Groin hernias & hydroceles in children are among the most common problems a pediatric surgeon sees. An estimated 1%-5% of all children suffer from either a groin hernia or hydrocele.
If you are looking for information on umbilical hernia (i.e., a hernia at the umbilicus), have a look here.
How does a groin hernia develop in children?
All human beings have a hole in the muscles of the abdominal wall in the groin region on both sides. In males, the blood vessels supplying and 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, a protrusion of the lining of the abdomen called the peritoneum passes through this hole in addition to the above. This lining gets progressively obliterated as the child reaches term. This protrusion closes down at birth in 95% of all newborn children. In the remaining kids, this abnormal communication with the abdominal cavity persists and, if significant enough, allows the passage of abdominal contents out of the abdominal cavity toward the genitals.
If fluid were to come out, it would be called a hydrocele, and if other structures, like intestines or the ovary, were to come out, it would be called a hernia.
Doctor, you say that this condition is present since birth, then why was it not seen earlier in my child?
The underlying predisposition to the development of the hernia-hydrocele complex has been present since birth. However, due to various factors, the actual condition may not manifest until late childhood.
So, Doctor, what should be done to treat this condition?
In children with simple hydroceles that do not change much in size, we advise observation until the child is one year old since there is a possibility of spontaneous closure of this protrusion by then. However, children who have hernias require an operation as soon as possible after diagnosis.
But Doctor, apart from the swelling, my child is fine, so why operate?
You are right. Most children with the hernia-hydrocele complex have hardly any symptoms apart from the swelling. However, complications are always possible.
- The most common complication is obstruction of the contents. When the intestine in a hernia gets obstructed, it compromises the lumen of the intestine and leads to a choke-up in the forward passage of intestinal contents. The child then develops pain, vomiting, and distention of the abdomen.
- An infinitely more dangerous possibility is that the blood supply of the contents or the testis may get cut off, and this may lead to the death of the tissue.
If either of these were to happen, urgent intervention would be required.
My child has a hydrocele, and he is less than one year of age. You have advised me to wait and watch. Can he have a GROIN hernia, too?
Sure, he can! A hernia may not manifest either to you or to me during a routine examination. However, if you notice a groin swelling, please make an early appointment. If he should develop redness and pain when touching the area, contact me urgently! Lastly, do bring the child in for examination when he is one year of age after scheduling 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. A hernia is a structural problem requiring an operation to close the abnormal communication with the abdominal cavity.
Can a groin hernia not be repaired laparoscopically?
Of course! I have done quite a few of these laparoscopically. Current recommendations for the laparoscopic approach are:
- Any child who already has a groin hernia on both sides when first seen.
- All female children with a hernia on one side.
- All boys who are less than two years of age with a hernia on one side.
The most significant advantage of the laparoscopic approach is that one can see the internal inguinal ring on the opposite side and simultaneously repair it, thereby saving the child from second anesthesia and surgery.
The Operation
During surgery for the hernia-hydrocele complex, we close the abnormal communication with the abdominal cavity after putting any of the abdominal contents back in their proper place. Rarely, if we find that the hole has become enlarged, we may narrow the hole. Unlike adults, children seldom 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 the nerves supplying the area. These injections take care of the pain 4-6 hours after the surgery.
Later, the child is given oral analgesics on an as-needed basis. However, individual variations in pain threshold do exist. In general, supportive and caring parents can do a lot to alleviate the pain that 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 inquire 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 on is inevitable and is due to the collection of fluid and blood from the operation site. This will eventually disappear but may take up to a month to look normal.
- Follow-up: In general, I call the child back on the second postoperative day to inspect the wound and for suture removal on the seventh postoperative day.
- Recurrence: This is extremely rare on the same side, and literature figures are about 0.5%. I, fortunately, had just three 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. One should operate a hernia that develops on the opposite side when diagnosed though; some surgeons will routinely repair the opposite side. The consensus is to wait and operate if it develops.
If we go in for open surgery, will the child have a 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.
