Pediatric Inguinal Hernia Repair

Overview

A hernia develops when an organ within the belly, such as the intestines, protrudes via a weakness in the abdominal muscles. A gentle bulging beneath the skin indicates the presence of a hernia. An inguinal hernia is a hernia that arises in the groin (inguinal) region.

An inguinal hernia can arise at any age, but one-third of all hernias in children occur within the first six months of life.

Inguinal hernia signs and symptoms include Swelling or a protrusion in the groin or scrotum may be noticed when screaming or straining, and it may diminish or disappear as the infant relaxes. A smooth, non-tender bulk. Localized discomfort in the hernia area

A complete medical history and a thorough physical examination by a physician are used to make the diagnosis.

Inguinal hernias necessitate surgery, which is usually performed as quickly as possible to reduce the risk of abdominal organs getting entrapped. Surgery may be postponed for two to three months in preterm infants who are only a few months old to verify that the lungs are working properly.

 

What is Inguinal Hernia?

An inguinal hernia is a hole in the abdominal or belly wall caused by an internal opening in the inguinal canal. The inguinal canal is a channel in boys that connects the abdomen to the scrotum—the skin sac that stores the testicles on the exterior of the body. The testicles are connected to the spermatic cord, which runs via the inguinal canal. A newborn boy's testicles are placed high inside his tummy before delivery.

The baby's testicles descend down down this canal into the scrotum as he develops within the mother. The inguinal canal in females serves as a pathway for a ligament that retains the uterus in place. The tunnel or opening normally closes on its own before the baby is delivered, whether he or she is a male or a girl. If it does not, a pouch may develop in the belly's inner lining. An inguinal hernia is the medical term for this pouch.

Although inguinal hernias can occur in both boys and girls, they are far more prevalent in boys. Because of its tiny size, hernias sometimes go unnoticed for years, and may not be identified until a kid is in his or her twenties. Pediatricians typically discover inguinal hernias during normal physical examinations. 

Inguinal hernias are almost often congenital, which means they were present at birth. Straining, coughing, or sobbing may accentuate the hernia, but they are not the cause of the hernia. Children's inguinal hernias are not the same as adult hernias or "ruptures" caused by straining or lifting.

 

What Causes Inguinal Hernia? 

The most prevalent surgical condition in children is inguinal hernia. It is caused by a tiny sac that enters the inguinal ring, which ordinarily remains open during fetal development and closes around the time of delivery. It does not shut in some newborns for reasons we do not understand. This is more prevalent when a baby is born prematurely.

This sac subsequently creates a channel for abdominal organs to enter the groin via the inguinal ring. In boys, the organ is commonly a loop of bowel, however in girls, it might be either a bowel or an ovary. In both boys and girls, the hernia begins as a bulge in the groin and might emerge and vanish, or it can be there all of the time. When the infant yells or strains, it will frequently "pop out." A hydrocele occurs when only fluid enters the sac through the inguinal ring.

 

Risks for an Inguinal Hernia?

Hernias are more common in premature infants. They are also more prevalent in children who have the following conditions:

• A parent or sibling who had a hernia as an infant.
• Cystic fibrosis.
• Developmental dysplasia of the hip.
• Undescended testes.
• Problems with the urethra.

 

Symptoms of an Inguinal Hernia in a Child?

Inguinal hernias appear as a groin or scrotum protrusion or swelling. When the baby cries, you may be able to notice the swelling more clearly. When the baby relaxes, it may shrink or disappear. If your kid's healthcare professional gently presses on this bulge while your kid is quiet and lying down, it will generally shrink or disappear.

If the hernia cannot be forced back into the stomach, the intestinal loop may become caught in the weaker section of the abdominal muscle. If this occurs, the following symptoms may occur:

• A full, round belly
• Vomiting
• Pain or fussiness
• Redness or a color that's not normal
• Fever

These symptoms may look like other health problems. Make sure your child sees his or her healthcare provider for a diagnosis.

 

Facts About Inguinal Hernia & its Repair

1. An inguinal hernia is a hole in the abdominal (belly) wall near the groin. If left untreated, fluid or intestines can leak through this incision.
2. In certain situations, a portion of the intestine might fall through the incision and become caught. If your kid is experiencing pain at the hernia site, you should contact your doctor right once. Because the confined intestine might die within a few hours, this disease is unexpected and can be fatal. It is possible that emergency surgery will be required. As a result, surgery may be required soon after your doctor identifies an inguinal hernia.
3. Fluid can accumulate in the scrotum, resulting in a bulge or swelling around the testicles. This fluid accumulation is known as a hydrocele. The fluid will be absorbed back into the body in most newborn boys over time, generally by 6 to 12 months of age. If the hydrocele changes size on a daily basis, it is more likely to be an inguinal hernia that will require surgical treatment.
4. Because an inguinal hernia does not heal on its own, surgery is always required.
5. Your child's operation will be performed under general anesthesia, which means he will be completely sleeping during the procedure.
6. In addition to general anesthetic, your kid may be given caudal anesthesia, which will relieve discomfort below the waist.
7. Your child's inguinal hernia will be repaired by a pediatric urologist, who is a specialist in surgery of the urinary system and reproductive organs in children.
8. This procedure might take anything from 30 minutes to an hour.

 

Home Preparation Before Surgery

When general anesthesia is required, there are strict food and drinking guidelines that must be observed in the hours leading up to the surgery. A surgical nurse will call you between the hours of 1 and 9 p.m. one working day before your child's operation. (These calls are not made by nurses on weekends or holidays.) Please have paper and a pen on hand to jot down these vital instructions.

Based on your child's age, the nurse will offer you particular feeding and drinking guidelines. The following are the standard eating and drinking instructions. Regardless of your child's age, you must follow the particular directions provided to you over the phone by the nurse.

For children older than 12 months:

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, chewing gum or candy.

For infants under 12 months:

• Up to 6 hours before the scheduled arrival time, formula-fed babies may be given formula. 
• Up to 4 hours before the scheduled arrival time, breastfed babies may nurse.

For all children:

• Up to 2 hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before scheduled arrival time, give nothing to eat or drink.

 

Time of Anaesthesia

After you have registered your kid for surgery, a nurse, nurse practitioner, or physician's assistant, as well as a member of the anesthesia staff, will meet with you to collect your child's vital signs, weight, and medical history. Before the anesthetic is administered, you will be asked to sign a permission form as the parent or legal guardian.

The anesthesia doctor will examine your child's medical history and determine which type of sleep medication he or she should get.

If your kid is really terrified or distressed, the doctor may prescribe a sedative to help him or her calm down. This flavored drug takes action in 10 to 15 minutes.

If you desire, you may accompany your kid to the operating room and remain while the sleep drug is administered.

Younger children will receive their sleep medicine via a "space mask" that will include both air and medication. Your youngster can choose a favorite smell to flavor the air that flows through the mask. While your kid is conscious, no injections or needles are used.

Older children may be given their medicine through a mask or straight into a vein through an intravenous (IV) line.

You will be transported to the waiting room after your kid has fallen asleep. If it hasn't already been done, an IV will be inserted so that medicine may be administered to keep your kid asleep during the procedure.

Your child will be flipped onto his or her side after the IV has been put. For the caudal anesthetic injection, the lower back near the spine will be cleansed.

 

The Surgical Procedure

A hernia repair is the surgical treatment of inguinal hernias. Due to the possibility of post-herniorraphy pain syndrome, it is not suggested in less symptomatic hernias, for which cautious waiting is advised. Outpatient surgery is the most prevalent type of surgery.

There are several surgical methods to consider when contemplating inguinal hernia repair. These include the use of mesh (either synthetic or biologic), open repair, the use of laparoscopy, the kind of anesthesia (general or local), the appropriateness of bilateral surgery, and so on. Mesh and non-mesh repairs offer advantages in different regions, although mesh repairs may minimize the risk of hernia recurrence, visceral or neurovascular damage, duration of hospital stay, and time to return to normal activities.

Although laparoscopy is more typically employed for non-emergency patients, a minimally invasive open repair may have a reduced incidence of post-operative nausea and mesh-related discomfort. During surgery under local anesthetic, the patient will be asked to cough and strain to assist demonstrate if the repair is free of tension and sound.

 

How Long Will My Child Stay In The Hospital? 

Your kid will be returned to the recovery area following the procedure, and you will be able to be with him or her when he or she awakens. As the anaesthetic wears off, some children become agitated and confused. This is a common and transitory occurrence. 

Most children will be discharged the same day, as soon as they are awake and ready to swallow liquids. If your kid was delivered prematurely or has other health issues, the surgeon may keep him or her overnight in the hospital to check his or her breathing. Your kid will just require Tylenolâ or ibuprofen for a few days after surgery to address any discomfort or pain.

 

What is Expected After Surgery? 

1. Waking up from anesthesia:

• When your kid is transferred to the recovery room, you will be notified so that you can be present when he or she awakens.
• The doctor who performed your child's surgery will meet with you to discuss the procedure and answer any concerns you may have.
• The caudal anesthetic will allow your kid to awaken pleasantly and pain-free following the procedure.
• Your kid will be monitored in the recovery room until he or she is aware and vital signs are stable. Because some children take longer than others to wake up following general anesthesia, the length of time your kid will remain in the recovery room will vary.
• Children who have just woken up from anesthesia may respond in a variety of ways. Your youngster may scream, be irritable or confused, vomit, or feel ill to his or her stomach. These are natural responses that will subside as the anesthetic wears off.
• Children who have had caudal anesthesia may have leg weakness, numbness, or tingling. These emotions are natural and should pass in a few hours. To avoid stumbling or falling, keep an eye on your child for a few hours.

 

2. Going home 

• When your kid is discharged and returns home, he or she may still be sleepy and should rest for the day.
• You will be instructed on how to properly care for your child's dressing. You may be prescribed an ointment to use in conjunction with the dressing.
• Bathing will be prohibited for your child for several days following surgery.
• When your child may resume typical activities will be determined by his or her surgeon.
• As long as your child is feeling healthy, he or she can start eating and drinking little by little and then resume normal eating and drinking.
• If you observe a temperature of more than 101.4 ° F, bleeding, or foul-smelling discharge from the region around the incision, contact the surgeon immediately.

 

Complications of the Procedure

1. Intraoperative Complications: 

• Bladder injury:

Bladder damage is most usually caused by port installation, dissecting a big direct sac, or a sliding hernia. To avoid trocar damage, it is necessary to empty the bladder prior to inguinal hernia surgery. It is recommended that beginners catheterize their bladders throughout the first stage of their learning curve. When urine is found in the extraperitoneal area, the diagnosis is obvious. Vicryl is applied in two layers, and a urinary catheter is placed for 7–10 days.

• Bowel injury:

It is uncommon with hernia surgery. It can happen while decreasing large hernias, when accidentally exposing the peritoneum and allowing the colon to enter the surgical area, or when reducing sliding hernias. In such cases, it is advisable to open the hernial sac as near to the deep ring as possible to avoid injury. Initial investigations revealed a greater incidence, particularly with TAPP, although this reduced with time.

• Vascular injury:

This is one of the most prevalent injuries in hernia repair and is frequently the reason for conversion. It can occur at a variety of sites, including rectus muscle vessel injury during trocar insertion, inferior epigastric vessel injury, bleeding from the venous plexus on the pubic symphysis, aberrant obturator vein injury, testicular vessel injury, and the most dangerous of all, iliac vessels, which necessitates an emergency conversion to control the bleeding and the immediate services of a vascular surgeon to repair.

• Injury to vas deferens:

While separating the hernial sac from the cord structures, an injury develops. The damage leads to fibrotic constriction of the vasculature. In a young child, a full transection of the vasculature must be restored. An damage to the vasculature is best avoided, which can be accomplished by finding and separating any structure near the deep ring or floor of the extraperitoneal space before dividing it. Separation of cord structures from the hernial sac must also be careful and direct; forceps should not be used to grip the vas deferens.

• Pneumoperitoneum:

It is a common occurrence in TEP which every surgeon should be prepared to handle. Putting the patient in the Trendelenberg position and increasing the insufflation pressures to 15 mmHg helps. If the problem still persists, a Veress needle can be inserted at Palmer's point.

 

2. Postoperative Complications:

• Seroma / hematoma formation: 

It is a frequent complication following laparoscopic hernia surgery, with a frequency of 5–25%. They are most common following major indirect hernia surgery. The majority of them resolve on their own after 4–6 weeks. In a direct hernia, a seroma can be prevented by avoiding dissection of the hernial sac from the cord structures, securing the direct sac to the pubic bone, and fenestrating the transversalis fascia. If there is considerable bleeding or extensive dissection, some surgeons will insert a drain.

• Urinary retention: 

This post-hernia repair problem has a documented incidence of 1.3 to 5.8 percent. It is commonly caused in older people, especially if they have symptoms of prostatism. These individuals should be catheterized before to surgery and have the catheter withdrawn the next morning.

• Neuralgias: 

This problem is reported to occur between 0.5 and 4.6 percent of the time, depending on the repair procedure used. In one research, the intraperitoneal onlay mesh approach had the greatest incidence of neuralgias and was thus abandoned as a feasible repair procedure. 

The lateral cutaneous nerve of the thigh, the genitofemoral nerve, and the intermediate cutaneous nerve of the thigh are the most usually affected nerves. They are frequently affected by mesh-induced fibrosis or tack entrapment. The problem is avoided by not fastening the mesh lateral to the deep inguinal ring in the triangle of the pain region, safe dissection of a big hernial sac, and no fascia dissection across the psoas. Testicular pain and swelling 

• Mesh infection and wound infection 

Infection rates from wounds are quite low. Mesh infection is a significant consequence, and strong aseptic measures must be followed during the process. Prior to surgery, any endogenous infection must be treated with an appropriate course of antibiotics.

• Recurrence:

It is the most crucial outcome of any hernia operation. Endoscopic repair involves a competent and detailed grasp of anatomy as well as a thorough approach of repair to assist reduce recurrence to a minimal.

 

Conclusion

A hernia arises when a section of the intestine pushes through a weakness in the muscles of the belly (abdominal). A soft protrusion appears beneath the skin where the hernia resides. An inguinal hernia is a hernia that occurs in the groin region.

A hernia can form within the first few months of a baby's birth. It occurs as a result of a weakening in the abdominal muscles. Hernias are not caused by straining or crying. However, the additional pressure in the abdomen might make a hernia more visible.

A doctor or nurse will do a physical examination to diagnose inguinal hernias. Ultrasound is rarely used to diagnose inguinal hernia. Ultrasound is not required by the pediatric surgeon to identify an inguinal hernia. If an inguinal hernia is not visible or felt at the initial clinic visit, your surgeon may ask you to snap a photo of the "bulge" when it "pops out" to confirm the diagnosis.

Inguinal hernias do not normally go away on their own. Your child will require emergency surgery if the hernia cannot be forced back (reduced) into the abdominal cavity.

Your child's pediatric surgeon will either seal the hernia sac opening laparoscopically or with a "open" procedure. Laparoscopy includes the passage of small tools via two or three small incisions.