias have many associated conditions (Table ). The most common
association is prematurity due to interruption of the normal process of testicular
descent as well as comorbidities (e.g., chronic lung disease) in this population [9].
Cystic fibrosis (CF) carries an increased incidence of 15% of inguinal hernia.
Interestingly, it has been shown a higher incidence of inguinal hernia in children
whose parents or siblings never had one. This may be because of genetic factors as
well as the physical effects of chronic lung disease and high intra-abdominal pressure.
Cystic fibrosis is also a risk factor for bilaterality and recurrence [9].
Prematurity
Family history
Cystic fibrosis and meconium peritonitis
Hydrocephalus (ventriculoperitoneal shunt) chronic lung disease
Peritoneal dialysis
Ascites
Hydrops
Intrauterine growth restriction
Table 1.
Conditions associated with inguinal hernias.
Pediatric Surgical Procedures – An Updated Guide – Volume I
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A small or absent vas is occasionally found during inguinal hernia repair in males.
Renal ultrasound should be electively obtained to evaluate for associated ipsilateral
renal agenesis. Congenital absence of the vas is a heterogeneous disorder, largely
due to mutations in the cystic fibrosis gene. Holcomb et al. [9] observed varying
genotypes, with congenital absence of the vas as an isolated entity versus congenital absence of the vas along with renal anomalies. Moreover, there is a correlation
between 15 and 25% of ventriculoperitoneal shunts (VPSs) used for hydrocephalus
treatment with a greater occurrence of inguinal hernia, as well as increased rates of
bilaterality, incarceration, and recurrence [8, 10, 11]. This is also more common in
neonates and boys than in older infants and girls. It is also important to highlight that
the average time between the insertion of a VPS and the surgical correction of an
inguinal hernia is between 5 and 12months. Peritoneal dialysis, ascites, and hydrops
have similar associations with the present inguinal hernia [11].
. Classification
As we have discussed, hernias can be classified into two major categories: direct
and indirect [3]. The formation of the inguinal canal is related to the descent of the
testis during fetal development or the formation of the labia in females, which is
why indirect hernias are more prevalent in children and are often linked with the
persistence of processus vaginalis. What characterizes this type of hernia is that the
content moves laterally to the inferior epigastric vessels to access the deep inguinal
ring [3, 5, 12–15]. On the other hand, direct hernias are more often observed in
adults, related to a weakness in the Hesselbach triangle. Nevertheless, they can
sometimes be observed in teenagers as well; frequently, they are acquired in surgery.
As an example, there are cases of recurrent inguinal hernia after ligation of a congenital defect during primary repair or metachronous contralateral inguinal hernia
after identifying the closed open process vaginalis in males or the open canal of Nuck
in females. Therefore, the acquired form of inguinal hernia can also manifest as an
indirect hernia. Unilateral and bilateral hernias can be observed as well [3, 16].
Additionally, it is crucial to determine whether the patient’s inguinal hernia is reducible or not, which leads us to define the term strangulation. This denotes the state in
which the hernia cannot be effectively reduced with manipulation. It is crucial to ascertain whether the patient requires urgent surgical surgery, since this particular hernia
might include the colon, omentum, or the ovary/fallopian tube in females. Incarcerated
hernia carries the risk of strangulation, which is the condition when the hernia’s contents have compromised blood flow. That is why this is a clinical emergency that requires
immediate surgery. It may cause a blockage in the intestines, reduced blood flow, tissue
death, perforation, or testicular atrophy in boys and ovarian injury in girls [3].
According to Kawalec et al. [3], there is a preoperative classification that has been
modified from the original Nyhus classification for pediatric patients. Based on this,
the first type, pediatric Nyhus type 0 (PN0), is characterized by a persistent process
vaginalis without any hernia symptons. Pediatric Nyhus type I (PNI) is a clinical
scenario in which the hernia is not detected during the examination and is diagnosed
through a reliable history and silk glove sign or during laparoscopy. In the same vein
as the PN0, there is no clinical hernia. Pediatric Nyhus type II (PNII) is identified
when the hernia takes time to manifest after repeated straining for more than 30seconds and manipulations are required, and it also encompasses irreducible hernias. In
pediatric Nyhus type III (PNIII), hernias manifest promptly upon minor straining or
spontaneously and are easily resolved with minimal manipulation [17].
Inguinal Hernia in Children: A Literature Review
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Additionally, other types of hernia can be found, such as pantaloon hernia that is
an indirect hernia that may cause dilatation of the deep ring, causing the weakening of
the posterior wall, which may cause bulging of the hernia sac on both sides of the inferior epigastric vessels. [18] Amyand’s hernia is when the appendix is trapped within an
inguinal hernia, which is only about 1% of all hernias. [19] Littré’s hernia is a clinical
entity defined by the presence of Meckel’s diverticulum within a hernia sac [20].
. Clinical findings
Parents typically discover inguinal hernias during bath time; if not, usually
the pediatrician discovers them during a physical exam (Figure ). When taking
the history of the present illness, it is important to separate inguinal hernias from
communicating hydroceles, undescended testis, and inguinal adenopathy. However,
although hernias may manifest right after birth or after days, weeks, months, or even
years later, the abnormality usually has been there since birth. This point becomes
important to remember when asymptomatic hernias are found, in terms of the
timing of surgery and the activities children should be allowed to participate in while
awaiting repair.
Usually, hernias are asymptomatic. However, they are frequently mistakenly
identified by parents as the cause of the distress symptoms of infants because they
commonly appear in conjunction. In fact, in accordance with Glick et al., many of
these symptoms, such as inguinal or groin pain during exercise, persist after the
surgery [7].
In the same vein, incarceration is one of the primary complications of inguinal
hernias in early infancy, which is why they are regarded as high-risk hernias, occasionally leading to intestinal obstruction and strangulation (Figure ) [21, 22].
Evidence shows that younger gestational age increases the risk of incarceration and is
up to 39% in premature and 3–16% in term infants. Other factors with increased risk
of incarceration are age less than 1year and female sex [23]. Although we have already
mentioned that this type of hernia is the result of the entrapment of the intestines
or other organs, the real question is whether entrapment occurs at the internal or
Figure 1.
Infant with an intermittent and unilateral inguinal bulge in the left side. (B) Girl with a bulge in the groin.
Pediatric Surgical Procedures – An Updated Guide – Volume I
75
Figure 2.
(A) An infant with an 8-hour incarcerated hernia. (B) The left testis is infarcted because of the incarcerated
inguinal hernia.
external ring. According to Glick et al. [7], it can occur at both levels, but mainly at
the level of the internal ring, leading to intermittent pain and irritability and signs of
bowel obstruction (distension, vomiting, and obstipation). They found that in a notreduced hernia, blood supply to the incarcerated organ may be compromised to the
point of infarction (strangulated inguinal hernia) (Figure ). Glick et al. [7] reported
that patients may show peritonitis. This process can occur in as little as 2hours.
Incarceration occurs most commonly in the first 6months of life, and after age 5, it is
a rare finding.
In accordance with Fraser et al. [11], peritonitis, hemodynamic instability, and
septic shock are considered absolute contraindications to attempt reduction, while
symptoms of bowel obstruction are considered relatives. According to Fraser et al.
[11], “a sudden ‘pop’ of the contents back into the peritoneal cavity usually confirms a
successful reduction. Reduction in mass, in which the hernia contents are reduced into
the peritoneal cavity but the bowel remains incarcerated internally in the hernia sac, is
a very rare occurrence, but the surgeon should be aware of this possibility” [11].
. Diagnosis
The diagnosis is often made through a physical exam and the history of a bulge in
the groin accompanied by weeping. In the event that a child is incapable of coughing
on command, alternative methods may be implemented to elevate intra-abdominal
pressure. Holding the legs and limbs of infants against the examination table in
a gentle manner to prevent them from moving always results in crying. For older
children, other strategies might be employed, such as blowing bubbles or tickling
them to induce laughter. In some cases, despite using this and other methods, the
bulge does not show up. In cases where this happens, the silk purse or silk glove sign
has been proposed as an alternative to observing the protrusion. The sensation of the
sac moving on its own during this maneuver is a positive discovery. The silk purse
sign was used with a wide range of diagnostic accuracy in reports published from
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Figure 3.
Inguinal surgery performed on a male child.
1950 to 1970. However, a recent prospective study conducted in China demonstrated
that this physical finding had a sensitivity of 91% and a specificity of 97.3% in the
diagnosis of inguinal hernias. In other words, this sign should not be considered
conclusive to establish a hernia diagnosis [24].
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. Radiologic investigations
Ultrasonography, computed tomography, and magnetic resonance imaging are among
the several radiologic modalities that are employed for diagnosis. Evidence has shown
that ultrasound is the least invasive one, although it is important to take into account that
its effectiveness is significantly contingent upon the abilities of the health professional.
In addition, it can detect an inguinal hernia with a sensitivity of 86% and a specificity of
77% [24]. Thickening of the spermatic cord generally helps diagnose inguinal hernias in
children [25]. However, in cases where the diagnosis is uncertain, computed tomography
(CT) imaging is advantageous. It has a sensitivity of 80% and a specificity of 65% for the
detection of complex inguinal hernias. On the other hand, despite its high percentage of
sensitivity (95%) and specificity (96%) in the detection of inguinal hernias, magnetic
resonance is infrequently used due to its cost. Nevertheless, it can be used to assist in the
differentiation of sports-related injuries versus inguinal hernias [24].
. Differential diagnosis
An increase in the volume of the groin or scrotum can be caused by other diseases,
which is why it may be confused with an inguinal hernia (
Table ) [26, 27]. A few
examples may be hydrocele, which can be associated with concomitant viral disease,
elevating intraabdominal pressure due to sneezing, and increased fluids. Other
examples are inguinal lymphadenopathy and idiopathic scrotal edema, which can be
recognized by a subacute redness and swelling that is typically not excruciating. An
abscess may also be confused with an incarcerated inguinal hernia, but it is important
to observe the presence of purulent fluid [5]. An inguinal hernia or a hydrocele of the
cord can also be confused with ectopic testicles with interstitial, preperitoneal, prepubic, and inguinocrural. As in all undescended testicles, the gonad will be missing in
the scrotum, which will make the diagnosis. Ultrasound is useful as well. In the case
of a torsion of an undescended testicle located in the inguinal region, the history of
having an empty scrotum since birth and continuous pain in the region can suggest
the diagnosis [27]. Uncommon conditions that should be considered include varicoceles, which may be identified by a palpable feeling of a bag of worms upon inspection. A healthcare provider would easily be able to detect and diagnose a testicular
tumor, making it impossible to reduce in size [5].
Examination
features
Is the hernia
reducible?
Can you get above the
swelling?
Is there any skin
change?
Transillumination No, except in neonates,
Table 2.
Differential diagnosis and diagnostic features.
Inguinal hernia Inguinal
Yes, except if it is
incarcerated
No Yes Ye s Yes
There may be edema
and erythema if it is
incarcerated
when the intestine wall
may be very thin
lymphadenopathy
No No No
No No No
No Yes No
Hydrocele Undescended
testis
Inguinal Hernia in Children: A Literature Review
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. Time of repair
The surgery is typically conducted promptly following the diagnosis. Sedation
and manual reduction are successful in over 80% of cases when attempting to reduce
an incarcerated hernia. Typically, an elective operation is performed within 24hours
of the reduction. Re-incarceration is inevitable when surgery is postponed [21, 28].
It is unnecessary to restrict the activities of an asymptomatic infant prior to surgery.
Prompt repair may reduce incarcerated hernias in infants [11].
A study conducted in Canada discovered that the risk of incarceration for children
under the age of one was doubled when the repair was performed more than 2 weeks
after the diagnosis [29].
Inguinal hernias are common in the neonatal intensive care unit, but the timing of repair is widely variable among surgeons and between institutions and is
controversial in premature infants. Repair of an inguinal hernia shortly prior to
neonatal discharge can be more technically demanding, has higher recurrence and
complication rates, may prolong mechanical ventilation and length of stay in the
neonatal intensive care unit, and is associated with an increased risk of apnea and
bradycardia [30, 31].
Late inguinal hernia repair (after 55-week postconceptual age) carries an
increased risk of incarceration (10–30%), more frequent emergency department and
clinic visits and readmissions, and potential failure of the family to follow-up [30].
Concerns about the long-term neurodevelopmental risks of anesthesia in premature
infants, if substantiated, would favor the late approach. In a recent database survey,
approximately 40% of premature infants underwent early repair, but the variability
between hospitals was significant [32].
. Management
Inguinal hernia surgery is one of the most frequently performed procedures
in childhood, with an average operation rate of 5% that can increase to 30% in
preterm infants [33, 34]. Surgical closure is always necessary because inguinal
hernias do not resolve spontaneously [7, 34]. The American Academy of Pediatrics
Surgical Section in 2005 emphasized that the majority of surgeons prefer to
perform the operation either before discharge from the neonatal intensive care unit
or as early as possible due to the high risk of inguinal hernia incarceration before
the age of 6 months and within the first 2 weeks of diagnosis. The exploration of
the contralateral groin in the event of unilateral hernia remains a subject of debate.
In male infants, most surgeons explore and repair only the clinically evident side,
but practice varies for female infants: Some prefer the routine exploration of the
contralateral side, others do so only in selected populations, and others do not
explore at all or avoid contralateral exploration unless indicated by laparoscopic
examination [33].
Routine use of prophylactic antibiotics is not recommended for laparoscopic or
elective open repair in low-risk patients. Antibiotic prophylaxis should be considered
if risk factors for infection are present. Risk factors include recurrent hernias, immunosuppressed patients, obesity, diabetes, contamination, and urinary catheters [35].
A combination of local anesthesia and peripherally acting agents (paracetamol,
non-steroidal antiinflammatory drugs, or a combination) is best treated for postoperative pain. Local infiltration of the wound or regional nerve blocks provide extra
pain control and limit the use of analgesics [35].
Pediatric Surgical Procedures – An Updated Guide – Volume I
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. Nonoperative management
In the absence of apparent indicators of shock or peritonitis in patients, nonoperative management is initially implemented. If feasible, elevate the child’s feet and
attempt to soothe them without feeding them [36]. Furthermore, it is necessary to
place the left index and middle fingers on the ipsilateral anterior superior iliac crest
and sweep them down along the inguinal canal toward the ipsilateral scrotum while
standing on the ipsilateral side of the child or at the feet of an infant, always maintaining the tension in the mass. Mahmood et al. [36] found that traction on the scrotum,
or labia majora, helps align the long axis of the hernia sac with the axis of the inguinal
canal. Subsequently, apply pressure to the hernia neck on either side using the right
index finger and thumb at the ipsilateral internal ring level. It assists in the alignment
and maintenance of the external and internal rings, in addition to providing traction
on the scrotum. It is beneficial to maintain the alignment and openness of the internal
and external rings. Lastly, while maintaining constant pressure on the bottom of the
hernia contents, gently walk your left fingers up the groin toward the internal ring,
keeping the left hand at the apex of the mass and the right index finger and thumb at
the level of the internal ring. The hernia contents will progressively dissolve into the
internal ring after taking several minutes to be successful. To confirm whether the
hernia has been reduced, compare it to the contralateral side. Sedation may be implemented in the event that this approach proves unsuccessful or the child experiences
difficulty enduring it. It is not advisable to reduce the intestine under general anesthesia, as it is possible for the bowel to be injured or for the gangrenous bowel to be
reintroduced into the peritoneal cavity without being recognized [13, 28, 37]. The use
of sedatives alone may be sufficient to facilitate spontaneous reduction. We advise that
the child be monitored in the hospital for 24hours following a challenging reduction,
as gangrenous colon reduction has been documented. Delay the definitive repair of the
hernia for a minimum of 24 to 48hours to allow the edema to subside [7, 37].
. Anesthesia
There have been numerous anesthesia technique combinations that have been
reported for the repair of neonate inguinal hernias. These include general anesthesia
with or without a regional block, as well as a spinal block or caudal block alone or
in conjunction with sedation. However, general anesthesia is the most frequently
employed anesthetic technique performed in children, as it possesses many benefits,
such as optimal surgical conditions, and is also a technique well-known to clinicians
who are frequently involved in the care of neonates [38].
Nevertheless, general anesthesia has been demonstrated to pose substantial
risks for neonate inguinal hernia surgery, including prolonged postoperative
ventilation and airway complications [38, 39]. This agrees with Massoud et al., who
reported a retrospective study of 485 neonates who underwent hernia surgery with
general anesthesia. The review revealed an overall respiratory complication rate
of 9%, which increased to 35.5% in babies under 45-week postmenstrual age at the
time of surgery [38, 40].
Something similar was found in another study conducted on 263 neonates who
underwent inguinal hernia surgery. The study revealed an overall postoperative ventilator dependence of 8.3%, reaching 14.7% in infants who underwent the procedure
prior to discharge. It has been reported that there is a 25% postoperative ventilator
dependence [38, 41].
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However, the use of regional methods in conjunction with general anesthesia
offers the benefit of decreasing the amount of anesthetic agents and the need for opioids. This is particularly important for term and preterm neonates who are at risk of
opioid-induced ventilatory impairment. The addition of caudal anesthesia to general
anesthesia has been proven to lower postoperative pain and the amount of opioids
that are required after urological surgery in pediatric patients, according to research
that was conducted on these patients [38, 42]. A meta-analysis of pediatric inguinal
hernia repair conducted in 2023 indicated that there was no significant difference
in postoperative pain ratings or rescue analgesia between caudal and nerve block or
wound infiltration [38, 39, 42].
The addition of caudal anesthesia to general anesthesia has been proven to lower
postoperative pain and the amount of opioids that are required after urological
surgery in pediatric patients, according to research that was conducted on these
patients [38, 42]. Nevertheless, a meta-analysis reported no significant difference
in postoperative pain ratings or rescue analgesia between caudal and nerve block or
wound infiltration [38, 39, 42].
Additionally, the majority of full-term neonates and older children undergo the
same procedure following hernia surgery. The acceptable age for same-day hernia
surgery on an ex-premature neonate is a topic of debate. According to Coran et al.,
a study demonstrated that preterm infants who were born before 41 to 46weeks
postconceptional age and had a history of neonatal apnea were at an increased risk of
developing postoperative apnea. Another extensive study, which employed advanced
monitoring techniques to monitor postoperative breathing disturbances, discovered
that neonates under the age of 44 postconceptual years were at an elevated risk of
experiencing clinically significant episodes of postoperative apnea. In 1995, prospective studies conducted a combined analysis and determined that the incidence of postoperative apnea was not less than 1% with 95% statistical confidence until 56weeks
for a 32-week premature infant and 54weeks for a 34-week premature infant [7].
. Operative technique
Open-inguinal hernia repair is still the standard approach at present [43].
Nevertheless, the laparoscopic approach is becoming more popular in practice [44].
In 2021, the results of two systematic reviews showed that there is no superiority
between the two methods since operation time and complication and recurrence rates
are the same for each one [43].
. Open repair
Nowadays, open herniorrhaphy remains the gold standard for primary inguinal
hernia repair [45].
The open repair of an indirect inguinal hernia (OHR) in children centers on high
ligation of the hernia sac (internal inguinal ring) (Figure ). A transverse inguinal
crease incision is used. The inguinal canal is more lateral than one might expect, a
finding made apparent with laparoscopic hernia repairs. It is necessary to open the
Scarpa fascia and identify the external oblique aponeurosis. This aponeurosis is
opened in the direction of its fibers. It is important to be careful to protect the ilioinguinal nerve, which provides cutaneous sensation to the skin of the anterior thigh.
Next, carefully separate the anteromedial hernia sac from the cord structures. The sac
may extend down into the scrotum. The sac is clamped after ensuring the absence of
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