Focus On: Inguinal Hernias in Children

<p><strong>Hernia</strong></p> <p><strong>Myth</strong>: “<em>If it’s not strangulated, it’s elective”</em></p> <p><strong>Reality</strong>: <strong>Unlike in adults, all hernias in children are repaired at the time of diagnosis because</strong>:</p> <ul> <li>The risk of incarceration and strangulation is high</li> <li>There is a 30% risk of testicular infarction due to pressure on the gonadal vessels</li> <li>It is not worth messing around and “trying to navigate the system”</li> </ul> <p>Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis).</p> <p>Most <strong>indirect hernias</strong> are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well.  15% are bilateral.</p> <p>Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney.  They hate it and will cry.  For older children, have them laugh, cough, or blow through a syringe.</p> <p>The “silk glove sign” is not reliable, but if found is highly suggestive of an inguinal hernia.  Roll the cord structures across the pubic tubercle.  If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis.</p> <p>Most (80%) <strong>incarcerated hernias</strong> can be reduced initially and admitted for surgery 24-48 hours after edema has improved.  Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation.</p> <p><strong>Hydroceles</strong> usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention.  Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age.</p> <p>Girls may have an ovary incarcerated in hernial sac.</p> <p>Open repair or laparoscopic techniques are used.  The laparoscope offers visualization of the contralat