Achieving excellent outcomes and avoiding complications in pediatric inguinal hernia surgery


1. Introduction
2. Embryology, Classification, and Incidence
3. Clinical features and Diagnosis
4. Incarcerated hernia and timing of surgery
5. Surgical approach and potential pitfalls

6. Unexpected operative findings

7. Routine exploration of the contra-lateral side – what’s the evidence?
8. Laparoscopic hernia repair in children
9. Preventing and recognizing complications
10. Anaesthetic considerations and outpatient hernia surgery
11. Specific considerations for Africa

 




1. Introduction
Pediatric hernia surgery is the most common operation done by pediatric general surgeons and it is a core competency for general surgeons in the developing world. In Africa, complication rates for large tertiary centers are low, as reported by Abantanga (1) who noted a 0.7% recurrence rate after repair of 396 hernias. Often, however, the operation may be delegated to less experienced or junior surgeons in smaller surgical centres who may not have an appreciation for how significantly pediatric hernias differ to adult hernias. Although surgical repair is straightforward, there are potential pitfalls in diagnosis and treatment of pediatric inguino-scrotal disorders that can lead to preventable complications. The purpose of this article is to highlight some key concepts and practice points for the surgical trainee and general surgeon in order to improve outcomes for this common but often under-rated procedure.

2. Embryology, Classification, and Incidence
Congenital inguinal hernias occur in 1% of children (2) and are almost always indirect, meaning they arise from a patent processus vaginalis (PPV) as opposed to a direct hernia in the floor of the inguinal canal. The processus vaginalis is a peritoneal sac that passes through the inguinal canal with the testis as it descends into the scrotum during the seventh to ninth month of gestation.


There is a PPV in 80-100% of newborns, with the incidence decreasing to 40-50% by age 2 years and 10% in adults.(2,3) When bowel or other viscera enter the PPV, a hernia is formed. The incidence of indirect hernia in the population is approximately 1%, so one can conclude that only 10% of the PPV in adults will ever become hernias.The left PPV closes before the right, resulting in a higher incidence of right sided hernias.


Indirect hernias are classified as inguinal or inguino-scrotal (complete) hernias; the latter contain the testis. Hydroceles contain peritoneal fluid and can be communicating (changing in size) or non-communicating. Once the PPV has closed within the first 2 years of life, the hydrocele becomes non-communicating and the fluid is reabsorbed. Hydroceles that are still communicating after 1-2 years of age should be surgically managed as potential hernias. Other factors that increase the likelihood of an indirect hernia include history of an abdominal wall defect, cryptorchidism, connective tissue disorders, ascites and presence of a ventriculo-peritoneal shunt. Increased incidence has also been reported in patients born prematurely as well as patients with a family history of inguinal hernia.

3. Clinical features and Diagnosis
An inguinal hernia may first present emergently with incarceration. Electively, hernia and hydrocele are diagnosed by a careful history and physical exam. A history of an intermittent bulge in the groin area, labia or scrotum should be confirmed by examining the child upright, while straining or crying, or by putting pressure on the abdomen. When no bulge is seen, palpable thickening of the spermatic cord (the silk glove sign) has over 90% sensitivity and specificity for presence of an inguinal hernia (3). Most pediatric surgeons will not rely solely on the history to diagnose a hernia, since a normal retractile testis can also appear to the parent as an intermittent inguinal bulge.

Inguinal hernias are usually painless unless they become incarcerated (irreducible) with viscera trapped in the hernia sac; this is most common in the first six months of life. When bowel is incarcerated it causes a tender bulge and eventually signs of bowel obstruction. This may progress to bowel infarction with bloody stools, and with edema and erythema of the overlying skin. Incarceration can also lead to testicular ischemia and subsequent atrophy.

A hydrocele is non-tender and usually located in the scrotum where trans-illumination can confirm the diagnosis. However this sign is not reliable in the newborn as intestine and fluid trans-illuminate equally as well. The less common hydrocele of the cord may give the appearance of a ‘third testicle’ in the inguinal canal. Acute presentation of hydrocele, where discomfort is present, is usually secondary to viral infection. In this instance, increased peritoneal fluid resulting from infection fills a pre-existing PPV. Aspiration of a pediatric hydrocele should be avoided.

If physical examination is equivocal, ultrasound can be diagnostic but is not indicated routinely. Chen et al (4) report an increase in the accuracy of diagnosis of hernia when using ultrasound (97%) versus physical exam alone (84%), using 4mm diameter as the upper limit of the normal inguinal canal. Erez (5) correlated a 7mm or greater inguinal canal on ultrasound with operative confirmation of a hernia.

4.Incarcerated hernia and timing of surgery
Infants may not localize the cause of their distress, and an incarcerated hernia is a common, though infrequently suspected, cause of bowel obstruction. The differential diagnosis of painful inguinal swellings in boys includes, in addition to incarcerated inguinal hernia, testicular torsion and inguinal lymphadenitis. Of these, only lymphadenitis is managed nonoperatively, however if the clinical diagnosis is uncertain then emergent surgery is necessary. Girls may have an incarcerated ovary in a hernia without signs of bowel obstruction.

The reported incidence of incarceration in large series of pediatric hernias ranges from 10-13% in western countries (6, 7) and from 4-8% in African reports (8, 9,10). An infant’s incarcerated inguinal hernia can usually be reduced without sedation using the ‘unilateral frogleg manoeuvre’: applying constant direct pressure on the hernia with the hip flexed and externally rotated thus shortening the inguinal canal (Fig A)(11).

Figure A

After difficult manual reduction of an incarcerated hernia, the child should be admitted and surgery deferred for 24-48 hours to allow some of the edema to resolve. Repeated episodes of incarceration increase the risk of complications including intestinal necrosis, infarction of the testis, recurrent hernia, and wound infection (6). In one series, major complications occurred in 11% of incarcerated hernias compared to 0.6% in those having elective surgery (7). Since the risks of incarceration are highest in young children, pediatric inguinal hernias should be repaired at the time of diagnosis.

5. Surgical technique and potential pitfalls.
The steps in elective pediatric hernia repair vary amongst pediatric surgeons (12), but all agree that the key surgical principles are precise identification of the anatomy, minimal handling of the vas and vessels during dissection of the sac, and high ligation of the indirect hernia sac. The operation lends itself to careful step-by-step routine to identify anatomic landmarks, which can be retraced if necessary especially in large, difficult or recurrent hernia repair. The author’s technique is illustrated in the accompanying photos.

(Figs B 1-10)

Most North American pediatric surgeons divide the external oblique aponeurosis +/- the external ring to expose and dissect the cord as described by Ferguson and Gross (2). This allows exposure of the deep inguinal ring to ensure high ligation of the sac at that level. Others use the Mitchell-Banks repair without opening the external oblique aponeurosis. Large series have shown similar hernia recurrence rates of 1% or less using either technique. However the commonest technical cause of hernia recurrence is inadequately high ligation of the sac (13) so opening of the external oblique is recommended.


5.1 Emergency surgery for an incarcerated hernia repair with associated edema can be technically challenging and is associated with higher complication rates especially testicular ischemia. Opening the external ring will usually allow the bowel to be reduced, but the deep ring may need to be enlarged laterally; or medially by ligating and dividing the inferior epigastric vessels. The bowel must be inspected for viability and, if this has reduced during surgery, bloody fluid would raise concern. If possibly strangulated bowel slides back into the peritoneal cavity, then the hernia is repaired and a second muscle-splitting ‘La Roque’ fascial incision can be made superior to the inguinal canal (14) through the same enlarged skin incision to examine and repair the bowel. Alternatively, laparoscopy or a separate laparotomy may be necessary to inspect or resect bowel of questionable viability.


5.2 If the sac tears, higher dissection through the deep inguinal ring is necessary. Sometimes a preperitoneal exposure through the La Roque fascial incision mentioned previously is necessary to identify and close the peritoneal opening

5.3 Large thin-walled complete inguino-scrotal hernias in infants are often best tackled by opening the sac and carefully dissecting it from the vas and vessels in segments under direct vision. The portions of sac are then gathered and high ligation is completed.

5.4 A modified Marcy repair, approximating the internal spermatic fascia and narrowing of the deep inguinal ring, is useful for large hernias with widely dilated internal ring in premature infants. (15) Care must be taken during narrowing of the internal ring, to avoid constriction of the spermatic vessels.

5.5 When there is a large associated hydrocele sac, it should be opened widely but not excised. Efforts to dissect the hydrocele sac off the cord will increase the risk of testicular ischemia and postoperative hematoma. Since the PPV has now been closed by repairing the hernia, any residual hydrocele fluid should reabsorb.

5.6 A hernia associated with an inguinal undescended testis should be repaired including an immediate orchiopexy (2). If surgery is necessary for an incarcerated hernia during infancy, there is an increased risk of testicular ischemia that may be aggravated by attempts to mobilize the spermatic cord for the orchiopexy. In such cases, the testis may be simply tacked into the scrotum. A subsequent full mobilization of the cord and repeat orchiopexy may sometimes be necessary.

5.7 Inguinal hernias in girls are more likely to contain ovary and/or fallopian tube, often attached to the peritoneal wall of the sac as a sliding hernia. For this reason, many surgeons routinely open the hernia sac in females to ensure that high ligation will not damage the fallopian tube. When a sliding hernia is present, it can be closed with a careful purse-string suture, or using a ‘flap’ technique (16). One should not attempt to dissect the fallopian tube off the sac since the tube will be damaged.

5.8 Recurrent inguinal hernias are approached in the same step-wise approach; identification of the inguinal ligament, opening of the external oblique aponeurosis and careful separation of the vas and vessels from the sac. Usually there is an indirect hernia sac and high ligation will be sufficient (13). It may be necessary to narrow the deep ring, repair a direct hernia caused by previous trauma to the floor of the inguinal canal, or look for a missed femoral hernia as the cause of the ‘recurrence’.

5.9 Direct and femoral hernias, while rare in children, are managed similarly to adults. Generally a Bassini or Cooper’s ligament (McVay) repair is done without introducing mesh. Femoral hernias were seen in 7 of 1213 groin hernias in one Nigerian series with only 5/7 diagnosed preoperatively (17).

5.10 Huge abdomino-scrotal hydroceles may be best treated by drainage alone since there is a higher risk of damage to the cord structures if a high sac ligation is attempted. A scrotal approach with modified Lord procedure has been advocated since the processus vaginalis is usually closed in these cases (18).

6. Unexpected operative findings
6.1 Occasionally the hernia sac may contain something unexpected. An appendix, Meckel’s diverticulum (Littre hernia) or even an omental cyst may be removed through the sac.

(Figs C1, C2)

6.2 Tiny ectopic yellow adrenal tissue rests on the spermatic cord occur as a common incidental finding in up to 2.6% of pediatric hernias (2).

6.3 A tiny or absent vas deferens should lead to an evaluation for cystic fibrosis (uncommon in Africa) or associated solitary kidney. If there is unilateral absence of the Wolfian duct structures, then the vas deferens, ureter, and kidney may all be absent.

6.4 Intersex problems may rarely be discovered when operating for an inguinal hernia. Phenotypic females may have bilateral inguinal hernias containing gonads (testes) as the first presentation of androgen-insensitivity syndrome (testicular feminization). Gender assignment is a complicated issue in which resources and many socio-cultural factors must be considered. Thus, a detailed discussion is outside the scope of this article. As a general rule, gender assignment should be dealt with electively whilst including as much anatomic and genetic information as possible in the decision making process. In the situation of testicular feminization syndrome, the best option when one is in doubt may be to biopsy the gonads and return later for bilateral orchiectomy and vaginal reconstruction (2).

6.5 Another rare syndrome of Persistent Mullerian Duct Syndrome causes persistence of the fallopian tubes and rudimentary uterus in a phenotypic male with XY chromosomes and congenital deficiency of Mullerian Inhibiting Substance (MIS). It may only come to light when a hernia sac is opened finding a normal testis, vas deferens and fallopian tube. The hernia should be repaired and orchiopexy completed if necessary. The mullerian duct remnants can be removed while carefully protecting the normal testicular vessels and vas deferens (19).

7. Routine exploration of the contra-lateral side – what’s the evidence?
The question of whether to routinely look for a contra-lateral patent processus vaginalis (PPV) is still debated amongst pediatric surgeons, more so with the advent of laparoscopy. As stated earlier, a contra-lateral PPV is present in 80% at birth, 50% at 2 years and 10% in adults. However only 5-10% of children ever develop a contra-lateral hernia, so most PPV remain asymptomatic and never lead to a hernia. This low risk of metachronous contra-lateral hernia requiring another operation, must be weighed against the low but real risk of testicular ischemia and vas injury causing infertility from a negative exploration. Most pediatric surgeons no longer routinely do an open exploration of the contra-lateral side (3, 20,21). Some surgeons reserve contralateral exploration for girls, boys under 5 years, left-sided hernias and children with ventriculo-peritoneal shunts.

Another option for assessing the other side is diagnostic pneumoperitoneum (the Goldstein Test), done by inflating the abdomen with gas with a catheter through the hernia sac and palpating the other side for crepitus that would indicate a PPV. The test is positive in about 10%, which is similar to the likelihood of developing a subsequent contra-lateral hernia. (2)

After creating the pneumoperitoneum, one can proceed to diagnostic laparoscopy, done through the sac with a 70 degree scope or through a separate abdominal trochar. This allows visualization of a contralateral PPV with minimal added risk, but cannot differentiate whether it would ever become a hernia. With routine laparoscopic exploration, a contra-lateral PPV is discovered and then repaired in 30% - although most of these would never have become hernias. (2,3)

With no evidence-based conclusion, the individual surgeon’s practice should depend on their own setting, philosophy and complication rate. When patients have access to emergency surgical care, it may be best to avoid operating on the asymptomatic side, following the dictum “first of all, do no harm”. When children are returning to remote locations without ready access to surgical care, there may be more justification for contra-lateral exploration at the time of repair of the symptomatic hernia repair.

8. Laparoscopic hernia repair
With the extremely low morbidity and high success of standard open pediatric hernia repair in boys, the only potential advantage of a laparoscopic approach would seem to be cosmetic, along with allowing visualization and repair of the other side. Even in experienced centres, there is higher risk of hernia recurrence or damage to the cord structures with laparoscopic repair, especially during the initial learning curve (22,23) One Egyptian centre (24) uses laparoscopy with incarcerated hernias to document the viability of the bowel and repair the hernia

(Figs D1,D2).

Female indirect hernias can be easily managed laparoscopically by inverting and ligating the sac (3), and there is not the associated risk of injury to the spermatic cord as in boys.

9. Preventing and recognizing complications
9.1 The most important factor in preventing complications is adequate surgical training, ongoing experience, and early diagnosis of incarcerated hernias. Long-term follow-up may be necessary to identify some of the most concerning complications such as testicular atrophy and infertility. Ibingira reported 86 patients with long term complications of inguinal hernia repair in a Ugandan surgical clinic, many who had repair in childhood (25). In addition to hernia recurrence and stitch abscess, other more serious complications included intestinal obstruction, fecal or urinary fistula, painful neuroma or scar, and testicular atrophy.

9.2 The incidence of postoperative wound infection should ideally be 1% or less since hernia repair is a clean procedure. Anemia and malnutrition in African children may increase that risk (9). The higher rates of infection seen in Africa such as the 5% infection rate reported by Nmadu, may be a reflection of less healthy patients, systemic hospital infection control factors, and a higher rate of strangulation and bowel resection (26). However in their RCT, Osuigwe et al. showed that prophylactic antibiotics make no difference to the infection rate for elective hernia surgery (27). Use of silk sutures has been associated with wound infection, granuloma, and para-vesical abscess (28), but absorbable suture (ex. chromic) used to ligate the sac is associated with higher hernia recurrence rates (13). The ideal suture may be a longer-lasting monofilament absorbable suture.

9.3 Postoperative scrotal swelling or hematoma is common when there has been a large inguino-scrotal sac. A non-communicating postoperative hydrocele will usually resolve within a month after the surgery. Rarely, chronic postoperative hydroceles may need aspiration or open drainage.

9.4 Testicular atrophy is reported after 1% of routine hernia repair, but up to 5% after repair of incarcerated hernia. Onuora reported an even higher rate of 20% when there was ischemic bowel (29). Ischemic testes (or ovary) identified at time of repair of incarcerated hernia should be left in place, since most will recover. It is important to be sure that the internal spermatic fascia is not constricting the spermatic veins at the deep inguinal ring, since venous obstruction is more likely to lead to postoperative swelling and testicular ischemia.

9.5 Injury to the vas deferens should be rare, but we know that rough handling of the vas increases that risk (3). There was a history of hernia repair in over 6% of one large series of men with infertility (2). Some had testicular atrophy and others had unrecognized obstructions to the vas deferens which were subsequently explored and repaired. If severance of the vas is recognized during surgery, the two ends of the vas should be approximated with fine sutures such as 8-0 absorbable monofilament (2).

9.6 Ilioinguinal nerve injury may cause numbness, neuroma or neuralgic pain; its incidence is unknown.

9.7 Bladder injury is rare, but one should be aware that the bladder is an abdominal organ in infants and forms part of the extra-peritoneal posterior wall of the inguinal canal. There is often a corner of the bladder sliding through the deep inguinal ring. An inexperienced surgeon may mistake the bladder for a direct hernia sac leading to postoperative urine leak from the wound.

9.8 Recurrent pediatric inguinal hernias should be uncommon; most large series report <1% recurrence rates, increasing to 15-20% in premature infants or after repair of incarcerated hernia. Repair of recurrent hernias is technically more challenging with a higher risk of testicular complications. The most common finding is a persistent indirect hernia sac that should be ligated at the deep inguinal ring (13). The deep ring may need to be narrowed or posterior wall of the inguinal canal repaired (technical details were discussed earlier).

9.9 Iatrogenic cryptorchidism may occur after repair of a large inguino-scrotal hernia, or when the testis is caught up in scar tissue in the inguinal canal. One should always ensure the testis is in the scrotum at the end of the operation.

9.10 Premature infants are more likely to develop incarcerated hernias, so most tertiary pediatric centres repair all premature infant hernias prior to discharge from hospital if the anesthetic risk is low. Otherwise the infant may return needing emergency surgery with a higher risk of surgical and anesthetic complications. Premature infants under 5kg have a higher risk of postoperative testicular atrophy, hernia recurrence, cryptorchidism and hydrocele (30).

10. Anaesthetic considerations and outpatient hernia surgery
With safe general anaesthesia, pediatric outpatient surgery is feasible in developing countries. Hariharan reported no serious morbidity or mortality and a 0.4% unplanned admission rate for ambulatory pediatric surgery in Trinidad (31). In a prospective randomized study from Nigeria, Ramyil et al. compared inpatient with outpatient surgery under general anaesthesia for inguinal hernia (32). There was no mortality and no difference in wound complications, but significant early postoperative complications were actually reported more often in the inpatients. They concluded that outpatient elective inguinal hernia repair is “relatively safe in our environment” for carefully selected patients. Premature infants are more likely to have postoperative apneas or bradycardias, and should be admitted overnight for observation if less than 60 weeks post-conceptual age or if there are co-morbidities (3).

When general anaesthesia is not available, pediatric hernia repair can be done safely using intravenous ketamine and local xylocaine infiltration (33). Irabor reported 98 pediatric hernia repairs done over 3 years in a secondary health care institution in Ibadan, Nigeria, without mortality. Caudal block, ilio-inguinal nerve block, or wound infiltration with local anaesthetic all decrease the need for postoperative analgesia. There is no difference in outcomes for preterm babies whether regional (spinal) or general anaesthetic is used (2).

11. Specific considerations for Africa
There is a paucity of literature surrounding the incidence of pediatric surgical conditions in Africa, in part due to the exclusion of surgical care from most pediatric health programs (1). In Kumasi, Ghana, inguinal hernias and hydroceles constitute a majority (42.6% and 8.3%, respectively) of all pediatric surgical conditions. A study from the same center shows that inguinal hernia repairs alone account for 74% of elective pediatric inguino-scrotal operations in children under five (1). Similarly, in their review of congenital anomalies in Nigerian children, Ekenze et al (34) report that inguinal hernia was the primary issue in 31.8% of their patient population. However, an Ethiopian review from a busy pediatric referral centre found that hernia repair accounted for only 3% of pediatric surgical procedures (35).
Reported rates of incarceration and strangulation range from 3-8% of all hernia operations in Nigeria (8, 9, 10, 26, 34). In the developing world, late presentation has been identified as a risk factor for the development of these complications (34) with patients presenting earlier demonstrating an appreciable decrease in strangulation and incarceration rates (10).

Lack of parental education, access to care, and costs are all barriers to attaining early surgical treatment that would likely prevent these complications (1). A preference for traditional medicines and healers may also contribute to the fact that medical attention is sought at a later time (36). To significantly improve the delivery of pediatric surgical care in the face of the aforementioned barriers, it is ultimately necessary to address the underlying issues of infrastructure (where adequate facilities, equipment and specially trained personnel are lacking) (34).

In summary, early presentation and elective surgical treatment lead to decreases in complication rates for inguinal hernia (1, 10). Efforts to provide elective hernia repair on a wider scale and to promote public awareness of potential complications are paramount (37). This, in addition to improved government funding and training for specialized personnel, will help to further improve outcomes (34).

Cindy Sklar, B.Sc., MD Program, Class of 2009
Michael G. DeGroote School of Medicine
McMaster University, Hamilton, Canada

Brian H. Cameron MD, FRCSC, FACS
Associate Professor of Surgery and Pediatrics,
McMaster Children’s Hospital, Hamilton, Canada

Reviewed by: Miliard Derbew MD, FRCS, FCS(ECSA)
Pediatric General Surgeon
Dean, Faculty of Medicine Addis Ababa University

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http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/47981

Figures:
A. Unilateral frogleg manoeuvre to reduce incarcerated inguinal hernia.
B 1-10. Photos of the steps in pediatric inguinal hernia repair.
C 1 -2. Photos of appendix and omental cyst in inguinal hernias.
D 1-2. Laparoscopic view of an incarcerated hernia.

 

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