Features of the manifestation of inguinal hernia in childhood

Symptoms

The main symptom that immediately catches your eye is swelling in the scrotum area or in the groin area . Depending on the position of the child, the protrusion may change size or disappear completely. The hernial sac has a soft consistency to the touch, is easy to reduce and does not cause pain.

Soreness is provoked by abdominal muscle tension or compression of the prolapsed organ by the hernial orifice. The structure of the hernia becomes dense with signs of cyanosis.

Diagnostic measures

The main method for determining an inguinal hernia is examination by a surgeon. The protrusion can be clearly felt upon palpation, and in a lying position you can carefully straighten the protrusion and feel the enlarged inguinal ring. Children are simply examined carefully; for older children, the doctor may ask them to bend over, cough, and strain to determine the elasticity and structure of the hernia.

The symptoms of an inguinal hernia may be similar to other diseases, so instrumental examination methods are used to clarify the diagnosis and assess possible complications. These include:

• Ultrasound of the abdominal organs;
• Ultrasound of the pelvic organs for girls;
• Ultrasound examination of the scrotum and inguinal canaliculi for boys.

Causes

The etiological process of the development of the disease is associated with the prolapse of the fold of the peritoneum and the intestinal loop into the tissue between the layers of the peritoneum through the unclosed processus vaginalis of the abdominal cavity. Pathological processes when an inguinal hernia in children, girls and boys, is congenital in nature, is due to various reasons.

A complete hernia in boys , in the form of a protrusion, is a consequence of the abnormal development of the superficial ring of the inguinal canal , as a result of which the baby’s testicle cannot descend into its natural bed, or is retained in the inguinal cleft or in the thickness of the abdominal muscles (cryptorchidism).

In girls, such protrusion is a consequence of the pathological development of the uterine ligaments (lig. teres uteri), which fix the genital apparatus. In the perinatal period of development, the location of the uterus is noted above the anatomical location. In the postnatal period, it gradually lowers into place.

Read also: Child's stomach hurts

As the uterus descends, it pulls together the inner abdominal lining, as it is connected to it, and forms a fold. Failure of the abdominal muscular system leads to protrusion of the fold into the funnel-shaped depression of the inguinal ring. Quite often, in girls, the ovary and fallopian tube fall out through an “open window”.

The cause of acquired inguinal hernias is due to:

• weakness of the connective tissue of the peritoneum;
• injuries of the abdominal walls;
• increased intra-abdominal pressure caused by frequent and severe crying;
• exposure to heavy loads when lifting weights.

Classification of inguinal hernias

The disease is classified according to several factors.

By origin there are:

• Congenital, or embryonic - formed during the period of intrauterine development of the fetus, clinically manifested immediately at birth or during the first year of life;
• Acquired are inguinal hernias in adults caused by unfavorable conditions.

According to the nature of the flow:

• Reducible - the protrusion in the lying position decreases, the hernia can be easily and painlessly reduced, the organs in the hernial sac are mobile and do not disturb;
• Irreducible - the protrusion does not reduce, the dimensions do not change with a change in body position, and complaints about deterioration of the condition appear;
• Uncomplicated - no problems with digestion, urination, no severe pain;
• Complicated – complications develop with obvious clinical symptoms that require emergency surgical care.

By location:

• Direct inguinal hernia - always acquired, typical for older patients, exits through the superficial inguinal ring, a rounded protrusion, disappears or noticeably decreases in size in the supine position;
• Oblique - can be congenital or acquired, passes through the inguinal canal, often descends into the cavity of the scrotum and labia majora, the protrusion is oblong, changes little when changing body position:
• Inguinoscrotal hernia;
• Funicular - the hernial contents are located inside the canal along the spermatic cord;
• Sliding - one of the walls of the hernial sac is an organ with a retroperitoneal location: the cecum, bladder, uterus with appendages; this is a difficult hernia to diagnose;
• Right-sided - occurs 2 times more often, because the right channel is shorter and wider than the left; congenital is formed when the testicle descends (inguinal hernia of the testicle);
• Left-sided inguinal hernia is a less common pathology;
• Bilateral – an extremely rare phenomenon, congenital in nature.

Why is an inguinal hernia dangerous?

The main danger is an asymptomatic course at an early stage. The patient can walk for several years without paying attention to a small lump in the groin area. In this case, complications that threaten life and require emergency surgical intervention can arise at any time.

Inguinal hernia strangulation

Against the background of complete well-being, compression of the hernial contents in the area of ​​the hernial orifice occurs. This is accompanied by sharp, intense pain in the area of ​​the protrusion, followed by spreading throughout the abdomen. The state of health deteriorates sharply, symptoms of intoxication and pain increase, and body temperature rises.

Due to compression of the vessels supplying the strangulated organ, it can become dead. Toxins released during the breakdown of dead tissue lead to circulatory problems throughout the body, kidney problems, and changes in blood clotting.

The following dangerous conditions are diagnosed:

• Peritonitis – acute inflammation of the peritoneum;
• Gangrene, intestinal perforation;
• Sepsis, infectious-toxic shock;
• DIC syndrome;
• Intestinal obstruction;
• Thrombosis of mesenteric arteries and veins;
• Acute renal failure;
• Bladder ischemia;
• Acute urinary retention;
• Multiple organ failure.

Inability to reduce the hernia

With a long-standing hernia, the organs in it become fused with the hernial sac and cease to be retracted into the abdomen. This is accompanied by dysfunction of the organs located in the hernial sac.

The patient is concerned about chronic abdominal or pelvic pain, pain in the protrusion itself, which intensifies with walking, exercise, difficulty urinating, defecating. In particularly advanced cases, phlegmon of the hernial sac, intestinal obstruction, acute urinary retention, and a clinical picture of an “acute” abdomen, indicating peritonitis, develop.

With forced reduction, perforation of the intestinal wall is possible.

Secondary infertility

In men, the spermatic cord passes through the inguinal canal, consisting of the vas deferens, vessels and nerves, and the levator testis muscle. An inguinal hernia leads to compression and disruption of blood circulation and innervation of the scrotum and testicles, changes in the functioning of the prostate gland, and inhibition of spermatogenesis. Problems with erection appear.

In half of the cases, an inguinal hernia in men turns into an inguinal-scrotal hernia, causing inflammation of the testicles - orchitis. Increases the risk of developing testicular torsion and malignant degeneration.

In a woman's body, the round ligament of the uterus passes through the inguinal canal . When a hernia forms, the fallopian tube with the ovary, and sometimes the uterus, is involved. This leads to menstrual dysfunction, chronic inflammation, the formation of adhesions, and intimate difficulties.

In the event of strangulation, removal of the affected organ may be necessary with subsequent loss of fertility.

Treatment methods

The only effective treatment method is surgery . Since the procedure for removing an inguinal hernia in a child is carried out using general anesthesia, there are a number of contraindications:

• acute infectious diseases in children;
• the presence of dermatitis and skin pathologies in the hernia area;
• congenital renal and cardiac pathologies.

Inguinal hernia surgery in children can be performed by open excision of the hernia formation, or laparoscopically, using small incisions and a laparoscope. The organs that have fallen into the hernial orifice are returned to the peritoneal cavity, and the hole in the muscular aponeurotic layer of the peritoneum is sutured using the child’s connective tissue.

As a non-surgical method, the prolapsed organs are repositioned into the peritoneum. Exercises and massage are prescribed to relieve swelling, relax and strengthen the muscles of the abdominal wall, as well as the mandatory wearing of a special fixing and supporting bandage.

For large hernia formations, a mesh method is used to strengthen the weak spot of the abdominal wall. But polypropylene mesh is sometimes rejected by the body as a foreign body. Processes of suppuration and inevitable repeated operations are possible, which is an undoubted disadvantage of this technique.

Inguinal hernia - symptoms and treatment

Any inguinal hernia is subject to surgical treatment. No other methods - taking medications, wearing bandages, following the advice of healers, fortune tellers and other adherents of alternative medicine - will eliminate it.

If there is an inguinal hernia, it must be operated on routinely in the surgical department. If an inguinal hernia is suddenly strangulated, the operation procedure changes to emergency. Ideally, the operation should be performed within two hours from the moment of infringement. So it’s better to put fears aside and solve the problem as early as possible.

Now let's look at the types of operations used to treat inguinal hernia. Putting aside the historical aspects and dozens of previously proposed proprietary techniques that are already being used, we can say: there are actually 3-4 methods left for plastic surgery of the inguinal canal. There is an open method and a laparoscopic one.

An open or external method of hernia repair is when, under general or spinal (but not local, this is also a thing of the past!) anesthesia, a 6-8 cm long incision is made in the groin area, and the inguinal canal is opened. Then the hernia is eliminated - by isolating, opening and excising the hernial sac, returning the hernial contents (intestine, omentum or bladder) to its place in the abdominal cavity. Next comes the most important part of the operation - strengthening, or plastic surgery of the inguinal canal. All the variability of the author's proposals lay precisely in this stage. Nowadays, the Lichtenstein method is almost always used, which involves sewing a polypropylene mesh implant into the back wall of the inguinal canal.[2][3][10]

Polypropylene is practically the same material that fishing line is made from, only thinner, more flexible and properly sterilized. It is very durable, does not dissolve, and its rupture is practically impossible. The mesh size is selected individually. The mesh is attached with separate sutures to the strong tendon structures of the groin area. The duration of the operation is on average from 30 minutes to 2 hours. The method is reliable: 95-98% probability of no relapse.[2][3][7][10] Among the nuances is the possibility of local wound complications (the formation of fluid accumulations near the mesh, the possibility of wound suppuration, pain after surgery, and sometimes persistent long-term pain associated with damage to the nerve trunks passing in the operation area).

Laparoscopic method of hernia repair. The full name is transperitoneal preperitoneal laparoscopic hernioplasty (TAPP in its English abbreviation) and total extraperitoneal inguinal hernioplasty (TEP).[1][4][10] Preferred over open method. The most modern, advanced and reliable method of getting rid of an inguinal hernia. It was first tested in 1991 in Europe, and has been widely used clinically in Russian medicine relatively recently—for 10 years. It is not performed in every clinic (an expensive laparoscopic stand and instruments are required) and not by every specialist (a certain level of training and experience is required). It is performed under general anesthesia, like any laparoscopic operation. Three incisions and punctures of the abdominal wall are made, 1-1.5 cm long. Carbon dioxide is injected into the abdominal cavity (it’s safe!), followed by the introduction of a video camera and special long instruments through special hollow tubes (trocars). During the operation, the hernia is eliminated from the inside, from the abdominal cavity. Then a mesh implant is installed from the inside (there are variations, but in general it corresponds to what is installed using the open method). The anatomical layer of mesh installation - preperitoneal - differs from the open method. The size of the mesh installed during laparoscopy is larger than with the open Lichtenstein method - on average 15x10 cm. And, what is very important, the zone of anatomical overlap of the mesh is also larger and covers the potential exit sites of 3 hernias - oblique inguinal, direct inguinal and femoral on the corresponding side. The mesh is attached with special staples to the tendon structures of the groin area and is closed from the inside by the peritoneal membrane to prevent the formation of adhesions. The reliability of the method is very high: the probability of relapse is 1-5%.[5][6][7][9][10] The advantages of the laparoscopic technique, in addition to high reliability, are also: high cosmetic effect (small incisions heal with the formation of almost imperceptible scars), low incidence of wound complications, lower level of pain, quick - within one day - mobilization of the patient, shorter stay in the hospital .[4][6][8][9]

Main predisposing factors for groin hernias

Hereditary predisposition is one of the most important reasons for the formation of an inguinal hernia. Of course, a hernia itself cannot be inherited - features of the anatomical structure of the abdominal wall, features of the tissue structure of muscles and aponeuroses (tendons) are inherited, which in one way or another can contribute to the formation of a hernial protrusion. Therefore, inguinal hernia often runs in families. On the other hand, one should not consider the hereditary factor as a kind of death sentence: the correct approach to the physical development of a child, a reasonable choice of profession, dosed physical work in adulthood play a big role and serve as an effective prevention of the development of a hernia in the inguinal region. Therefore, the fact of the presence of a hereditary predisposition should be considered as a warning and a reason for a more responsible attitude towards one’s own body.

Constitutional features . Doctors have long noticed the relationship between body type (hyper-, normal-, asthenic) and the likelihood of developing certain diseases. This pattern also applies to inguinal hernias. In particular, people of the hypersthenic type (with a wide chest, wide abdomen, relatively short limbs and developed muscles) more often develop direct inguinal hernias. On the contrary, asthenics (people with a narrow chest and long limbs) are more likely to develop indirect inguinal hernias. This circumstance is explained by the fact that different types of body structure and the abdominal wall in particular correspond to various specific nuances of the structure of the abdominal wall, its muscles, ligaments and aponeuroses. It is worth considering that a particular body type in itself is not a determining factor in the development of a certain type of hernia - it only indicates an increased likelihood of this.

On the other hand, there are a number of genetic pathologies that are associated both with a certain body type and with connective tissue weakness, which results in the development of hernias. For example, Marfan syndrome. However, in this case, we are not talking about a connection with the constitution of the body, but about the result of congenital underdevelopment of connective tissue formations. Often in such pathologies, hernias are accompanied by articular dysplasia, scoliosis, flat feet, malocclusion and other manifestations of connective tissue deficiency.

Connection with gender - numerous statistical observations indicate that in the vast majority of cases, representatives of the stronger half of humanity experience inguinal hernias. This circumstance is explained, as mentioned above, by the specific structure of the male inguinal canal, as well as by the peculiarities of the intrauterine formation of the male body.

Pregnancy is a condition in which there is a significant increase in intra-abdominal pressure. It is absolutely physiological and by nature a certain margin of safety is built into the body of the expectant mother, which allows her to go through the period of bearing a baby without serious harm to her health. However, with multiple pregnancies, polyhydramnios, and frequent births, compensatory mechanisms may not be enough and there is a possibility of developing a hernia. In addition, it should be taken into account that the state of pregnancy affects connective tissue at the biochemical level. This is necessary for subsequent childbirth: muscles, ligaments, and joints soften, become more mobile and elastic, which also contributes to the formation of abdominal wall hernias. However, pregnancy more often causes hernias of the white line of the abdomen; inguinal hernia develops relatively rarely.

Obesity is a common cause of hernias. A thick layer of subcutaneous fat in the abdominal wall, which is almost always observed with excess body weight, provokes sagging and atrophy of the underlying muscle tissue. In addition, in obesity, adipose tissue is usually located in the lower abdomen. A thick layer of skin and fat creates additional stress on the muscles and aponeuroses of the lower third of the anterior abdominal wall, which leads to their degeneration, weakening and also creates a significant predisposition to the formation of inguinal hernias.

Exhaustion is the opposite of obesity, which can also serve as a prerequisite for the occurrence of an inguinal hernia. A sharp decrease in body weight, on the one hand, may indicate diseases that themselves can contribute to the formation of a groin hernia. On the other hand, the lower part of the anterior abdominal wall, even in fairly slender people, contains a fairly noticeable layer of fat. The disappearance of such a layer inevitably weakens the abdominal muscles and can provoke inguinal hernias.

Femoral hernia on ultrasound

To view the femoral hernia, the probe is placed below the inguinal ligament (position 4). A femoral hernia emerges medially from the femoral vein. Please note that during the Valsalva maneuver, the femoral vein dilates.

Important!!! An enlarged Pirogov-Rosenmuller lymph node, which is located under the inguinal ligament, is sometimes mistaken for an inguinal hernia. It appears to be a homogeneous structure of medium echogenicity with smooth, clear contours.

Rehabilitation after surgery to remove an inguinal hernia in children

After surgery for an inguinal hernia, children, as a rule, recover quickly and without any problems. Parents will have to somewhat limit the child’s mobility, change bandages regularly, and also follow a number of simple rules.

• For 5–7 days after the intervention, it is undesirable to give children foods that increase gas formation and the risk of constipation - beans, potatoes, sweet pastries, fatty meats and fish.
• For 1-2 weeks you will have to limit physical activity: running, jumping, bending and squatting.
• Bathing and washing should be postponed until the wounds have completely healed.
• After removing the bandages, it is necessary to treat the wound area with a local antiseptic for 1–2 days.

Under no circumstances should you:

• warm the area of ​​inflammation;
• apply medicinal ointments and healing compounds to the wound;
• give babies any medications without consulting a doctor.

Spigelian hernia on ultrasound

Near the outer edge of the rectus sheath there is a semilunar line (linea semilunaris), connecting the navel with the anterior superior iliac spine; in the aponeurosis of the transverse abdominal muscle there are gaps from 3 to 16 mm through which the branches of the lower epigastric vessels pass, they are the site of exit of Spigelian line hernias.

To view a Spigelian hernia, the transducer is placed transversely at the outer edge of the rectus abdominis muscle at the level of the umbilicus (position 1) and moved towards the anterior superior iliac spine.

Spigelian fascia is located lateral to the rectus abdominis muscle along the semilunar line.

Its definition is somewhat vague, but is often used as a synonym for transversus abdominis aponeurosis.

Hernias through this fascia are called Spigelian hernias.

They are very rare and account for approximately 1% of all abdominal hernias.

Eighty-five to ninety percent of Spigelian hernias occur as a transverse band 0 to 6 cm cephalad to the plane between the anterior, superior iliac processes, also called the Spigelian hernia belt, where the fascia is widest.

It has been suggested that Spigelian hernias may be associated with previous surgery or distension of the abdominal wall due to obesity or pregnancy, or as a complication of peritoneal dialysis.

Patients may have visible and palpable swelling in this area, in which case the diagnosis is obvious, but this is rare.

In some cases, the hernia penetrates only the transverse abdominal aponeurosis, but since it is tightly connected to the internal oblique muscle, the hernia usually penetrates both aponeuroses.

Because the external oblique aponeurosis is thick and not so tightly connected to the others, it usually does not penetrate, and the hernia tends to slide between the oblique muscles and rarely reaches the subcutaneous tissue.

In addition to the fact that hernias are often closed by at least one aponeurotic layer, they are usually small and therefore very difficult to see and feel.

Symptoms are usually vague, intermittent, and nonspecific, and although pain is the most common symptom, there is no typical pain associated with Spigelian hernias.

Symptoms may mimic other conditions such as appendicitis, abscesses, peptic ulcers, or cholecystitis.

Diagnosis based on clinical picture is often problematic, but can be made with high accuracy using ultrasound or CT.

CT shows the anatomy in detail and is more sensitive, but also more expensive and produces radiation.

Ultrasound, although slightly less sensitive, is more dynamic because the patient can be examined in the supine and upright positions, as well as during the Valsalva maneuver.

In addition, the radiologist can benefit from the patient being able to directly indicate the location of their symptoms during the examination.

If doubt remains after X-ray examination, diagnostic laparoscopy is usually performed.

Clinical Point of View: Spigelian hernias are rare and difficult to diagnose, but diagnosis is important due to the high risk of strangulation due to their usually small hernial ring.

Treatment planning: Hernias are usually treated surgically, either by open surgery or by laparoscopy with mesh inserted inside or outside the abdominal cavity to close the hernial ring.

Result: The desired outcome is to relieve symptoms and avoid strangulation and relapse.

Prognosis: There is a risk of recurrence after surgery, but it is usually low.

Strangulated hernia

A strangulated inguinal hernia is accompanied by the following symptoms:

• weakness, tachycardia;
• nausea, vomiting;
• bloating, lack of stool;
• negative reaction to a cough impulse; when coughing, placing a finger on the inguinal ring, shocks are usually felt; if the hernia is strangulated, the impulse is not transmitted;
• the hernia stops being reduced;
• the hernial sac is very tense;
• sharp, acute pain in the hernia area and in the abdomen.

A strangulated inguinal hernia is a very dangerous complication, so medical care should be provided as soon as possible. The operation must be performed as quickly as possible, since serious complications may develop, such as:

1. Necrosis is the necrosis of parts of the intestinal loops or omentum that have fallen into the hernial sac.
2. Peritonitis - with prolonged strangulation of the groin hernia, inflammation of the abdominal cavity develops.

At the same time, irreducible and large hernias, even without complications, cause discomfort to patients: they limit their activity and are accompanied by unpleasant symptoms.

Possible complications after surgery

Complications after removal of an inguinal hernia are quite rare. In 0.5–1% of cases the following may occur:

• slight swelling;
• temperature increase;
• accumulation of lymphatic fluid in the tissues of the pelvic organs.

The risk of recurrent hernia does not exceed 1%. Relapses are more often observed in premature babies and children who have undergone emergency intervention. The chances of a new hernia forming increase if the child moves little, is obese, or does not exercise.