management of hernia and hydrocele in children

1. HERNIA INGUINALIS
LATERALIS AND
HYDROCELE
MOCHAMAD SYAHRONI FARDIANSYAH

2. OVERVIEW HERNIA
Definition
Protrusion of whole or part of viscus through the wall
that contains it.
Clinical types
 Reducible
 Irreducible
 Incarcerated : Irreducible + Obstruction
 Strangulated : Irreducible +Obstruction +
cut off of blood supply to contents

3. HERNIA INGUINALIS
LATERALIS VS MEDIALIS

4. HERNIA INGUINALIS
LATERALIS VS MEDIALIS
 Direct
 Leaves abdominal cavity
medial to inferior
epigastric vessels,
through inguinal triangle
 Travels through medial
portion of inguinal canal,
runs parallel to
spermatic cord
 Sac formed by
peritoneum and
transversalis fascia
 Less common
 Indirect
 Leaves abdominal cavity
lateral to inferior
epigastric vessels
 Enters deep inguinal ring
and runs inside
spermatic cord
 Sac formed from
persistent processus
vaginalis

5. HERNIA INGUINALIS
CONGENITAL VS ACQUIRED
 Congenital
 Processus Vaginalis
does not seal after
the descent of the
testes
 Fluid or intestines
occupy the space in
the inguinal canal
left open by the
patent processus
 The processus
vaginalis remains
patent in 25% of
adults
 Indirect are far more
 Acquired
 Exercise or strain
can induce a direct
hernia
 Direct Hernias are
more common in
males over 40
 Problem lies in a
weak falx inguinalis
(conjoint tendon)
either by trauma or
lack of exercise.

6. Types of
abdominal wall Location Congenital Acquired
Epigastric Upper midline *
Umbilical Umbilicus * ?
Inguinal/femoral Groin * *
Incisional Anywhere *
Lumbar Petit’s ∆ *
Interparietal Lateral hypogastric *
Obturator Obturator foramen *
Spigelian Arcuate x semilunar
lines
? ?
Traumatic Anywhere *
Diastasis Upper midline Not a hernia Not a hernia

7. Pathophysiology
 As the testis descends into the scrotum from its
abdominal position, it carries with it a tongue of
peritoneum (processus vaginalis)
 During the embryologic processes, the processus
vaginalis did not closure and obliteration of the
processus (patent processus vaginalis), that can
result in commonly seen inguinal or scrotal
pathology.

8. Anomalous closure of the processus vaginalis

9. Transillumination test

10. A case of hydrocele (5 y-o)

11. Hydrocele in cord

13. Incision line along Langer’s lines in a skin crease
Kogan BA. Communicating hydrocele/hernia
repair in children. BJU Int 2007;100:703-13

14. Incise the aponeurosis of external oblique
along the course of its fiber
Ilioinguinal nerve

15. The patent PV is seen anteromedial to the rest of
the cord structures
Cremasteric m. fiber

16. Use of Methylene Blue
 Moderate but not tense hydrocele: the blue dye flows
upwards into the inguinal canal → clearly outlines the PV
 Tense scrotal hydrocele: delineation of the loculated area

17. Dissection of PV:
direct isolation or open on anterior wall of PV

18. Omentum or bowel in the hernia sac

19. Separation of the PV from the cord structures
up to and above the internal ring

20. High ligation of the hernia sac

21. Removal of distal sac (large &/or tense hydrocele):
Incision, unroofing or aspiration

22. Closure

24. HERNIA dan HYDROCELE
 Embryologi dan anatomi
→ Procesus vaginalis (12 mgg) adalah peritoneal
diverticullum yang keluar dari cavum peritoneum
melalui annulus inguinalis interna
→ sama dengan testis turun ke scrotum menyerupai
tunica vaginalis

25. Jenis/type
→ Hernia inguinalis direct and indirect
Hernia scrotalis?
Hernia communican?
→Hydrocele

29. Klinis
→Benjolan inguinal – scrotum
peningkatan tekanan intra abdominal
“Silk glove sign”
→Benjolan pada medial vassa epigastrica
(dasar canalis inguinalis )
→ menyerupai dewasa (Tx)