Congenital hernia & hydrocoele

2. Congenital Inguinal HerniaCongenital Inguinal Hernia
 Indirect Inguinal HerniaIndirect Inguinal Hernia
 Continued patency of the ProcessusContinued patency of the Processus
VaginalisVaginalis
 Patent PV sac is potentialPatent PV sac is potential
hernia/hydrocoelehernia/hydrocoele
 In hernia the sac is wider & contains anIn hernia the sac is wider & contains an
intraabdominal structureintraabdominal structure
 In hydrocoele the sac is narrow & containsIn hydrocoele the sac is narrow & contains

3. Processus VaginalisProcessus Vaginalis . . .. . .
 PV develops during12th wk of gestationPV develops during12th wk of gestation
 Out pouching of the peritoneal cavity through theOut pouching of the peritoneal cavity through the
internal ringinternal ring
 PV plays an integral role in the descent of testesPV plays an integral role in the descent of testes
 PV obliterates spontaneously from the deep ring to thePV obliterates spontaneously from the deep ring to the
testistestis
 possible role of CGRP in fusion of PVpossible role of CGRP in fusion of PV
 Distal portion persists as tunica vaginalisDistal portion persists as tunica vaginalis

4. At birth PV is patent in up to 80% infants.At birth PV is patent in up to 80% infants.

6. IncidenceIncidence
 0.8 – 4 %0.8 – 4 %
 Highest in 1st year of lifeHighest in 1st year of life
 Incidence in premature infants 16 – 25%Incidence in premature infants 16 – 25%
 M:F is 6:1M:F is 6:1
 Right 60%, Left 30%, Bilateral 10%Right 60%, Left 30%, Bilateral 10%

7. Factors contributing to development ofFactors contributing to development of
herniahernia
 Undescended testisUndescended testis
 Increased peritoneal fluid :Increased peritoneal fluid :
Ascites, VP shuntAscites, VP shunt
 Increased abdominal pressure :Increased abdominal pressure :
Severe ascites, Meconium peritonitis,Severe ascites, Meconium peritonitis,
post repair of Exomphalos / CDHpost repair of Exomphalos / CDH
 Chronic respiratory disease :Chronic respiratory disease :
Cystic fibrosisCystic fibrosis
 Connective tissue disorders:Connective tissue disorders:
Ehlers –Danlos, Marfans, MucopolysaccharidosisEhlers –Danlos, Marfans, Mucopolysaccharidosis

8. Clinical FeaturesClinical Features
 Bulge in inguinal area extending towards / intoBulge in inguinal area extending towards / into
scrotum with crying / strainingscrotum with crying / straining
 may be present at birth or appear latermay be present at birth or appear later
 reduces in size when the child is relaxed / asleepreduces in size when the child is relaxed / asleep
 smooth soft-firm mass that emerges from thesmooth soft-firm mass that emerges from the
external ring lateral and above pubic tubercle,external ring lateral and above pubic tubercle,
enlarges with increased abdominal pressureenlarges with increased abdominal pressure

9.  Can be reduced with gentle pressure, mayCan be reduced with gentle pressure, may
reduce with gurgling noisereduce with gurgling noise
 Examine position of testis – undescended /Examine position of testis – undescended /
retractileretractile
 Reappears on crying / valsalva (blowing aReappears on crying / valsalva (blowing a
balloon / coughing ) preferably whileballoon / coughing ) preferably while
standingstanding
 Thickening & silkiness on palpating the cordThickening & silkiness on palpating the cord
as it crosses pubic tubercle –as it crosses pubic tubercle – Silk GloveSilk Glove
signsign
 If in doubt re-evaluate at second visitIf in doubt re-evaluate at second visit

10. ManagementManagement
 Inguinal hernia does not resolveInguinal hernia does not resolve
spontaneouslyspontaneously
 Must be operated because of high riskMust be operated because of high risk
of incarcerationof incarceration
 Operation :Operation :
HerniotomyHerniotomy - High suture ligation of the- High suture ligation of the
sac at the internal ringsac at the internal ring
 Open technique / LaparoscopyOpen technique / Laparoscopy

11. TechniqueTechnique
 Anaesthesia:Anaesthesia:
In infants – ETGAIn infants – ETGA
Older children – facial or laryngeal maskOlder children – facial or laryngeal mask
 Transverse groin skin crease incisionTransverse groin skin crease incision
 Open layersOpen layers
 Incision in external oblique aponeurosisIncision in external oblique aponeurosis
lateral to external ringlateral to external ring

13.  Fibres of cremasteric fascia are separatedFibres of cremasteric fascia are separated
 Shiny glistening white hernial sac identified &Shiny glistening white hernial sac identified &
lifted with blunt forcepslifted with blunt forceps
 In males the sac lies anterior & medial to vasIn males the sac lies anterior & medial to vas
& vessels& vessels
 Vas & vessels are never held with forceps,Vas & vessels are never held with forceps,
dissected off the sac with overlying areolardissected off the sac with overlying areolar
tissuetissue

15.  In females there are no significant structures otherIn females there are no significant structures other
than round ligament of uterusthan round ligament of uterus
 Ensure there are no contents in the sac, divideEnsure there are no contents in the sac, divide
between clampsbetween clamps
 Dissect proximally upto neck of the sacDissect proximally upto neck of the sac
 Twist the proximal sac & transfix the neck at the levelTwist the proximal sac & transfix the neck at the level
of deep ringof deep ring
 Traction on the testis to return it to the scrotumTraction on the testis to return it to the scrotum
 Closure in layersClosure in layers

16. Contralateral explorationContralateral exploration
Selected contralateral exploration:Selected contralateral exploration:
 Age:Age: 40% contralateral hernias occur after unilateral surgery in40% contralateral hernias occur after unilateral surgery in
children under 1 yrchildren under 1 yr
 Side of hernia:Side of hernia: LeftLeft
 Sex:Sex: FemaleFemale
 Patency of PV sac on opposite side:Patency of PV sac on opposite side: Herniography,Herniography,
intraoperative pnuemoperitoneum, Choledochoscope /intraoperative pnuemoperitoneum, Choledochoscope /
laparoscopelaparoscope
 Conditions predisposing to hernia on the opposite side:Conditions predisposing to hernia on the opposite side:
VP Shunt, connective tissue disordersVP Shunt, connective tissue disorders
 Poor risk for GAPoor risk for GA

17. Irreducible HerniaIrreducible Hernia
Incarcerated hernia: contents cannot beIncarcerated hernia: contents cannot be
easily reduced into peritoneal cavityeasily reduced into peritoneal cavity
 Irritability, pain in the groin / abdomen,Irritability, pain in the groin / abdomen,
vomitingvomiting
 Tense, tender, non fluctuant mass in theTense, tender, non fluctuant mass in the
groin, may extend into scrotum, notgroin, may extend into scrotum, not
transilluminanttransilluminant
 Bilious vomiting, abdominal distensionBilious vomiting, abdominal distension
indicates obstruction of bowelindicates obstruction of bowel

18. Strangulated hernia: Tightly constricted atStrangulated hernia: Tightly constricted at
the neck resulting in ischemia ofthe neck resulting in ischemia of
contents.contents.
 Pain intensifies, vomiting becomes bilious.Pain intensifies, vomiting becomes bilious.
Blood in stoolsBlood in stools
 Mass is tender, edema & reddening ofMass is tender, edema & reddening of
overlying skin, feveroverlying skin, fever

19. Management:Management:
 Non operative:Non operative: only when there is noonly when there is no
e/o ischemiae/o ischemia
 Under sedation & analgesia reduce theUnder sedation & analgesia reduce the
hernia by gentle compressionhernia by gentle compression
 Elective herniotomy after 48 hrs byElective herniotomy after 48 hrs by
which time there is less edemawhich time there is less edema

20.  Operative:Operative: When hernia cannot beWhen hernia cannot be
reduced or hernia is strangulatedreduced or hernia is strangulated
 Hernial sac opened. Look for viability ofHernial sac opened. Look for viability of
bowelbowel
 Deep ring can be enlarged by incising theDeep ring can be enlarged by incising the
arching fibres of conjoint tendon superiorlyarching fibres of conjoint tendon superiorly
 Tell tale e/o ischemia – bloody or foulTell tale e/o ischemia – bloody or foul
smelling fluid in the sac. Explore thesmelling fluid in the sac. Explore the
abdomenabdomen

21. Complications of herniotomyComplications of herniotomy
 Ascending / trapped testisAscending / trapped testis
 Recurrence – 0.8%Recurrence – 0.8%
 Injury to vasInjury to vas
 Testicular atrophyTesticular atrophy

22. Congenital HydrocoeleCongenital Hydrocoele
 Usually noted in early infancy, can occur atUsually noted in early infancy, can occur at
anytimeanytime
 Often bilateralOften bilateral
 Soft, bluish, fluctuant swelling surrounding theSoft, bluish, fluctuant swelling surrounding the
testistestis
 Fluctuate in size: smaller at night when theFluctuate in size: smaller at night when the
child is relaxedchild is relaxed

23.  Neck of the hydrocoele narrows at the externalNeck of the hydrocoele narrows at the external
ring & usually does not extend into the inguinalring & usually does not extend into the inguinal
canalcanal
 Hallmark: Brilliant transilluminationHallmark: Brilliant transillumination
 In most children with congenital hydrocoele theIn most children with congenital hydrocoele the
PV sac closes and hydrocoele resolvesPV sac closes and hydrocoele resolves
between 12 – 24 monthsbetween 12 – 24 months
 There is no e/o hydrocoele will evolve intoThere is no e/o hydrocoele will evolve into
herniahernia

25. ManagementManagement
 Observation for first 2 years unless large,Observation for first 2 years unless large,
painfulpainful
 Herniotomy if it persists > 2 yrsHerniotomy if it persists > 2 yrs