More About Pediatric Inguinal Hernia Repair
An inguinal hernia is an opening in the inguinal canal, within the abdominal or stomach wall. It is a widely occurring surgical issue found in children and occurs when a protrusion of the abdominal cavity forms a small sac-like structure and extends via the inguinal ring into the groin. The inguinal ring opens during foetal life and closes around the time of birth. However, in an inguinal hernia, the ring does not close and the small sac allows the abdominal organs to also bulge into the groin area. In boys, there may be a loop of the bowel while in girls it may also include the ovary along with bowel loop. Initially, the hernia, looks like a swelling in the groin area, whether it is in a boy or a girl, and may later disappear, or may be present most of the time. When the child strains the bulge may come out and the fluid might release via the inguinal ring into the sac leading to hydrocele.
Symptoms of Inguinal Hernia
- A bulge or swelling in the groin area indicates a hernia. In boys, the scrotum may be swelled due to the internal organ or bowel loop entering it.
- The swelling may aggravate when the child cries, coughs or sneezes
- There may also be a pain the groin region
Inguinal hernias occur both in boys and girls; they are, however, more common in boys than girls. A hernia may be undetected for years due to their small size, and may not be noticed until teenage. Inguinal hernias are usually found during routine physical exams. All these cases of inguinal hernias are congenital that are present from the birth. Straining and coughing and crying might make a hernia visibly clear, however, these may not be a cause hernia. Inguinal hernias in children are not the same as hernias that adults may get from lifting or straining.
Inguinal hernias never go away without treatment. Surgical intervention is the only treatment that may be done as soon as the child is strong enough to withstand surgery. The doctor’s advice regarding when the surgery can be done is the best for the child. It is the only treatment as in case the sac is left open, a loop of bowel or another organ may become trapped or incarcerated or strangulated in the sac.
Advantages of Surgery
- The surgery gives relief from swelling
- Postoperative care is essential in both open and laparoscopic methods of repair.
- Most procedures require the patient to stay overnight and are usually performed on an outpatient basis.
- If a unilateral inguinal hernia is repaired laparoscopically with the closing of contralateral opening, the risk of development of a metachronous hernia becomes almost negligible which otherwise may be 6-8%.
- Patients may be expected to resume normal activity within 48 hours post surgery.
Types of Surgery
Inguinal Hernia repair may be done with Open surgery or Laparoscopically
Open hernia repair:
A tiny incision will be made in the groin, along with the skin crease, and the hernia will be closed using sutures. In this procedure, there will be a separation of the hernia sac from the surrounding cord structures with muscles, testicular vessels around the ligament. The anesthesia, given to the patient during an open hernia repair, is usually local anesthesia in the abdomen with sedation; however, some patients may have
- Sedation with a spinal block, in which anaesthetics inject around the nerves in the spine, making the body numb from the waist down
- General anesthesia
In the groin area, the surgeon makes an incision, compelling hernia back into the abdomen, and reinforces the abdominal wall with stitches. The surgeon then reinforces the weak area with a synthetic mesh to provide additional support.
Laparoscopic hernia repair:
A laparoscope is placed through a stomach with an incision. The inguinal hernia repair will be performed using surgical tools and are inserted through tiny incisions in the lower portion of the abdomen. The laparoscopic hernia repair is performed by the surgeon under general anaesthesia. This approach can be performed trans-peritoneally or through a pre-peritoneal with trans-peritoneal visualization.
- The surgeon makes several half-inch incisions in the lower abdomen and inserts the laparoscope. The camera attached to the laparoscope captures and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of a hernia and surrounding tissue. The surgeon performs the repair process of a hernia with the use of a synthetic mesh and watching a video in the monitor.
- Trans-peritoneal: The umbilical port is used to pass the Laparoscope. The deep inguinal rings can thus be seen clearly. Other instruments are then passed through the same passage to continue the surgery. This procedure helps to confirm the diagnosis and inspect the contra-lateral side for the presence of a hernia. The deep ring is then closed with either an absorbable / non-absorbable suture as purse string or similar.
- Pre-peritoneal: In this approach, a small incision is made in the inguinal region. A small hook carrying a suture is passed across the deep ring, its passage being made visible with the help of an endoscope being used at the umbilicus. The orifice of the hernia is then closed by bringing together the ligature extra-corporally and tying it.
- The surgery is performed under general anesthesia that makes the patient sleep soundly during the surgery.
- The nurse will give proper eating and drinking instructions based on child’s age.
- Apart from the general anesthesia, caudal anesthesia is also given to the child to have pain relief in the area below the waist region. The child should not eat anything for at least six hours to minimize the risk of vomiting and inhaling fluids under anesthesia.
- The surgery will take between 30 minutes to 1 hour.
- A small incision is made in the groin. The hernia sac is identified. The protruding intestine is put back in proper position and the sac is removed.
- The muscle wall will then be reinforced with stitches to prevent another hernia.
- The incision is closed with dissolving stitches. Tissue glue and strong tape that sticks for 7 to 10 days are used to seal the surface of the incision.
- After surgery, the children will be able to go home in few hours. In contrast, children or premature infants with medical conditions need to spend one night in the hospital.
- Usually, the child will feel fine again the evening after surgery or by the next morning. Normal activities and eating habits may be resumed after that.
- Keeping the child clean is a must for which a sponge bath is recommended. A day after surgery you can use a wet towel to clean the child. Tub baths after surgery can be difficult and can be resumed only 2 days after surgery.
- The tape covering the child's incisions usually fall off after some time on their own. If not, they will be removed by the surgeon on your next visit.
- Pulling these strips off on your own is not recommended.