Inguinal hernias and hydroceles
Inguinal (groin) hernia is the most common surgical disorder of children. Hernias usually cause infants and children little discomfort and may, in fact, be visible only intermittently. Yet, hernias can lead to terrible consequences such as the death of a piece of intestine, loss of a testicle or an ovary, or even death of the child. In order to avoid these complications, surgeons usually recommend that hernias be repaired as soon as they are noticed.
What is a hernia?
An inguinal hernia is a sac that is an outpouching of the peritoneum, the inner membrane lining the abdomen, that extends into the groin and maybe the scrotum. When the sac contains only water it is called a hydrocele, but when bowel, ovary, abdominal fat, or another structure enters the sac, it is called a hernia.
What causes a hernia?
Hernias is adults are often thought of as a "rupture" of muscle that allows an outpouching of the contents of the abdomen. This does occur sometimes in adults, but rarely if ever in children. Inguinal hernias in children are the result of a persistent connection between the inside of the abdomen and the scrotum (or labia). This connection, also called the processus vaginalis, is normal during fetal life, but usually closes before birth. When it does not close, a hernia or hydrocele may develop.
How common are hernias?
About 1-5% of babies develop hernias and boys are 10 times more likely than girls to have a hernia. Hernias are found in as many as 30% of prematurely born babies because birth occurs before natural closure of the sac has been completed.
When the peritoneal sac contains only fluid and not intestine, the abnormality is called a hydrocele. In a typical appearance of a hydrocele, one half of a boy's scrotum is always large and shiny. We can usually differentiate a hydrocele from a hernia on examination.
A hydrocele that is always the same size or slowly decreases in size over weeks to months is called a "non-communicating" hydrocele, because the sac is probably not connected to the abdominal cavity. In these hydroceles, it is unlikely that intestine can enter the sac to potentially incarcerate. These hydroceles usually resolve when their fluid eventually is absorbed.
When a hydrocele fluctuates in size throughout the day and it persists beyond six months to a year, we suspect that there may be a connection to the abdominal cavity, and it is called a "communicating" hydrocele. These hydroceles carry a risk for incarceration of intestine, like a hernia, and therefore must be repaired.
Hernia repair should be scheduled soon after the diagnosis has been made. As long as the herniated intestine will slide back into the abdomen with gentle manipulation or when the child relaxes, there is no urgency for surgical repair. Discomfort from an uncomplicated hernia is usually minimal. When herniated intestine becomes trapped in the inguinal canal and cannot easily be pushed back into the abdomen it is called an "incarcerated" hernia. This is a true emergency because the intestine within the hernia can die within only a few hours. If this occurs, you should bring your child to the emergency room immediately. Incarceration is unpredictable, and prevention of this emergency is the principal reason that hernia repair is recommended.
In young children with a hernia on one side, there is a good chance that a hernia is present on the other side as well, but has just not yet become apparent. Therefore, if only the presenting side is repaired, there is a 15-40% chance that a noticeable hernia will eventually develop on the other side--depending upon the side of the original hernia. For this reason, when we repair hernias in children under five years of age, we usually examine the other side for the presence of a hernia by putting a laparoscope through the original hernia opening. This allows us to see inside the abdomen. Only when a hernia is present on the other side is it necessary to make a separate incision.
The rate of complications with repair of inguinal hernias in infants and children is very low, especially for surgeons who specialize in pediatric surgery. However, there is approximately a one percent incidence of injury to the vas deferens (sperm-carrying tube) or to the blood vessels that supply the testicle when hernias are repaired.
The office visit
When your child sees us, he or she will be seen by either the pediatric surgery nurse practitioner or the surgery resident. They will perform a history and physical examination on your child, answer any questions you may have, and complete all necessary paperwork. They will then discuss their findings with the attending pediatric surgeon. Your child's pediatric surgeon will also examine your child and explain the procedure in detail.
If surgical repair is indicated, once the paperwork has been completed, you will be taken to meet the surgery scheduler. She will be your contact person. She will inform you of the surgery date as well as the date of their PAT'S (Pre-Admission Testing) appointment.
Your child's operation may be performed at the Outpatient Surgery Center (OSC) if your child meets the criteria; otherwise, it will be performed at the Loma Linda University Children's Hospital. When premature babies have hernia repairs or other operations, there is a risk of apnea (suddenly stopping breathing) within the first 24 hours of the operation. For this reason, babies whose period of gestation plus age adds up to less than 60 weeks are admitted to the hospital overnight after their operation so that their breathing can be monitored closely.
Your child's surgeon will answer any questions you may have after the procedure is completed.
The procedure involves a small incision in the skin fold above the groin crease. Stitches are buried beneath the skin and do not require removal. Small paper tapes (Steristrips) usually cover the incision and should be left in place until your child returns for the postoperative visit. If there are hernias on both sides, two incisions will be made.
Sometimes, there is swelling of the scrotum after the operation that may persist for a week or so. This is usually no problem and results from collection of fluid or a small amount of blood.
Pain control rarely requires more than over-the-counter pain relievers such as Children's Tylenol or Children's Advil. These may be given every four hours as needed.
Any other medications which your child required before the operation should be continued on the regular schedule afterward.
Nausea following general anesthesia is uncommon in infants. However, older children may experience nausea after discharge. Initially, liquids may be tolerated better than solids. There are no dietary restrictions once the nausea has passed and your child is alert and hungry.
Small children require no restriction of activity following inguinal hernia surgery. They may have enough initial discomfort to limit their activity voluntarily for a day or so. However, larger children should avoid body contact sports for at least two weeks.
Always wash your hands before touching or cleaning the incision area. Some blood staining of the paper tapes on the incision is common. If the blood is dry and not spreading, the staining is not a problem. If the blood seems fresh, the amount is increasing, or if the paper tape is blood soaked and partially floating above the skin, apply gentle pressure with a clean washcloth for five to six minutes. Then, contact the pediatric surgery resident on call at (909) 558-4000. The problem is usually minor but the surgeon needs to know about it.
No tub baths should be given for at least two days after the operation. Sponge bathing for infants and showering for older children are permitted the day following the operation. Carefully pat dry the incision tapes after showering.
When to call your child's surgeon
- Fever above 101oF that does not come down with Tylenol (mild fever is common)
- Difficulty breathing, with or without a croupy cough
- Active bleeding from the incision
- Redness, swelling, or persistent pain in the incision
A clinic appointment needs to be scheduled one to two weeks after the operation. Please call (909) 558-4848 to schedule this appointment.