Groin hernias & hydroceles in children are among the most common problems that are seen by a pediatric surgeon. 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) then have a look here.
How does a groin 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 human beings. 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, 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. At birth, in 95% of all newborn children, this protrusion closes down. 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 towards the genitals
If the 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 underlying 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, which 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 an operation at the earliest after diagnosis.
But Doctor, apart from the swelling my child is absolutely fine so why operate?
You are right. In most children with the hernia-hydrocele complex, there are hardly any symptoms apart from the swelling. However, there is always a possibility of developing complications.
- 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 this were to happen, urgent intervention is required.
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 GROIN hernia too?
Sure he can! A hernia may not be manifest either to you or to me during a routine examination. However, if you notice 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, 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 and will require 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 who have a hernia on one side.
- All boys who are less than two years of age with a hernia on one side.
The biggest 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 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. These injections take care of the pain for 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 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 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 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 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 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. TOne should operate a hernia that develops on the opposite side 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 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.
