Editing Paediatric inguinal hernia

Indirect inguinal hernias are very common in boys. Direct may also be seen rarely in preterm infants or those with neurologic/spinal conditions.

== Aetiology ==

* Arises from persistence of processus vaginalis/failure of this structure to fuse and obliterate the entrance of the canal.
** If it only contains fluid, it is known as hydrocoele
** If the processus remains open it is a communicating hydrocoele
** If the processus has been obliterated proximally, it is a non-communicating hydrocoele
* It CAN also occur in girls but less common - they can still get herniation down to level of labia majora and can technically get a hydrocoele.

== Risk factors ==

* Boys: girls 9:1
* Premature
* Anterior abdo wall defects
* Conditions with increased ascites

== Presentation ==

* Mostly asymptomatic
* Sometimes have to rely on the word of parents/paediatrician - get them to take a photo
* Incarceration
** Surgical emergency - both bowel and testis may become ischaemic
** Highest risk in newborns and first 2 years
* Examination
** Should be able to differentiate hydrocoele and hernia as follows
*** If reducible - it's a reducible inguinal hernia
*** If irreducible and non-tender it's a hydrocoele
*** If irreducible and tender it's an incarcerated hernia
*** Should also be able to get above a hydrocoele and feel a normal spermatic cord
*** Hydrocoeles should be transillumable
*** USS can settle any ambiguities
** Make sure it's not a femoral hernia - these are possible, especially between 5-10yo girls who have a lump inferior to inguinal ligament - need to be repaired urgently

== Treatment ==

* Most hydrocoeles will undergo spontaneous involution by 1 year old
** As long as it doesn't change in size, these can be observed
** Communicating hydrocoele should be repaired electively if it hasn't closed by then
* All other inguinoscrotal abnormalities should be repaired
* Incarcerated
** Resuscitate
** Attempt to reduce - appropriate to be aggressive to prevent testicular ischaemia. Multiple attempts and use of sedation may be necessary. Mostly can be reduced.
** Surgical repair is very difficult - thin and oedematous sac, and risk of damage to cord structures is high. Should be done by paeds surg.
** Herniotomy is the treatment of choice rather than herniorraphy
** If an incarcerated hernia is reduced, repair should be done within the next two days

== Herniotomy: (from Kirk's) ==

* 2cm incision in a skin crease, midway between the deep ring and pubic tubercle
* Clear a small patch of EO about 1cm above the inguinal ligament
* Incise EO, but not as far as the external ring
* Find the cord (the ilioinguinal nerve is a useful landmark, because the cord lies between the nerve and the inguinal ligament) and open cremaster muscle, separating the cord from cremaster circumferentially
* Split internal spermatic fascia longitudinally and gently sweep vas and vessels away from the sac
* Ensure the sac is empty, perhaps by opening it, clamp it and divide distal to the clamp, allowing the distal part of the sac to fall away
* Dissect the outside of the sac back to the inferior epigastric vessels
* Suture transfix the sac
* Close the inguinal canal and re-approximate Scarpa's
* Check testis is back in scrotum



[[Category:Paed Surg]]