Inguinal Hernia & Hydroceles

If you are looking for information on umbilical hernia (i.e. from the umbilicus) then have a look here.

How does a hernia develop in children?

There is a hole in the muscles of the abdominal wall in the region of the groin on both sides in all individuals. In males the blood vessels supplying and those draining the testes along with the vas deferens, pass through this hole. In the female, a relatively unimportant structure called the round ligament that stabilizes the uterus passes through this hole.

When the child is in the womb, along with the above structures, a protrusion of the lining of the abdomen passes through this hole. This lining gets progressively obliterated as the child reaches term so that in 95% of all newborn children, this protrusion does not exist. However, in the remaining kids, this abnormal communication with the abdominal cavity persists and if big enough allows the passage of abdominal contents out of the abdominal cavity towards the genitals.

If fluid were to come out, it is called a hydrocele, and if other structures like intestines or ovary were to come out then it is called a hernia.

Doctor, you say that this condition is present since birth, then why was it not seen earlier in my child?

The basic predisposition to the development of the hernia-hydrocele complex is present since birth. However, due to a various combination of factors the actual condition may not manifest well into late childhood.

So Doctor, what should be done for this condition?

In children with simple hydroceles that do not change much in size, we advise a period of observation till the child is one year of age since there is a possibility of spontaneous closure of this protrusion by then. However, children who have hernias require to be operated on at the earliest after diagnosis.

But Doctor, apart from the swelling my child is absolutely fine so why operate?

You are absolutely right. In most children with hernia-hydrocele complex there hardly are any symptoms apart from the swelling. However, the possibility of complications like obstruction of the contents like intestine or ovary,that can occur at any time, necessitates early intervention.

What are these complications?

The most common complication is irreducibility. This means that previously the swelling would be visible intermittently, but is now persistently present. If there are intestines as a content of the protrusion then they become blocked and this can lead to disastrous complications including damage to the viability of the bowel.

If there are other structures like ovary these can get twisted and their blood supply can be cut off leading to permanent irreversible damage to the structure. In boys, obstructed hernias can also compromise blood supply to the testis and damage it permanently. Since these complications are catastrophic and since the underlying pathology is not likely to go away we advise early intervention at a convenient time when the child is otherwise hale and hearty.

My child has a hydrocele and he is less than one year of age and you have advised to wait and watch. Can he have a hernia too?

Sure he can! This may not be manifest either to you or to me during examination. However if your child should develop a groin swelling then please take an early appointment. If he should develop redness and pain on touching the area then contact me urgently!. And lastly, if the hydrocele does not resolve by one year of age then schedule an appointment to see me at a convenient time.

What does surgery involve? Are there any injections or medications to cure this condition?

Unfortunately, there are no injections or medications which can cure this. This is a structural problem, and will require an operation to close the abnormal communication with the abdominal cavity.

Can this not be done laparoscopically?

Of course! I have done quite a few of these laparoscopically. Current recommendations for the laparoscopic approach are:

  • Any child who already has hernia.
  • All female children
  • All boys who are less than two years of age

The biggest advantage of the laparoscopic approach is that one can see the internal inguinal ring and simultaneously repair a hernia on the opposite side, thereby saving the child from a second anesthesia and surgery.

The Operation

During surgery for the hernia-hydrocele complex, we close the abnormal communication with the abdominal cavity after putting back any of the abdominal contents back in their proper place. Rarely if we find that the hole has become enlarged then we may narrow the hole. Unlike adults, children almost never require a mesh during hernia repair.

POST-OPERATIVE CARE OF THE CHILD WHO HAS UNDERGONE HERNIA REPAIR

  • In the immediate postoperative period please follow the General postoperative instructions.
  • The child will have a small dressing over the groin.
  • In general, children do not have much pain after this operation. During surgery, we do give injections to block pain in the wound and/or the nerves supplying the area. Later the child is given oral analgesics. However, individual variations in pain threshold do exist. In general, supportive and caring parents can do a lot to alleviate the pain which the child has. Analgesics in full doses are already being given so do try to divert the mind of the child. If you are hyper-anxious and constantly enquire about pain to your child you are likely to aggravate his symptoms!
  • Some amount of swelling in the scrotum and in the area where the child has been operated is inevitable and is due to the collection of fluid and blood from the operated site. This will eventually disappear but may take up to a month to look normal.
  • Follow up: In general, I call the child back for inspection of the wound on the second postoperative day and call for suture removal on the seventh postop day.
  • Recurrence: This is extremely rare on the same side and literature figures are about 0.5%. However, I fortunately have had just two recurrences since 1989, when I started my practice. However, the child may develop a hernia at any time on the opposite side in about 15% of all children undergoing open hernia surgery. This should be operated on when diagnosed though some surgeons will routinely repair the opposite side. The general consensus is to wait and operate if it develops.
If we go in for open surgery, will the child have bad scar?

Not at all! the scar on the child, after we have operated is like our signature and, our best advertisement. We take great pains to give the best possible scar to the child, so much so, that it is difficult to spot the scar after a few years. Have a look at the picture below for an example.

Old scar
Child operated 12 years back for hernia. Difficult to say which side has been operated

 

Have questions or comments?