How are simple inguinal hernias repaired in children?

Answer

A simple inguinal hernia repair is possible in children because of the smaller size, better muscle tone in the canal, and rapid recuperation. Excision of the hernial sac (processus vaginalis) is usually sufficient, with little need for prosthetic repair of an attenuated internal ring or posterior wall of the inguinal canal. Either preincisional injection of the incision site or a caudal block is preferable to no preincisional therapy.^[34]

A small incision is made just superior and lateral to the pubic tubercle in the suprapubic skin crease, centering the operative field near the internal ring. The external oblique aponeurosis is incised in the direction of its fibers, or the internal and external rings are transposed by laterally retracting the latter. Tugging on the testis helps visualize cord structures. The glistening white hernia sac often bulges up amid the cord. The sac, located anteromedial to the cord, is elevated from the floor and carefully dissected free from the vas deferens and testicular vessels.

Short hernia sacs are freed to the internal ring, but long sacs are often best divided. Proximal dissection to the internal ring should extend until preperitoneal fat is visible circumferentially. Twisting the sac before ligation provides strength and narrows the internal ring. The sac is ligated at its base. Because of occasional postoperative “spitting” of a nonabsorbable (eg, silk) suture, synthetic sutures are used for sac ligation.

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Media Gallery

Large right inguinal hernia in 3-month-old girl.
In this baby with gastroschisis, bowel is uncovered and presents to right inferior aspect of cord.
Hernia of umbilical cord.
Note translucent sac in baby with large omphalocele. Umbilical vessels attach to sac.
Hernia content balloons over external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied first.
Infant with Silon chimney placed in treatment of gastroschisis.
Atrophy of right testis after hernia repair. Note adult-type incision.
Iatrogenic cryptorchid testis in child. Taking care to position testis in scrotum is integral part of completion of hernia repair in boys.
Erythematous edematous left scrotum in 2-month-old boy with history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
Testis at operation in 2-month-old boy with history of irritability and vomiting for 36 hours. Capsulotomy was performed, but atrophy occurred. Patient also required bowel resection.
Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy.
Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy. Abdominal radiograph shows incarcerated shunt within communicating hydrocele. Repair of hydrocele relieved increased intracranial pressure.
Bassini-type repair approximating transversus abdominis aponeurosis and transversalis fascia to iliopubic tract and inguinal ligament.
Anatomic locations for various hernias.

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Author

Assar A Rather, MBBS, MD, FACS Minimally Invasive General and Colorectal Surgeon, Bayhealth Kent General Hospital

Assar A Rather, MBBS, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Colon and Rectal Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Bret A Nicks, MD, MHA Chief Medical Officer (DMC), Professor of Emergency Medicine, Department of Emergency Medicine, Wake Forest Baptist Health

Bret A Nicks, MD, MHA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Christian Medical and Dental Associations, International Federation for Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

Kim Askew, MD Assistant Professor, Director of Undergraduate Medical Education, Department of Emergency Medicine, Wake Forest University School of Medicine