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CLINICAL PROFILE OF INGUINAL HERNIA IN INFANTS

Dissertation submitted to

The Tamil Nadu Dr.M.G.R Medical university, Chennai In partial fulfillment of the requirements for the degree of

Doctor of Medicine in Paediatrics

Under the guidance of DR. K. NEELAKANDAN.,

Department of Paediatrics

P.S.G Institute of Medical Sciences &Research, Coimbatore Tamil NaduDr.M.G.R Medical University, Chennai

(2)

CERTIFICATE BY THE HOD AND DEAN OF THE INSTITUTION

This is to certify that the thesis entitled “CLINICAL PROFILE OF

INGUINAL HERNIA IN INFANTS” is the bonafide original research work of Dr. SHYAM K, has been done under the guidance of Dr. K.NEELAKANDAN

Professor and Head of the Department of Paediatrics PSG IMS&R, Coimbatore in

fulfilment of the regulations laid down by The Tamilnadu Dr.M.G.R Medical

University for the award of MD degree in Paediatrics.

Dr. K.NEELAKANDAN Dr.RAMALINGAM

Professor Dean

Head of the Department PSGIMS&R

Department of Paediatrics

(3)

CERTIFICATE

This is to certify that the thesis entitled “CLINICAL PROFILE OF

INGUINAL HERNIA IN INFANTS” is the bonafide original research work of

Dr. SHYAM K, has been done under my guidance and supervision in the Department of Paediatrics, PSG IMS&R, Coimbatore in fulfilment of the

regulations laid down by The Tamilnadu Dr.M.G.R Medical University for the

award of MD degree in Paediatrics.

DR. K.NEELAKANDAN

Professor,

Head of the Department,

Department of Paediatrics,

(4)

DECLARATION

I, hereby declare that this dissertation entitled “CLINICAL PROFILE OF

INGUINAL HERNIA IN INFANTS” was prepared by me under the guidance

and supervision of Dr. K.NEELAKANDAN Professor and Head of the

Department of Paediatrics, PSG IMS&R, Coimbatore.

This dissertation is submitted to The Tamilnadu Dr. M.G.R Medical

University, Chennai in fulfilment of the university regulations for the award of MD

degree in Paediatrics. This dissertation has not been submitted elsewhere for the

award of any other Degree or Diploma.

(5)

CERTIFICATE-II

This is to certify that this dissertation work titled“CLINICAL PROFILE

OF INGUINAL HERNIA IN INFANTS” of the candidate Dr. SHYAM K with

registration Number 201517504 for the award of DOCTOR OF MEDICINE in

the branch of PAEDIATRICS. I personally verified the urkund.com website for

the purpose of plagiarism check. I found that the uploaded thesis file contains from

introduction to conclusion pages and result shows 1%of plagiarism in the

dissertation.

(6)
(7)

ACKNOWLEDGEMENT

I am extremely grateful and indebted to my guide Dr.K.Neelakandan,

Professor and HOD, Department of Paediatrics, PSG IMS&R, for his invaluable

guidance, concern, supervision and constant encouragement to complete this

dissertation.

I extend my sincere gratitude to Dr. John Matthai, Professor, Former Head

of the Department of Paediatrics, PSG IMS&R, who gave his unflinching support

and invaluable advice in preparing this dissertation.

I sincerely thank Dr. Sarah Paul, Professor, Department of Paediatrics,

PSG IMS&R for her valuable suggestions throughout the study period

I sincerely thank Dr.Pavai, Professor, Department of Paediatric Surgery,

PSG IMS&R for his valuable suggestions throughout the study period

I sincerely thank Dr.S.Ramesh Assistant Professor, Department of

Paediatrics, PSG IMS&R for his valuable suggestions throughout the study period.

I wish to express my gratitude to Dr.K.Jothilakshmi, and

(8)

I also thank Dr.Nirmala, Dr.Bharathi, Dr.Vadivel, Dr.Sudhakar, Dr.Muruganantham, Dr.Suchithra and Dr.Kavitha for their support and assistance in helping me to complete this work.

I am very thankful to my colleagues Dr.Nandhini, Dr.Bhuvanesh,

Dr.Raaghul, Dr.Lavanya and Dr.Arya S for their constant support. I also thank my seniors, juniors and all other friends and family members for their support.

I also express my gratitude to the Principal and Dean, faculties of ethical

committee of PSG IMS&R for granting me the permission to conduct the study.

I am extremely grateful and obliged to all the patients without whom this

(9)

CONTENTS

1. INTRODUCTION 1

2. AIM 3

3. METHODOLOGY 4

4. REVIEW OF LITERATURE 6

5. RESULTS 49

6. DISCUSSION 73

7. CONCLUSION 78

8. LIMITATION 79

9. REFERENCES

10.ANNEXURES

i. CONSENT FORM

ii. PROFORMA

(10)

LIST OF TABLES

TABLE NO.

TITLE

1 Factors Contributing to the Development of an Indirect Inguinal

Hernia

2 Gender distribution

3 Order of birth

4 Inborn / Outborn

5 Gestational age of babies at birth

6 Mode of delivery

7 NICU care

8 TPN given / not

9 Had abdominal distension or not

10 Ventillator / CPAP

11 Other associated anomalies

12 Obstruction / not at presentation

13 Sidedness of hernia

14 Reducibility

15 Incarceration /gangrene

(11)

17 Unilateral / bilateral

18 Post operative complications

19 Recurrence / wound infections

20 Teticular atrophy

21 Hydrocele

22 Occurrence of opposite side hernia

23 Maternal risk factors

(12)

LIST OF FIGURES

FIGURE NO.

TITLE

1 The most common variants of hernias and hydroceles arising

from failure of complete obliteration of the processusvaginalis.

2 Gender distribution

3 Order of birth

4 Inborn / Outborn

5 Gestational age of babies at birth

6 Mode of delivery

7 NICU care

8 TPN given / not

9 Had abdominal distension or not

10 Ventillator / CPAP

11 Other associated anomalies

12 Obstruction / not at presentation

13 Sidedness of hernia

14 Reducibility

15 Incarceration /gangrene

(13)

17 Unilateral / bilateral

18 Post operative complications

19 Recurrence / wound infections

20 Teticular atrophy

21 Hydrocele

22 Occurrence of opposite side hernia

23 Maternal risk factors

(14)

1

INTRODUCTION

Inguinoscrotal swellings are one of the commonest surgical problems in

infancy and childhood throughout the world. Among the inguinoscrotal

swellings, inguinal hernia tops the list in frequency. They represent the

conditions frequently requiring surgical repair in the pediatric age group. Hernia

is a Latin term meaning rupture of a portion of a structure. It can be defined as a

“protrusion of a viscus or part of a viscus through a normal or an abnormal

opening in the wall of its containing cavity.” Refinements in neonatal intensive

care have increased the number of surviving premature and very low birth

weight infants and consequently the incidence of neonatal inguinal hernia is

increasing.

The inguinal hernia is the commonest defect the paediatric surgeon

performs surgery on and is usually indirect. It is believed that these hernias

rarely go away, and therefore; virtually all should be repaired. Several issues are

contentious, such as optimal time of herniotomy after diagnosis, obstruction,

feed intolerance, the role of contralateral exploration and for the premature

group; issues are type of anaesthesia and need for post-operative mechanical

ventilation support.1, There is very limited study in India analysing the

incidence of hernia and the risk factors associated with the incidence, like

(15)

post-2

operativecomplications and so on. This study is designed to look into the

incidence of hernia in infants with an analysis of the risk factors involved in the

occurrence of inguinal hernia in them like age, sex, sidedness, gestational age at

birth , birth weight, age at the time of occurrence of hernia, use of positive

pressure ventilation, reducibility, time of repair, urgency of repair(done as an

emergency or elective procedure), complications due to the hernia and post

operatively.

STUDY JUSTIFICATION:

Studies suggest that inginal hernia is a common condition requiring

surgical repair in the paediatric age group.The incidence of inguinal hernias is

approximately 3% to 5%in term infants and 13% in infants born at less than 33

weeks of gestational age1. Increased survival of preterm and low birth weight

infants due to better intensive care and has resulted in increased incidence of

hernia in infancy. There is also limited data available from India in assessing the

risk factors involved in the occurrence of inguinal hernia and the pre and post

operative complications associated with it. This study may help us in predicting

(16)

3

AIM

To study the clinical profile ie the incidence and risk factors of inguinal

(17)

4

METHODOLOGY

This study is based on retrospective collection of data for a period of 3

years from the records library at PSGIMSR and prospective follow up of

patients who are getting admitted at paediatric or paediatric surgery department

in a tertiary care centre(PSGIMSR) for inguinal hernia; for 2 years and

collection of data from them and retrospectively analysing it for the different

risk factors involved in the incidence of inguinal hernia in infants less than 1

year of age and also to look into the complications that occur in them post

operatively.

FLOW CHART:

Proposal to ethics committee and approval from ethics committee

All patients seen as op / getting admitted as a case of inguinal hernia < 1 year of

age in Paediatrics and Paediatric Surgery departments at PSGIMSR

Collection of data and analyzing the risk factors associated with the occurrence

of Inguinal Hernia.

Descriptive and statistical interpretation of risk factors.

(18)

5

STUDY DESIGN:

It is a retrospective& prospective observational study.

INCLUSION CRITERIA:

All inguinal hernia cases that are seen as op / getting admitted as a case of

inguinal hernia < 1 year of age in Paediatrics and Paediatric Surgery

departments at PSGIMSR < 1 year of age, for surgical intervention.

EXCLUSION CRITERIA : NIL

STUDY PERIOD: From 01/01/2012 to 31/12/2016 ( 5 Years)

DATA RETRIEVAL:

Data for the retrospective cases will be collected from the records library

at PSGIMSR and for the prospective study; will be collected from the cases that

are seen as op / getting admitted in paediatrics / pediatric surgery department as

(19)

6

REVIEW OF LITERATURE

Inguinal hernias are one of the most common conditions seen in pediatric

practice and the most common surgical procedure performed inpediatric

surgical practice. The frequency of this condition in concert with its potential

morbidity of ischemic injury to the intestine, testis, or ovary makes proper

diagnosis and management an important part of daily practice for pediatric

practitioners and pediatric surgeons.

The overwhelming majority of inguinal hernias in infants and children are

congenital indirect hernias (99%) as a consequence of a patent

processusvaginalis (PV); a developmental structure important in

testiculardescent. The incidence of inguinal hernia in children is up to 10 times

higher in boys than in girls. Two other types of inguinal herniaare direct

(acquired) hernia (0.5-1.0%) and femoral hernia (<0.5%).Approximately 50%

of inguinal hernias manifest clinically in the 1st yrof life, most in the 1st 6 mo.

Premature infants have an incidence of inguinal hernia approaching 30%. The

risk of incarceration and pgossiblestrangulation of an inguinal hernia is also

greatest in the 1st yr oflife (30-40%) and mandates prompt identification and

(20)

7

HISTORY

Inguinal hernia most probably has been a disease ever since mankind

existed1. In view of its existence in different kinds of animals, and in particular

ofprimates6, one can assume that already prehistoric human beings were

affected with thedisease7. Written proof of this statement became available from

manuscripts and found in Mesopotamian7 and Egyptian cultures.

What appears to be an inguinal hernia has been found on an ancient

Greek statuette, and Egyptian writings describe groin bulges elicited by

coughing (the Papyrus of Ebers, ca 1552 bc ). 8 There is also evidence to

suggest that surgery for hernias had been performed as early as 1200 bc.The

Roman physician Celsus is credited with some of the earliest surgery for

inguinal hernia, circa 50 ad . 8 About that same time Galen described the

anatomy of the processusvaginalis; however, he believed that hernias were the

result of “rupture” of the peritoneum with stretching of overlying muscle and

fascia. 8 This is where the slang term for hernia, “rupture,” may have had its

derivation.

Modern hernia surgery began in the nineteenth century when an accurate

understanding of the anatomy of the inguinal canal became available. 8 Richter,

Camper, and Scarpa, among others, contributed to the field during this period.

Cooper in 1804 described the transversalis fascia and pectineal ligament, or

(21)

8

ligament, and in 1817 Cloquet described the processusvaginalis and noted that it

was rarely closed at birth. With a thorough understanding of inguinal anatomy,

modern hernia surgery had only to await the development of aseptic techniques

of surgery.

In 1870 Lister introduced the concept of antisepsis in surgery, and in

1896 Halstead began operating with gloves. 8 In 1904 Von Mickulicz took

aseptic surgery one step further. These developments allowed rapid progress to

be made in hernia surgery. In 1871 Marcy described an operation still in use by

pediatric surgeons to this day: high ligation of an unopened sac through the

external ring and tightening of the internal ring. This technique, however, had

an unacceptably high recurrence rate in adults. 9 In 1887 Bassini reported his

results using a technique involving opening the external oblique, high ligation

of the sac, tightening of the external ring, and reconstruction of the posterior

inguinal floor. 9 Along with Halsted, Bassini is credited with the development of

the modern hernia repair.

Incidence

Inguinal hernia repair remains the most common operation performed by

pediatric surgeons. The reported incidence of inguinal hernia in children ranges

(22)

9

Age

Inguinal hernia most commonly presents during the first year of life with

a peak during the first few months. Approximately one third of children are

younger than 6 months of age at the time of operation. 10 The highest incidence

of hernia is found in premature infants, 16% to 25%. 11,12 This correlates fairly

well with the patency rates of the processusvaginalis. At birth 80% are patent

and the rates decrease dramatically by the first 6 months of age. 13 However, all

indirect hernias, regardless of age at presentation, are likely secondary to failure

of the processusvaginalis to close completely during fetal and newborn

development.

Sex

Males are much more likely to have hernias, with the reported

male-to-female ratios between 3:1 and 10:1. 10 Although premature infants have a higher

incidence of hernia, there does not appear to be a significant gender difference

at this age. 14,15,16

Side

Approximately 60% of hernias are right sided. 17 This is true for both

males and females. In males, this is possibly the result of later descent of the

right testicle than the left, but this does not explain the observation in females.

(23)

10

suggested that patients with left-sided hernias are more likely to develop a

right-sided hernia than vice versa. 18, 19 More recent data, however, suggest that this

may not be true. 20,21,22

Family history

Approximately 11.5% of patients have a family history. 10 There is an

increased incidence in twins as well, about 10.6% in males and 4.1% in female

twins. 23

Embryology

Indirect inguinal hernias are fundamentally the result of failure of closure

of the processusvaginalisTheprocessusvaginalis is an invagination of the

peritoneum through the internal ring, which can first be identified during the

third month of foetal life. 24 Some have suggested that formation of the

processusvaginalis is a result of intra-abdominal pressure, 25 whereas others

believe this to be an active process.26,27 The intra-abdominal testis passes

through the processus during the seventh to ninth months of gestation. During

this time the processus elongates. Following this, the portion of the

processusvaginalis lying above the testicle obliterates, closing the internal

inguinal ring, while the distal portion persists as the tunica vaginalis. Failure of

this to occur results in patency of the processusvaginalis and potentially an

(24)

11

hydrocele (peritoneal fluid only)(fig 1). In females the canal of Nuck

corresponds to the processusvaginalis and communicates with the labia majora,

the female homologue of the scrotum. The canal of Nuck normally closes

[image:24.595.78.521.230.435.2]

around the seventh month of gestation, earlier than in males.

Fig :- 1.

The most common variants of hernias and hydroceles arising from failure

of complete obliteration of the processusvaginalis.

The exact timing of closure is uncertain. Studies have suggested that up

to 80% to 100% of infants are born with a patent processusvaginalis and that

closure, if it occurs, is most likely to happen within the first 6 months of

life. 13,28 After 6 months of age, patency rates fall more gradually and plateau

generally around age 3 to 5. It also appears that the left side closes earlier than

(25)

12

distal) is unknown. After closure of the processus, it persists as a cord, which

subsequently disappears and becomes incorporated into the external spermatic

fascia. The high rate of patency associated with undescended testis suggests that

closure most commonly occurs only after descent of the testicle or that these

processes are linked.

The biologic mechanisms that signal and induce descent of the testicle

through the inguinal canal and obliterate the processus are for the most part

unknown. Androgens appear to play a role because patency of the processus is

common in androgen insensitivity syndrome. However, the processus itself has

no androgen receptors. Work from Hutson and colleagues has implicated the

genitofemoral nerve (GFN) and calcitonin gene–related protein (CGRP) in both

testicular descent and obliteration of the processusvaginalis. 24 They have

suggested that reduced CGRP release from the GFN prenatally may result in

undescended testis, whereas reduced CGRP postnatally may lead to hernias and

hydroceles. Although it is clear that a patent processusvaginalis is a prerequisite

for an inguinal hernia, it is not sufficient and other factors are involved. Table 1

(26)
[image:26.595.104.478.94.771.2]

13

Table :- 1 Factors Contributing to the Development of an Indirect Inguinal Hernia

Urogenital

Undescended testis

Exstrophy of bladder

Increased peritoneal fluid

Ascites

Ventriculoperitoneal shunt

Peritoneal dialysis

Increased intra-abdominal pressure

Repair of exomphalos or gastroschisis

Severe ascites (e.g., chylous)

Meconium peritonitis

Chronic respiratory disease

Cystic fibrosis

Connective tissue disorders

Ehlers-Danlos syndrome

Hunter-Hurler syndrome

Marfan syndrome

(27)

14

Clinical Features

Inguinal hernias are generally found by parents at bath time or during

well-child examinations by their pediatricians. There is typically a history of

intermittent bulge in the groin, labia, or scrotum. It is most often apparent when

there is increased intra-abdominal pressure such as during episodes of crying or

straining. When taking the history of present illness, it is important to sort out

inguinal hernias from communicating hydroceles, undescended testis, and

inguinal adenopathy. Hernias may present at birth or not until days, weeks,

months or even years later, but the defect to a variable extent has been there

since birth. This becomes important to remember when asymptomatic hernias

are found, in terms of the timing of surgery (i.e., not an emergency) and the

activities children should be allowed to participate in while awaiting repair (i.e.,

no restrictions if asymptomatic).

Hernias are usually asymptomatic. Because hernias often appear during

episodes of infant distress, parents often feel the hernia is the cause of these

symptoms. Unfortunately, many of these perceived symptoms persist after the

repair.

Incarcerated hernias result from entrapment of bowel or other viscera

within the hernia sac. Debate has continued as to whether “entrapment” occurs

at the internal or external ring. The answer is that it can occur at both, but

(28)

15

and irritability. Subsequently, signs of bowel obstruction result, such as

distension, vomiting, and obstipation. If hernia is not reduced, blood supply to

the incarcerated organ might be compromised to the point of infarction, called

“a strangulated inguinal hernia.” The patient may present with peritonitis at this

time. This process can occur even within 2 hours. Incarceration occurs most

commonly in the first 6 months of life and after age 5 is relatively rare.

Prematurity

It is well established that premature infants have a higher incidence of

inguinal hernias and are likely to have a bilateral presentation. Moreover, the

more premature the infant, the higher is the incidence of inguinal hernia. In a

review of 82 infants weighing less than 2000 g, Walsh found a 13% incidence

of inguinal hernia. Of 28 infants less than 1500 g, 7 (25%) had an inguinal

hernia compared with 4 (7%) infants greater than 1500 g. 12 Rescorla and

Grosfeld reviewed 100 infants younger than 2 months of age who required

inguinal hernia repair; 30% of these infants were premature and 44% had

bilateral hernias. 73 Of 1391 very-low-birth-weight infants (weight < 1500 g)

reported by Rajput and colleagues, 11 222 (16%) developed an inguinal hernia

between 28 days and 20 months of corrected age. Peevy, Speed, and Hoff

studied 397 newborn infants and found a 9% incidence of inguinal hernias in

infants weighing between 1000 g and 1500 g and 30% in those weighing 500 g

(29)

16

Harper and colleagues 113 reported that 11 (30%) developed an inguinal hernia.

Two of these 11 were incarcerated (18%). Although the incidence of

incarceration is increased in infants and may be as high as 28%, it appears to be

lower in premature infants, with reported incidences of 13% to 18%, compared

with mature infants.

Ventriculoperitoneal shunts/peritoneal dialysis:

A significant factor in the development of an inguinal hernia is excess

fluid in the peritoneal cavity, and in patients with a patent processusvaginalis,

procedures that introduce fluid into the peritoneal cavity may induce a hernia or

hydrocele. Whether hernia is due to the physical presence of the fluid or is

secondary to increased intra-abdominal pressure is unknown. Abnormal

neuromuscular function may also be a factor. Moazam and

colleagues 114 reviewed 134 patients who had ventriculoperitoneal shunt

procedures; inguinal hernias developed in 19.5% of patients with

meningomyelocele and 47% of those with intraventricular hemorrhage. All of

the latter were premature, however. Grosfeld and Cooney 85 found a 14%

incidence of inguinal hernia after insertion of ventriculoperitoneal shunts; 20%

developed an incarceration and the hernia recurred in 16%. On the basis of this

study the authors recommended that (1) after ventriculoperitoneal shunts,

infants should be closely watched for the development of a clinical inguinal

(30)

17

because of the increased risk of incarceration, and (3) in these patients the

contralateral side should be explored in the case of a clinical unilateral hernia.

Clarnette and colleagues 115 evaluated 430 patients who underwent

ventriculoperitoneal shunt placement. In their series, 15% developed an inguinal

hernia and a hydrocele developed in another 6% of boys. Hernias were bilateral

in 47% of boys and 27% of girls. The incidence of subsequent inguinal hernia

development closely paralleled the age at which the shunt was performed. In the

last 8 weeks of gestation or in the first few months of life the incidence was

30%, then falling sharply to 10% at age 1 year. They argue that raised

intra-abdominal pressure is the likely etiology of these hernias. They also conclude

that patency of the processusvaginalis is 30% in the first few months of life and

supports the possibility that a patent processusvaginalis can close in the first

year of life.

The concern in this younger population is that they are preverbal and their

caretakers may not recognize the signs and symptoms of an incarceration in a

timely manner. We instruct our families of preverbal infants with hernias

waiting for elective surgery that the differential diagnosis of a crying baby

includes (1) needs to be fed, (2) needs a diaper change, (3) needs a nap, and (4)

“needs an operation” (may have an incarcerated hernia). We also instruct the

(31)

18

Examination:

To examine for an inguinal hernia, the patient is placed supine and

undressed on an examining table in a warm room. The examiner first observes

for an inguinal mass or asymmetry of the groins. The testis should be “trapped

in the scrotum” with a finger across the top of the scrotum to account for both

testes and to sort out true inguinal bulges from retractile testis. If no mass can be

identified, the older child should stand and perform a Valsalvamaneuver. An

infant may be allowed to strain or cry to provoke an inguinal bulge to appear. If

a mass is still not present, the spermatic cord can be palpated to determine

thickening (the silk glove sign). 29 This is performed by laying a single finger

over the spermatic cord at the level of the pubic tubercle. The finger is lightly

rubbed over the cord from side to side over the pubic tubercle. A positive silk

glove sign indicates that the cord structures within the inguinal canal are

thickened compared with the normal side. The examination imparts to the

examiner the sensation of rubbing two pieces of silk together or the sensation of

feeling a plastic bag with few drops of water in it (“plastic baggy sign”), but

these signs are not accurate completely and are subjective.

If the hernia is not demonstrable on physical examination, some surgeons

will still operate if the hernia has been seen previously by a physician or if the

parents give a history. 30 However, with parental education, follow-up

(32)

19

avoided. Advantage can be taken of photographic documentation by parents.

Kawaguchi and Shaul (2009) 31 found that they could accurately diagnose an

inguinal hernia in equivocal cases using parents' images.

Radiologic Investigations

In most cases the diagnosis of an inguinal hernia can be made by history

and physical examination alone. However, in a small subset of patients

radiologic testing may be of value. Previously, the technique most commonly

used had been contrast herniography, but this has now been replaced by

inguinal ultrasonography (US).

Herniography is performed by injecting water-soluble contrast material

into the peritoneal cavity via an infraumbilical fluoroscopic-guided

injection. 32 Gravity will allow the contrast material to pool into the hernia sac,

which is identified by plain radiographs taken at 5, 10, and 45 minutes apart.

Hydroceles can be identified by this technique, and femoral hernias can be

differentiated from inguinal hernias. This test is also useful for detecting the

contralateral hernias or in postoperative patients with recurrent ipsilateral groin

symptoms. It has no value, however, for incarcerated hernias because the neck

of the sac is occluded in those cases. Complication rates for this technique are

rare and include intestinal perforation, intramural intestinal hematoma, and

allergic reactions to the contrast media. 32,33 Despite this, herniography had not

(33)

20

Ultrasound has gained some popularity as an adjunct to the physical

examination. It has the advantage of being rapid, non-invasive, and

complication free. Chen and colleagues 34performed usg on 244 boys presenting

with unilateral or bilateral hernias.Usgwere performed on both groins. They

noted an accuracy of 97% when using 4 mm as the upper limit of the normal

diameter of the inguinal canal. In a series of 642 children, Erez and

colleagues 28 noted that a preoperative measurement of the inguinal canal of 3.6

± 0.8 mm was associated with normal findings at surgery, whereas 4.9 mm ±

1.1 mm was associated with a patent processusvaginalis and 7.2 ± 2 mm or

greater was associated with a true hernia. 35 Therefore using appropriate

measurements, Ultrasonogram is a reliable tool for diagnosing hernias when a

good history is present, but the examination is equivocal and is potentially

useful for preoperative evaluation of the contralateral groin in patients

presenting with unilateral hernias.

Management

An inguinal hernia will not resolve spontaneously, so surgical closure is

always indicated. Because of the high risk of incarceration, particularly in

young infants, repair should be performed expeditiously. Some reports suggest

90% of complications can be avoided if repair is undertaken within 1 month of

diagnosis. 36,37 More recently Langer and colleagues found that repair

(34)

21

with a 30-day wait. Furthermore, most patients can be done safely in an

ambulatory setting. Exceptions include premature infants and older children

with significant risk factors such as cardiac or respiratory problems. Choice of

anesthetic type varies with the patient. Although most patients are treated under

general anesthesia with endotracheal intubation or laryngeal mask, several other

options exist and the choice of technique depends on several factors including

age and significant comorbidities.

Anesthesia

Anesthesia techniques can be classified as general, regional, or local

techniques. Healthy full-term infants and older patients are treated under

general endotracheal anesthesia, andhas been found to be safe. However, others,

particularly premature infants (>36 weeks gestational age and gestational age

plus chronologic age younger than 60 weeks) require a more varied approach.

Regional techniques (spinal, epidural, or caudal anesthesia) are often chosen in

these situations. Although each has its proponents, none has been shown to be

definitively superior. A recent review of the Cochrane database found several

small trials comparing regional versus general anesthesia. No statistical

difference was demonstrable in the proportion of premature infants having

postoperative apnea/bradycardia, respiratory rate, or postoperative oxygen

desaturations. However, the total enrolled number of patients in the trials was

(35)

22

Postoperative pain control has also been a matter of some debate. Caudal

blocks are routinely performed in some centers, whereas other centers use

instilled local anesthetic. A recent randomized prospective trial comparing

instillation of 0.25% bupivacaine without epinephrine (2.5 mg/kg) versus caudal

block found no difference in the level of postoperative pain. 39 Additionally,

instillation of local anesthetic (so-called splash technique ) is as effective as

injection into the wound.

Recently concerns have been raised about the effect of anesthesia in the

developing brain. Most research has been in animal models and has clearly

shown the anesthetics can induce brain cell apoptosis. However, conclusions

about effects on humans have been mixed. In 2009 Wilder and

colleagues 40 looked at a population of children and identified that learning

disabilities were more common in children younger than age 4 who had

undergone general anesthesia. Similar results were found by DiMaggio and

colleagues 41 in children younger than 3 years of age undergoing inguinal

hernia.

Age for overnight stay

Most full-term infants and older children undergo same-day hernia

surgery. The age at which an ex-premature infant can safely have same-day

hernia surgery is debatable. One study showed preterm infants younger than 41

(36)

23

greater risk of postoperative apnea. 42 Another large study, using sophisticated

monitoring techniques for monitoring postoperative breathing disturbances,

found that infants younger than 44 postconceptualage were at increased risk of

clinically significant episodes of postoperative apnea. 43 In 1995 a combined

analysis from eight prospective studies was performed and concluded that the

incidence of postoperative apnea was not less than 1%, with 95% statistical

confidence, until 56 weeks for a 32-week premature infant and 54 weeks for a

34-week premature infant. 44

Timing of surgery

Most surgeons currently recommend repair of the hernia soon after

diagnosis. 45 This practice can result in a significant reduction of complications

from the hernia and is practicable because of the safety of modern anesthesia.

Regarding premature infants, most surgeons recommend repair before discharge

after the child has attained a weight of about 2 kg. 45 This is in contradistinction

to surgical practice up to 1996, in which only 33% of surgeons polled would

operate on a premature infant. 37 Langer and colleagues reviewed a series of

infants and children undergoing inguinal hernia repair. In infants younger than 1

year of age, the risk of incarceration doubled with surgical wait times of more

(37)

24

Sex

Historically, many surgeons have performed bilateral exploration on

females, primarily on the premise that routine bilateral exploration poses little

risk to the patients because of the relative rarity of finding reproductive

structures in the sac. In a survey in 1981, Rowe and Marchilidon reported that

90% of surgeons routinely explored the contralateral groin in girls younger than

1 year of age. 30 Weiner and colleagues 37surveyed surgeons in 1996 and found

that 84% performed routine exploration in females younger than age 4. 37 It

appears that this trend is on the decline because Levitt and colleagues 45 2002

found that only 39% of surgeons performed bilateral exploration in females

younger than age 5. Despite the rare findings of reproductive structures in the

hernia sac, damage to the inguinal floor and to the ilioinguinal and iliofemoral

nerves still exists and is generally ignored in arguments for contralateral

exploration. Because little follow-up data exist in the literature, it is difficult to

quantify these risks. It is evident that only about 20% of females with a

unilateral hernia will develop a contralateral hernia. Thus a large number of

explorations would be necessary to prevent a few hernias from developing. Puri

and colleagues recently reviewed 300 females undergoing unilateral hernia

repair. 60 In a follow-up ranging from 1 to 4 years, only 8% developed a

contralateral hernia and this was not influenced by age at operation of side of

(38)

25

Age

On the basis of the findings of Rothenberg and Barnet 28 that 100% of

infants younger than 1 year of age will have bilateral patent processusvaginalis,

many surgeons routinely perform contralateral exploration in infants. In the

most recent survey, 51% of surgeons routinely perform contralateral exploration

in premature infants and 40% perform contralateral exploration in boys younger

than 2 years of age. 45 This is considerably less than reported from the 1981

survey in which 80% routinely explored the contralateral side in boys. 30 In a

large series of 1052 patients followed up to 11 years, contralateral hernias

appeared in 13.1% of boys younger than 1 year of age and 13.7% younger than

2 years of age. In females contralateral hernias appeared in 9.6% of patients

younger than 1 year of age and 13.9% of patients younger than 5 years of age.

Another recent series looked at 181 infants younger than 1 year of age

undergoing unilateral repair. Contralateral hernias developed in 7.7% in

follow-up ranging from 5 to 10 years. On the basis of these results, it is not completely

clear that younger children have a significantly higher chance of developing a

contralateral inguinal hernia.

Side and size

It is speculated that right-sided hernias are more common than left

because the right processusvaginalis closes later than the left side. Therefore

(39)

26

likely to have bilateral hernias than those patients initially presenting with a

right-sided hernia. As a result, many surgeons recommended routine exploration

in patients presenting with left-sided hernias. McGregor and

colleagues 19 reviewed a 20-year experience and found 41% of patients having

an initial left inguinal hernia presented with a right hernia, whereas only 14% of

patients developed a left inguinal hernia after the right side was operated

upon. 19 Others have reported much lower rates of contralateral occurrence after

left-sided repair. Kemmotsu and colleagues 47 reviewed 1052 patients who had

undergone unilateral repair and found that the side of initial repair did not

influence contralateral recurrence. 47 Miltenburg and colleagues 48 found that the

risk of contralateral hernia repair was 11% (50%) higher than if the initial

hernia had been on the right. Overall, it appears that the side of the initial hernia

has no bearing on the risk of developing a contralateral hernia.

Laparoscopy

In an effort to limit the number of negative contralateral explorations,

alternative techniques have been used to determine the patency of the

contralateral processus. These have included diagnostic pneumoperitoneum (the

Goldstein test) in which the abdomen is insufflated via the hernia sac and the

contralateral groin is palpated for crepitance, indicating the patent

processusvaginalis. A recent study of 62 patients found 11% had a positive

(40)

27

a contralateral patent processusvaginalis. Of the 55 patients with a negative

Goldstein test, only 3 (5%) have subsequently developed a clinical hernia. In

our opinion this technique is both safe and reliable. However, others have found

that this test is unreliable and often misses patent processes. Bakes dilators have

been used to probe the contralateral groin, but this technique is often difficult

and unreliable. Herniography has been discussed previously and is rarely used

today. Ultrasound has also been discussed previously and found to be fairly

sensitive for the presence of patent processes vaginalis when appropriate-size

criterion are used.

In the early 1990s laparoscopy was used as a means of assessing the

contralateral inguinal canal. Laparoscopy has advantage of being technically

easy and allowing direct visualization of contralateral internal ring.

Nonreducible Hernia

Most inguinal hernias are readily reducible into the abdominal cavity.

Those which are difficult to reduce are “incarcerated.” A strangulated hernia

occurs when there is vascular compromise of entrapped viscera. This is due to

constriction by a tight internal or external ring. Most children will progress

rapidly to strangulation if the hernia is not reduced. This process can take as

little as 2 hours. Initially, constriction by the ring leads to venous and lymphatic

obstruction and subsequent swelling of the viscera. Arterial compromise then

(41)

28

the bowel or other viscera. Incarceration and strangulation can also damage the

testicle by compromising the blood supply to the testis. Patients with

incarcerated hernias are more likely to have testicular atrophy after hernia

repair.

Various series have reported the incidence of incarceration to be in the

range of 12% to 17% and seem to be similar in boys and girls. 50,51 Incarceration

is most likely to occur in the first year of life and then falls off thereafter .

Interestingly, the data in premature infants suggest that they are less likely than

full-term infants to have an incarceration, even though the incidence of hernia is

higher in this subgroup. Full-term infants younger than age 2 to 3 months are

found to have a rate of incarceration of 28% to 31% 50,52 and 24% in infants

younger than 6 weeks of age. 53 Interestingly, premature infants were found to

have lower incidence of incarceration compared with full-term infants (13% to

18%). This may be a result of larger rings and less chance of viscera becoming

entrapped and many of these infants are in neonatal intensive care units under

constant surveillance; incarcerated hernias may be prevented by early reduction

or may simply be underreported as caretakers in the nursery reduce them.

Diagnosis

If a loop of bowel becomes entrapped in a hernia, the patient often

becomes extremely irritable and develops intense pain followed by signs of

(42)

29

tense, nonfluctuant mass will be found in the groin, possibly extending into the

scrotum. As the viscera strangulate, the mass becomes more and more tender.

Occasionally the mass will transilluminate and be confused with a hydrocele.

Under no circumstances should the mass be aspirated in an attempt to diagnose

and treat a supposed hydrocele.

Late signs of a patient with a strangulated hernia are those of shock,

blood in the stool, and peritonitis. The testes are usually palpable, but

occasionally they can be large and firm and difficult to distinguish from a

testicular torsion. Abdominal radiographs reveal a partial or complete bowel

obstruction. Bowel gas may also be seen in the scrotum. In uncertain cases

ultrasound can be useful to distinguish bowel from hydrocele fluid or a

testicular torsion.

Nonoperative management

In patients without obvious signs of shock or peritonitis, nonoperative

management is first attempted. Lay the child down and try to calm him or her

without feeding with the feet elevated if possible. Standing on the ipsilateral

side of the child, or at the feet of an infant, place the left index and middle

finger on the ipsilateral anterior superior iliac crest and sweep the fingers down

along the inguinal canal toward the ipsilateral scrotum, keeping tension on the

testicle in the male child, inguinal mass, or scrotal skin with the left hand.

(43)

30

of the hernia sac with the axis of the inguinal canal. Next, at the level of the

ipsilateral internal ring, apply pressure with the right index finger and thumb on

either side of the hernia neck. This, along with traction on the scrotum, helps to

align and to keep open the external and internal rings. It also prevents the hernia

sac from overlapping or being caught on these potential barriers during

reduction. Finally, with the left hand at the apex of the mass, and with constant

pressure at the level of the internal ring from the right index finger and thumb,

walk your left fingers slowly up the groin toward the internal ring, keeping

constant pressure on the bottom of the hernia contents. This may take several

minutes. If successful, the hernia contents will gradually disappear into the

internal ring. To be certain it is reduced; compare it with the contralateral side.

Use a mirror image technique for the right side. If this technique is unsuccessful

or the child has a difficult time tolerating it, sedation may be used. We do not

recommend reduction of the bowel under general anesthesia because injury to

the bowel may occur or gangrenous bowel may be placed back into the

peritoneal cavity and be unrecognized. Often sedation alone may be sufficient to

promote spontaneous reduction. Reduction of gangrenous bowel has been

reported, so we recommend watching the child in the hospital for 24 hours after

a difficult reduction. Delay of definitive repair of the hernia for at least 24 to 48

(44)

31

Operative management

In those situations where nonoperative management fails or the patient

has signs of shock or peritonitis, surgery is indicated. Intravenous fluids are

initiated, and urine output is monitored. Broad-spectrum antibiotics are given,

and if signs of obstruction are present a nasogastric tube is placed. When the

patient is adequately resuscitated, the patient is taken to the operating room. If

the hernia reduces after the general anesthetic is induced, but before surgery, the

operation should still proceed. Several operative approaches have been

advocated for incarcerated hernias including inguinal approaches and

preperitoneal approaches. The use of laparoscopy can also be valuable in the

management of incarcerated hernias.

Postoperative Complications

Scrotal swelling

After hernia repair and particularly communicating hydrocele repair, fluid may

accumulate in the distal sac, forming a noncommunicating hydrocele. Usually

this resolves spontaneously: rarely, aspiration or secondary scrotal hydrocele

repair may be necessary. Scrotal hematoma may follow excision of the distal

(45)

32

Iatrogenic undescended testicle

Iatrogenic undescended testis after hernia repair is an uncommon but

possibly underreported complication. Kiesewetter 83 reported 2 patients with

this abnormality in a series of 248 patients, and Hecker and

Ring-Mrozik 84 reported 5 patients in a series of 1957 patients, an incidence of 0.2%.

Except in the case of congenital undescended testicle, this abnormality results

from failure to replace the testis back in the scrotum at the conclusion of the

procedure or the testis subsequently trapped in a retracted location. Secondary

orchidopexy is required to correct this problem.

Recurrence

It is difficult to determine the precise incidence of recurrence after indirect

inguinal hernia repair because factors such as sex and incarceration are not

always clearly defined in reported series. In general, the reported recurrence rate

for uncomplicated hernia repair is 0% to 0.8%; this rises to about 15% for

preemies and about 20% after operation for incarcerated hernias. In many

series, patients were not contacted for long-term follow-up; therefore the true

incidence is not known and is probably higher than stated. Reports on patients

with incarcerated inguinal hernias do not state whether the initial management

(46)

33

Many factors associated with the development of primary hernias may

also predispose to recurrence. For instance, Grosfeld and Cooney, in a series of

25 patients with ventriculoperitoneal shunts, identified three recurrent inguinal

hernias (12%). 85Incarceration is also an important risk factor for recurrence.

Steinau and colleagues 86found that in 24% of 29 patients (25 boys, 4 girls) with

a recurrent inguinal hernia, the primary hernia had been incarcerated compared

with 7.6% incidence of recurrence in 2754 patients without incarceration. Other

risk factors in their study were postoperative complications (9.4% recurrence

rate) and concomitant diseases and abnormalities. 87Interestingly, Harvey,

Johnstone, and Fossard found that the level of experience of the surgeon was

not a factor, although technical inadequacies contributed to recurrence. 88Most

recurrent inguinal hernias are indirect and probably result from tearing of a

friable sac, failure to dissect the complete sac, a slipped ligature at the neck of

the sac, or failure to ligate the sac high at the internal ring. Another risk factor

for recurrence is prematurity. Several series of inguinal hernia repairs in

premature infants have reported increased recurrence rate ranging from 2% to

about 15%. Large hernias and inadvertent opening of the hernia sac during

surgery have also been noted to increase recurrence. 89Interestingly, in 2006,

Ein and colleagues 90 did not note significantly increased recurrence rates in

(47)

34

Less frequently, a “recurrence” presents as a direct inguinal hernia or a

femoral hernia missed and not properly diagnosed and repaired at the first

operation. Of the 34 recurrences reported by Steinau and colleagues, 87 4 were

direct and one was femoral. In the Fonkalsrud, Delorimier, 91 and Clatworthy

series of 14 direct inguinal hernias, 4 (31%) followed repair of an indirect

hernia. A direct hernia following repair of an indirect hernia is either a

concomitant hernia not recognized at the initial operation or new pathology

caused by damage to the posterior wall of the inguinal canal during the initial

dissection. A recurrent hernia in the femoral area is also likely to have been a

missed hernia rather than a true recurrence.

Several large series exist of laparoscopic inguinal hernia repair in

children. Schier reported 403 inguinal hernia repairs on 279 patients and had a

recurrence rate of 2.3%. 92The technique of laparoscopic inguinal hernia repair

varies from surgeon to surgeon and is still in evolution. Moreover, there is

likely to be a learning curve with the laparoscopic techniques, such that

recurrences are more likely to be higher earlier in one's experience.

Injury to the vas deferens

Although vas transection may be obvious interoperatively, accidental

operative crush injury to the vas deferens is unlikely to be recognized until

adulthood and possibly then only if the injury is bilateral. Sparkman 93 reported

(48)

35

“segments of the vas deferens” in 5 of 313 hernia sacs from children who had

undergone hernia repair. Details of the five cases were not published, however,

and no histologic or clinical information is available. Walker and Mills found

small glandular inclusions in approximately 6% of hernia sacs from prepubertal

boys, which they believe to be müllerian duct remnants and not segments of the

vas deferens.94 They emphasized that these structures were of no clinical

significance. It is likely that similar structures accounted for some of the

findings reported by Sparkman. Perhaps a better estimate is provided by

Steigman, Sotel-Avila, and Weber, 95 who reviewed the histology of hernias

sacs submitted from 7314 males undergoing hernia repair over a 14.5-year

period. Seventeen cases contained vas deferens (0.23%); 22 had epididymis

(0.3%), and 30 had embryonal rests (0.4%). Three sacs contained coexisting vas

deferens and epididymis. Either vas or epididymis was found in 0.53% of sacs.

Also, Patrick and colleagues 96 found a rather low incidence of 0.13% of vas

injury in an analysis of 1494 sacs. They also argued that the incidence is so low

that routine histologic evaluation of the sac is not warranted.

Shandling and Janick demonstrated the vulnerability of the vas during

hernia repair. 97In their experiments, the vas deferens of rats were exposed and

grasped with fingers, nontoothed forceps, bulldog vascular clamps, or mosquito

hemostats. Serial studies of the vas were done over 6 months, and damage to the

(49)

36

colleagues 98 demonstrated that stretching of the spermatic cord might also

damage the vas and testicle. They applied horizontal stretch force of varying

amounts to the spermatic cord of rats. Significant thinning of the smooth

muscle layer of the vas was noted with all degrees of stretching, as was

testicular atrophy.

The relationship between male fertility and previous inguinal hernia

repair is not well defined. Hommonnai and colleagues 99 reported findings on

131 men referred to an infertility clinic who had undergone inguinal hernia

repair between the ages of 2 and 35 years. Although 14% of these men had

testicular atrophy or abnormal sperm findings that could be related to the hernia

operation, clinical details such as the incidence of incarceration and experience

of the surgeon were not reported.

Operative injury to the vas deferens may result in obstruction of the vas with

diversion of spermatozoa to the testicular lymphatics, and this breach of the

blood-testis barrier produces an antigenic challenge with formation of spermatic

autoagglutinating antibodies. In a review of 76 infertile men with spermatic

autoagglutinating antibodies, 12 (16%) had unilateral inguinal hernia repair

during childhood. 101 In 10 of these men the site of the inguinal hernia repair

was explored, and in 5 patients an obstruction of the vas deferens was

identified. The authors concluded that accidental transection or ligation of the

(50)

37

reason for infertility in men. Parkhouse and Hendry reported similar

findings. 102 Thus although these reports do not indicate the incidence of

infertility of men after inguinal hernia repair, they do suggest that an association

exists.

Testicular atrophy

The testicular vessels are vulnerable to operative injury, particularly in small

infants, but reports of testicular atrophy after routine hernia repair are rare.

Fischer and Mumenthaler 104 and Fahlstrom, Holmberg, and Johansson 103 each

reported an incidence of testicular atrophy of 1%. In these studies the operative

technique varied, and the number of incarcerated hernias was not reported;

therefore this may not indicate the true incidence of testicular atrophy when

hernia repair is performed by an experienced surgeon using a simple high

ligation to obliterate the open sac.

With incarcerated hernia, the blood supply to the testis may be impaired by

compression of the testicular vessels by the incarcerated viscus. The incidence

of testicular compromise in association with incarcerated inguinal hernia ranges

from 2.6% to 5%. The finding of a cyanotic testicle at emergency operation is

common, reportedly 11% to 29%. The actual incidence of testicular atrophy as

indicated by histologic examination or diminished size at follow-up is much

lower, varying from 0% to 19%. Unfortunately, reported series of patients

(51)

38

length of follow-up and the criteria for evaluation of the testis vary

considerably. Puri, Guiney, and O'Donnell, 105 in an analysis of 87 boys with

incarcerated hernia treated by nonoperative reduction, found unilateral testicular

atrophy in 2 patients or 2.3%. From the available data, we conclude that

vascular compromise is common but the risk of actual infarction is low.

Therefore unless the testis is frankly necrotic, it should not be removed.

The herniated ovary and fallopian tube are also susceptible to vascular

compromise, either as a result of incarceration or, perhaps more likely, torsion

of the ovary within the hernia sac. The reported incidence of strangulation of

irreducible ovaries is as high as 32%. Boley and colleagues 106 reported a 27%

strangulation rate in 15 females presenting with incarceration. In addition,

several case reports have demonstrated injury to the fallopian tubes from

bilateral hernia repair, resulting in female infertility.

Intestinal injury

With incarcerated hernias, the incidence of intestinal infarction is remarkably

low. Between 1960 and 1965, the incidence of intestinal resection in the report

by Rowe and Clatworthy 70 of 351 patients with incarcerated hernias was 1.4%.

A review of three series published since 1978 shows no resections in 221

(52)

39

Loss of abdominal domain

A complication of hernia surgery that is not rotuinley discussed is

postoperative respiratory failure as a result of lost abdominal domain. The right

of domain is the concept that each organ occupies a space within the body that it

has a right to fill. In giant inguinal hernias, particularly bilateral giant hernias,

the majority of the intestine can lie within the hernia sac and outside of the

peritoneal cavity. If this occurs for some time, the intestine can lose its right of

abdominal domain. During repair, the intestine is returned to the abdominal

cavity, resulting in increased intra-abdominal pressure and respiratory failure.

Bascombe, Caty, and Glick 107 reported an ex-premature infant with large

bilateral inguinal hernias who required 41 days of mechanical ventilation after

repair.

Respiratory failure after inguinal hernia repair is common, especially in

premature infants. Gollin and colleagues 108,109 found 34% of premature infants

required mechanical ventilation after herniorrhaphy. It is possible that increased

intra-abdominal pressure as a result of loss of domain may be an unrecognized

contributor to this problem. As a result of their experience, Glick and

colleagues 108 have recommended staged repair of large bilateral hernias in the

elective setting, especially because the risk of a second anesthesia is so low

using modern technique. In an emergency setting (e.g., repair of giant

(53)

40

considered to alleviate abdominal compartment pressures and allow the

intestine to be slowly returned to the abdomen.

Chronic pain

Chronic pain after adult hernia repair is found in about 10% of patients.

This incidence is unknown in patients undergoing hernia repair in childhood. In

2007 Aasvang and Kehlet110 surveyed adults who had undergone hernia repair

younger than the age of 5. Although 13.5% reported some pain from the

operated groin (usually associated with physical activity), only 2% reported this

pain to be severe.

This issue may be of relevance in the older teenager in whom mesh is

used. In fact, there seems to be no general consensus as to the age when mesh

repair may be appropriate and the older teenager may receive a different

operation if corrected by an adult surgeon versus a pediatric surgeon.

Inguinodynia can be effectively improved in the great majority of patents

by combined neurectomy and mesh removal. As noted previously, Ein 90 found

in his personal series that teenagers had a significantly higher recurrence rate

than other age groups. Interestingly, there are no published studies comparing

mesh versus standard repair in adolescents. Clearly, this is an issue that is best

(54)

41

Ventriculoperitoneal shunts/peritoneal dialysis

A significant factor in the development of an inguinal hernia is excess

fluid in the peritoneal cavity, and in patients with a patent processusvaginalis,

procedures that introduce fluid into the peritoneal cavity may induce a hernia or

hydrocele. Whether hernia is due to the physical presence of the fluid or is

secondary to increased intra-abdominal pressure is unknown. Abnormal

neuromuscular function may also be a factor. Moazam and

colleagues 114 reviewed 134 patients who had ventriculoperitoneal shunt

procedures; inguinal hernias developed in 19.5% of patients with

meningomyelocele and 47% of those with intraventricularhemorrhage. All of

the latter were premature, however. Grosfeld and Cooney 85 found a 14%

incidence of inguinal hernia after insertion of ventriculoperitoneal shunts; 20%

developed an incarceration and the hernia recurred in 16%. On the basis of this

study the authors recommended that (1) after ventriculoperitoneal shunts,

infants should be closely watched for the development of a clinical inguinal

hernia, (2) operation should be done promptly after diagnosis of a hernia

because of the increased risk of incarceration, and (3) in these patients the

contralateral side should be explored in the case of a clinical unilateral hernia.

Clarnette and colleagues 115 evaluated 430 patients who underwent

ventriculoperitoneal shunt placement. In their series, 15% developed an inguinal

(55)

42

in 47% of boys and 27% of girls. The incidence of subsequent inguinal hernia

development paralleled the age at which the shunt was performed. In the last 8

weeks of gestation or in the first few months of life the incidence was 30%, then

falling sharply to 10% at age 1 year. They argue that raised intra-abdominal

pressure is theetiology of these hernias. They also conclude that patency of the

processusvaginalis is 30% in the first few months of life and supports the

possibility that a patent processusvaginalis can close in the first year of life.

There is a well-established risk of inguinal hernia developing in patients

on long-term ambulatory peritoneal dialysis, ranging from 7% to 15%. In such

cases the patent processusvaginalis is likely to develop into a frank hernia.

Intraoperative herniography is recommended when the peritoneal dialysis

catheter is inserted. Water-soluble contrast is infused through the catheter, and

the patient is placed in a head-up position for 15 minutes. If a patent

processusvaginalis is identified, repair is in order. Alternatively, direct

laparoscopic visualization of the internal ring can be performed at the time of

catheter placement, particularly if the catheter placement itself is performed

laparoscopically. Repair can then be performed open or laparoscopically.

Sliding hernia

The fallopian tube or mesosalpinx is frequently found in the wall of the

hernia sac in girls and is at risk of injury. The operative management has

Figure

Fig :- 1.
Table :- 1 Factors Contributing to the Development of an Indirect Inguinal
Table 2:
Table 3:
+7

References

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