Inguinal hernias are the most common operation performed by pediatric surgeons, often presenting in infants during the first year of life. They occur when the processus vaginalis fails to close after descent of the testes in utero. Clinical diagnosis is based on history and physical exam findings of an inguinal bulge or mass. Management involves early surgical repair to prevent incarceration, with open or laparoscopic techniques used depending on surgeon preference and risk factors. Postoperative complications are rare if repaired promptly.

1. Inguinal Hernias in pediatrics
By Dr Mengistu.K 3/22/2021
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2. Outlines
• Introduction
• Embryology
• Diagnosis
• Management
• Summery
• Reference
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3. Introduction
• The most common operation performed by
pediatric surgeons.
• Occur in 0.8% to 4.4% of childrens and in 16%
to 25% premature infants
• Most commonly presents during the first year of
life with a peak during the first few months
• One third of children are younger than 6 months
of age at the time of operation
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4. • At birth 80% are patent and the rates decrease
dramatically by the first 6 months of age
• Male-to-female ratios between 3:1 & 10:1
• Right sided 60% of cases.
• Bilateral in approximately 10% of the time
• Family history: 11.5%
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5. Embryology
• Processus vaginalis
▫ Evagination of the peritoneum through the
internal ring during the third month of fetal life.
▫ Result of intra-abdominal pressure or to be an
active process.
▫ Elongate during seventh to ninth months of
gestation when intra-abdominal testis passes
through it
▫ Portion lying above the testicle obliterates, closing
the internal inguinal ring
▫ Distal portion persists as the tunica vaginalis.
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6. • Up to 80% to 100% of infants are born with a
patent processus vaginalis
• Exact timing of closure is uncertain.
• If it occurs, is most likely to happen within the
first 6 months of life
• Patency rates fall after 6 months of age more
gradually and plateau generally around age 3 to
5
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7. • The biologic mechanisms that signal and induce
descent of the testicle is unknown.
• Proposed mechanism
▫ Androgens-release neurotrophins calcitonin
gene–related protein (CGRP) released from
GFNa local chemotactic gradient to guide the
gubernaculum.
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8. • Failure of closure of the processus vaginalis
results in
▫ An indirect inguinal hernia (if bowel or other
organs can enter the processus) or
▫ Hydrocele (peritoneal fluid only).
• In females the canal of Nuck corresponds to the
processus vaginalis and communicates with the
labia majora
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9. Associations and Risk Factors
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10. Clinical Features
• Diagnosis is clinical and rests on the Hx and P/E
• Most are found by the parents or the pediatrician on
routine physical examination
• The usual presentation: asymptomatic,
intermittent, unilateral
inguinal bulge elicit by
crying, coughing,
straining, etc.
• Incarceration
▫ Commonly in the first 6 months of life & rare after the
age of 5
▫ Intermittent pain, irritability, distension, vomiting, and
obstipation.
• A convincing history is acceptable as an indication for
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11. Examination
• Place the patient supine and undressed on an
examining table in a warm room
• Observes for an inguinal mass or asymmetry of
the groins
• Trappe the testis in the scrotum to sort out true
inguinal bulges from retractile testis
• Valsalva maneuver in older child
• Silk glove sign: 90% sensitivity
• Plastic baggy sign
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12. 3/22/2021
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13. The most common variants of hernias and hydroceles arising from
failure of complete obliteration of the processus vaginalis.
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14. Radiologic Investigations
• Herniography
▫ Injecting water-soluble contrast material into the
peritoneal cavity
▫ Identified by plain radiographs taken at 5, 10, and
45 minutes apart
▫ Importance ?
• Ultrasonography (US)
▫ Accuracy of 97% when using 4 mm as the upper
limit
• Laparoscopy: the Goldstein test
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15. Management
Timing of surgery
• Repair soon after diagnosis
• Repair with in 1 month of Dx decrease
complication by 90% and decrease 50%
incarceration risk if done with in 2 wks
compared with 30 days wait
• Premature infants repair before discharge
after the child has attained a weight of about 2
kg or post conception age of 60 wks
• Safely in an ambulatory setting except?
• Choice of anesthetic type
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16. Operative Technique
OPEN REPAIR
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17. 3/22/2021
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18. Procedure in females
• Somewhat simpler than in males
• Same surgical approach
• The ovary, tube, or mesosalpinx is contained
within the sac
• Up to 40% of indirect inguinal hernias in
females have a sliding component
• Bevan repair:- if fallopian tube is in hernial sac
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19. Laparoscopic repair
• Advantages
▫ less pain
▫ Earlier return to work
▫ Repair of bilateral hernias though the same ports,
and
▫ Easier repair of recurrent hernias.
• Disadvantages have included
▫ Increased cost,
▫ longer OR times and
▫ A prolonged learning curve
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20. • Patient on rendelenburg
position
• Reduce the hernial content
manually
• Place A 3-mm trocar through
umbilical incision and
insuffilate with CO2 to 5–8
mmHg pressure
• Two 2-mm ports are placed
superior and medial to the
anterior superior iliac spine
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21. Intraperitoneal purse-string closure
• Confirme internal opening of the
hernia and examine the
contralateral side
• subperitoneal injection of 2 ml of
normal saline to separate the vas
deferens and testicular vessels
• Purse-string stitch commences at
the 2 o’clock position of the
internal hernia opening
• Lowered intraperitoneal pressure
to 2–4 mmHg before the stitch is
tied
• Teste airtightness increasing the
IAP transiently to 15 mmHg
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22. Extraperitoneal closure
• Place A 3-mm trocar through
umbilical incision
• Inserte a 2- or 3-mm grasper
midway between the
umbilicus and suprapubic
tubercle under telescopic
guidance.
• Made small stab wound just
lateral to the internal inguinal
ring.
• The incision is deepened to the
preperitoneal space.
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23. Postoperative care
• Resume oral intake when the child awakens.
• Discharge within 2 hours of operative repair
• Analgesia for approximately 48 hours
• Baths can be resumed on postoperative day 3
Postoperative complications include
• Wound infection
• Scrotal hematoma
• Postoperative hydrocele, and
• Recurrent inguinal hernia.
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24. Contralateral Exploration
• One of the most contentiously debated issues
• Rothenberg and Barnet recommended routine
exploration
• Puts both testicles and both vas deferens at risk
• About 20% of patients presenting with a
unilateral hernia will develop a clinical hernia on
the other side
• Basis of age , sex , or side of the hernia.
• Laparoscopy use of an angled scope (e.g., 70
degrees)
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25. Nonreducible Hernia
• Incarcerated
• A strangulated hernia
• DIAGNOSIS
▫ Hx: irritable , intense pain, abdominal
distension,vomiting, absence of flatus/stool).
▫ P/E: tense, nonfluctuant mass, shock, blood in
the stool, and peritonitis, large and firm testis
▫ Abdominal radiographs and U/S
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26. Management
• Nonoperative management
• Operative management
▫ Inguinal Approach
▫ Preperitoneal Approach
▫ Pfannenstiel Approach
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27. Postoperative Complications
• Scrotal swelling
• Iatrogenic undescended testicle
• Recurrence
• Injury to the vas deferens
• Testicular atrophy
• Intestinal injury
• Loss of abdominal domain
• Chronic pain
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28. Congenital hydrocele
• Noncommunicating –commonest
• Communicating
• Diagnosis
• Management
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29. Summery
• The most common operation performed by
pediatric surgeons
• Most commonly presents during the first year of
life with a peak during the first few months
• Inguinal herniarepair soon after diagnosis
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30. Reference
• Coran pediatric surgery 7th edition
• Ashcraft’s Pediatric Surgery7th edition
• Operative Pediatric Surgery 7th edition
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