The second commonest operation performed in children all over the world is for the inguinal hernia. The parents notice a bulge in the groin and get in touch with the surgeon. The following questions and answers will help the parents to understand the subject well. Please make a note that this publication is about the inguinal hernia in children and in adults the management is different as compares to the children.
What is an inguinal hernia?
As a male fetus grows and matures during pregnancy, the testicles develop inside of the abdomen and then move down into the scrotum through an area called the inguinal canal. Shortly after the baby is born, the inguinal canal closes, preventing the testicles from moving back into the abdomen. If this canal does not close off then it forms a communication between the abdomen and scrotum allowing abdominal contents to protrude through the canal into the scrotum.
Although girls do not have testicles, they do have an inguinal canal, so they can develop hernias in this area as well.
How commonly inguinal hernia occurs?
The incidence of inguinal hernia is in the range of about 1-3 % of all children. It is more common in premature infants as well as in boys as compared to the girls. The inguinal hernia can occur on both sides however it is more common on the right side compared to the left. In a younger age frequency of bilateral hernia is more common.
What are the symptoms of a hernia?
Hernias can occur at any age from newborns to old person. Inguinal hernias appear as a bulge or swelling in the groin or scrotum. The swelling may be more noticeable when the baby cries and may get smaller or go away completely when the baby relaxes. Straining and crying do not cause hernias; however, the increased pressure in the abdomen can make a hernia more noticeable. If your physician pushes gently on this bulge when the child is calm and lying down, it will usually get smaller or go back into the abdomen.
Why is a hernia a concern?
Occasionally, the loop of intestine that protrudes gets stuck into the sac and it cannot be pushed back into the abdomen. When this happens, that section of the intestine which is caught in the hernial sac may lose its blood supply. It is a life-threatening emergency and needs emergency management. The risk of surgery in any emergency is always higher than the planned operation and hence the hernia is a concern.
What happens when the complication due to hernia occurs?
This child develops the acute onset of swelling in the groin with pain. After a few hours are passed child may develop distension of abdomen and vomiting. It is an emergency and parents must consult the surgeon at the earliest.
Is there any need for investigation?
Normally hernias are diagnosed by a physical examination by the doctor. Occasionally ultrasonography is performed to differentiate between hernia having bowel versus fluid or omentum. The child needs complete blood count, viral markers and bleeding profile before surgery.
What is the treatment?
These hernias do not go away without surgery and it needs to be repaired to prevent the complications like irreducibility- obstruction- strangulation: because if these complications occur then the affected bowel may get damaged and may need it to be removed with the increase in the risk and morbidity.
Is anaesthesia is necessary? If yes, which type of anaesthesia?
Yes, in children all surgeries are performed under general anaesthesia.
How long the child needs to be fasting for the surgery under general anaesthesia?
How long the child should be kept fasting before repair of inguinal hernia?
| Type of feed | Duration |
| Mothers Milk | Four hours |
| Formula Feeds | Six hours |
| Solid food | Eight hours |
What exactly is done in the surgery?
The surgeon closes the opening through which the hernia was protruding from the abdomen into the groin.
How long the child will need to be fasting after the surgery?
Usually, the child is started feeding after 2-4 hours. Initially sips of water followed by liquids and then solids. If the child has nausea or vomiting then the feeding should be stopped for 2 hours.
What type of food is allowed after the surgery?
The child is allowed regular food, preferably non-spicy, non-sour and non-oily.
Is there any pain after the operation?
There is some pain, which is easily controlled with medication.
Must Read : Laparoscopic surgery in children
How long the child needs to be in the hospital?
The surgery can be performed as a daycare operation, meaning that the child can be admitted on the day of operation and the child is discharged on the same day after the surgery.
How about the activity after the surgery?
The child can have normal activity. This will not affect the healing of the wound. The strenuous exercises should be avoided for 10-15 days.
When should the child follow up with the surgeon?
The child is usually seen in the outpatient clinic 5-7 days after surgery and dressing are removed. The self-dissolving stitches are beneath the skin and they dissolve by themselves. There will be a scar in the skin crease of the groin. As the child grows, the scar will fade but never completely disappear.
What is the long-term outlook for this disorder?
The incidence of recurrence after surgery is less than 1 %. The incidence of recurrence increases if the surgery was performed in an emergency.
Is it possible to repair of inguinal hernia in children using laparoscopic or keyhole surgery?
Yes. It can be performed
What are the advantages of keyhole repair of inguinal hernia in children?
It is less traumatic to the child.
It allows the visualisation of the opposite inguinal ring and if the ring is opened then it is possible to repair it in the same operation.
It is performed under magnification and hence the incidence of injury to the vas deference and testicular vessels is less.
There is minimal disruption of lymphatics and injury to veins and hence there is minimal post-operative swelling of the scrotum.
In girls, it is possible to evaluate internal genital organs. There can be an anomaly of these structures in 1 % of girls.
Is there is any disadvantage of keyhole surgery in the repair of an inguinal hernia?
The general anaesthesia techniques need intubation of the trachea with the endotracheal tube. And the theoretical risk of an increase in the incidence of recurrence from 1 to 3 %. However, in the technique published by the author, the recurrence rate of laparoscopic repair of inguinal hernia is almost zero.
Is there any need for the placement of mesh in surgery?
There is no need for mesh in the repair of the inguinal hernia in children.
REMEMBER
- Inguinal hernias will not resolve on its own and they need to be operated to prevent complications.
- The younger the child, the sooner it is needed.
- If your child develops a painful groin swelling, see a doctor as an emergency to prevent complications and morbidity.
- After the operation, your child can play normally.