Overview
Definition:
An inguinal hernia in children occurs when a portion of the intestine or other abdominal contents protrude through a weak spot in the abdominal wall, specifically in the inguinal canal
Laparoscopic repair is a minimally invasive surgical technique used to correct this condition by reducing the herniated contents and repairing the defect using a laparoscope and specialized instruments.
Epidemiology:
Inguinal hernias are common in pediatric surgery, occurring in 1-5% of term infants and up to 30% of premature infants
They are more common in males and on the right side
Recurrence rates after traditional open repair vary from 1-5%, while laparoscopic techniques aim to reduce this.
Clinical Significance:
Undiagnosed or untreated pediatric inguinal hernias can lead to serious complications such as incarceration (trapping of the hernia contents) and strangulation (compromise of blood supply to the trapped organ), which are surgical emergencies
Early diagnosis and appropriate surgical management are crucial for preventing morbidity and ensuring optimal long-term outcomes in young patients.
Clinical Presentation
Symptoms:
A palpable bulge in the groin or scrotum, often more prominent when the child is crying, straining, or standing
Intermittent or absent bulge when the child is relaxed
Discomfort or pain in the groin area, especially if incarcerated
Irritability, poor feeding, vomiting, and abdominal distension in cases of incarceration or strangulation
Testicular asymmetry or absence in the scrotum may be noted.
Signs:
A reducible bulge in the inguinal canal or scrotum that can be pushed back into the abdomen
Incarcerated hernia presents as a tense, tender, irreducible mass in the groin or scrotum
Signs of strangulation include erythema or dusky discoloration of the overlying skin, fever, increased heart rate, and signs of peritonitis.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on physical examination findings of a palpable, reducible or irreducible bulge in the inguinal region
Imaging is rarely needed in diagnosed cases but may be considered in ambiguous cases or to confirm incarceration/strangulation, with ultrasound being the modality of choice
The presence of a palpable sac in the groin is the hallmark sign.
Diagnostic Approach
History Taking:
Detailed history should include onset and duration of the bulge
Factors that exacerbate or diminish the bulge (e.g., crying, straining, lying down)
Presence of associated symptoms like vomiting, abdominal distension, fever, or changes in bowel habits
History of prematurity or previous abdominal surgery
Family history of hernias.
Physical Examination:
A thorough examination of the groin and scrotum in both standing and lying positions is essential
The examiner should attempt to elicit a bulge using maneuvers like asking the child to cry or bear down
Palpation for a reducible mass in the inguinal canal or scrotum
Assess for signs of incarceration or strangulation, including tenderness, erythema, and edema of the sac.
Investigations:
Generally, no investigations are required for uncomplicated pediatric inguinal hernias, as the diagnosis is clinical
In cases of suspected incarceration or strangulation, an abdominal X-ray may show dilated bowel loops or a sentinel loop
Ultrasound of the groin can confirm the presence of a hernia sac and its contents, and help differentiate from other groin masses
Laboratory tests (CBC, electrolytes) may be useful in assessing for complications.
Differential Diagnosis:
Undescended testis, hydrocele, spermatic cord cyst, lymphadenopathy, undescended processus vaginalis, femoral hernia (rare in children), adnexal torsion in female infants
Incarcerated hernias must be differentiated from acute scrotum, appendiceal or omental torsion, and hematoma.
Management
Initial Management:
For reducible hernias, elective surgical repair is indicated
For incarcerated hernias, immediate management involves attempting manual reduction under sedation or analgesia
If reduction is successful, surgery should be performed electively within 24-48 hours
If irreducible, urgent surgical exploration is required to rule out strangulation.
Medical Management:
Medical management is generally not indicated for pediatric inguinal hernias
For incarcerated hernias, conservative management with manual reduction under sedation and observation may be attempted, but surgical repair remains the definitive treatment once the child is stable.
Surgical Management:
The standard treatment is surgical repair
Laparoscopic repair involves making small incisions (1-3 mm) to insert a laparoscope and instruments
The hernia sac is identified and dissected from the surrounding structures
The internal inguinal ring is then closed, typically with a laparoscopic instrument
The goal is to occlude the patent processus vaginalis
Techniques vary, including using a suture to ligate the sac at the internal ring or using a laparoscopic knot-tying technique
The contralateral side may be explored and repaired prophylactically in certain high-risk populations or if a patent processus vaginalis is identified laparoscopically.
Supportive Care:
Post-operatively, patients typically receive analgesia and are monitored for pain, nausea, and wound complications
Fluid and electrolyte balance is maintained
Early mobilization is encouraged
In cases of strangulation with intestinal resection, appropriate antibiotic coverage, nasogastric decompression, and parenteral nutrition may be required.
Complications
Early Complications:
Wound infection, bleeding, hematoma formation in the scrotum or groin, recurrence of hernia, injury to vas deferens or testicular vessels (rare), injury to bladder or bowel, port site hernia (rare)
Incarceration or strangulation if not promptly managed.
Late Complications:
Chronic groin pain, testicular atrophy or injury (rare), infertility (extremely rare), recurrence of hernia if the repair is inadequate or if there is a new hernia formation.
Prevention Strategies:
Meticulous surgical technique, proper identification and ligation of the hernia sac, adequate closure of the internal ring, and appropriate use of laparoscopic instrumentation
Careful post-operative care to prevent infection and hematoma
Thorough intraoperative exploration to identify and manage contralateral patent processus vaginalis if indicated.
Prognosis
Factors Affecting Prognosis:
Promptness of diagnosis and treatment, success of surgical repair, presence and management of incarceration or strangulation
Age and overall health of the child
Experience of the surgical team.
Outcomes:
Laparoscopic repair of pediatric inguinal hernias generally has excellent outcomes with low recurrence rates and minimal morbidity
Most children recover quickly and return to normal activities within days to a week
The risk of testicular damage is significantly reduced compared to older open techniques in some regards due to less extensive dissection.
Follow Up:
Routine follow-up is generally not required for uncomplicated laparoscopic hernia repairs
Patients should be advised to report any recurrence of a bulge, significant pain, or signs of infection
In cases of incarcerated or strangulated hernias, or if there were operative complications, more extensive follow-up may be warranted based on clinical judgment.
Key Points
Exam Focus:
Laparoscopic technique for pediatric inguinal hernia repair emphasizes closure of the internal ring and/or ligation of the processus vaginalis
Contralateral exploration and repair in infants with unilateral hernias and risk factors for contralateral disease is a key discussion point
Incarceration and strangulation are critical complications requiring urgent management.
Clinical Pearls:
Always examine the contralateral side visually, especially in infants, even if repair is unilateral
Consider an orchidopexy if the testis is found to be intra-abdominal or undescended during hernia repair
Differentiate between a true hernia and a hydrocele of the cord or testis during examination
Recognize the signs of strangulation immediately.
Common Mistakes:
Failure to identify and address a patent processus vaginalis on the contralateral side when indicated
Inadequate closure of the internal ring leading to recurrence
Delay in surgical intervention for incarcerated or strangulated hernias
Misinterpreting a hydrocele or lymph node as a hernia.