An inguinal hernia is a pathological protrusion of internal organs outside the abdominal cavity. Inside this reservoir there may be intestinal loops, omentum and other structures. In childhood, congenital forms of pathology are most common, especially in premature infants. Boys suffer from this disease 10 times more often than girls.
Any situation that causes an increase in pressure in the abdominal cavity can provoke the formation of a hernia: heavy lifting, prolonged crying, screaming, constipation, a strong, prolonged cough. To avoid a threat to health, pediatric surgeons recommend that children undergo surgery to remove an inguinal hernia immediately after diagnosis. It is called hernioplasty.
Indications for surgery
The absolute reason for emergency surgical intervention is a strangulated hernia - a dangerous complication that, without timely help, threatens the lives of children. With it, there is a gradual necrosis of the structures that are inside the hernia due to the cessation of blood circulation in them. This is accompanied by severe intoxication and severe pain in the abdominal area.
Emergency assistance is needed for acute intestinal obstruction. It is formed if intestinal loops get into the hernial sac, resulting in an obstacle to the movement of feces.
In all other cases, even with a mild degree of the disease, a planned operation to remove an inguinal hernia in children is performed.
Testicular hernia - causes
Causes of inguinal hernia:
- congenital weakness of formations in the inguinal canal;
- increased pressure in the abdominal cavity;
- weakness of the abdominal wall;
- tension during bowel movements and urination;
- lifting heavy objects;
- fluid in the abdominal cavity - ascites;
- excess weight;
- chronic cough.
In some men, abdominal wall weakness occurs at birth and causes testicular hernia in children. In other cases, hernias develop later in life when the muscles weaken due to aging, heavy exercise, or coughing associated with smoking.
Possible contraindications
Emergency surgery is performed for life-saving reasons. Planned intervention is postponed or canceled if the patient has the following problems:
- individual intolerance to anesthesia;
- acute infectious diseases;
- exacerbation of chronic pathologies;
- inflammatory processes in the abdominal organs.
Possible contraindications and the balance between the risks and benefits of surgical intervention are assessed in each specific case.
Treatment
The only definitive treatment option remains surgery.
The tactics of action and the method of access are selected taking into account the age and general condition of the child, the presence of other diseases, the nature of education and other individual parameters of the patient. In most cases, removal of pathology is carried out using minimally invasive laparoscopic techniques. In case of extensive formation with strangulation, open hernia repair may be indicated. Conservative treatment for inguinal hernias is irrational, except in cases where strangulation pathology is diagnosed in newborn boys; however, if conservative tactics do not give the desired results, surgery is also indicated.
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.
Extracorporeal methods
Extracorporeal method using an awl
Extracorporeal
method with steel awl
R. Prasad [10] (Fig. 9 a, b)
Rice. 9. Extracorporeal method using an awl.
Using an instrument that resembles an awl and has a hole at the end through which a hernial ligature is passed, an external injection is made in the projection of the lateral aspect of the internal inguinal ring. The awl is passed extraperitoneally and its end is punctured into the abdominal cavity. The ligature is left in the abdominal cavity. Then the needle is reinserted from the medial side of the internal inguinal ring and by placing the end of the thread into the hole of the instrument, the hernial ligature is removed and tied subcutaneously.
Subcutaneous endoscopically assisted ligation
Subcutaneous
Endoscopically Assisted Ligation ( SEAL
)
M. Harrison [13] (Fig. 10)
Rice. 10. Subcutaneous endoscopically assisted ligation.
An atraumatic needle with a hernial ligature is inserted percutaneously into the projection of the lateral side of the internal inguinal ring and passed extraperitoneally, including over the elements of the spermatic cord. On the opposite side, a Tuohy needle is injected, the end of which is also passed under the peritoneum until it meets the needle containing the hernial ligature. With a mutual movement, the needles are brought out, and the thread is tied subcutaneously.
Laparoscopic percutaneous extraperitoneal closure
Laparoscopic Percutaneous Extraperitoneal Closure
H. Takehara [14, [15] (Fig. 11 a, b, c)
Rice. 11. Laparoscopic percutaneous extraperitoneal closure.
A special Lapaherclosure needle (Hakko Medical Co., Japan) is used, which contains an internal mandrel insert in the form of a metal catching loop extending from the lumen of the needle. A needle with a hernial ligature threaded through it is injected percutaneously into the projection of the lateral aspect of the internal inguinal ring and is passed extraperitoneally, including over the elements of the spermatic cord. After piercing the peritoneum, the ligature remains in the abdominal cavity. Repeated injection of the needle from the medial side is accompanied by the capture of the thread and its removal out.
Percutaneous suturing of the inner ring
Percutaneous
Internal Ring Suturing
D. Patkowski [16] (Fig. 12 a, b)
Rice. 12. Percutaneous suturing of the inner ring.
A regular 18G injection needle is used with a ligature thread threaded through it in the form of an “endless” loop. The needle is passed extraperitoneally and its end is punctured in front of the testicular vessels. The ligature is left in the abdominal cavity in the form of a loop. Then, from the medial side of the internal inguinal ring, an 18G needle with a second ligature is re-injected, and by placing the end of the suture material in the loop of the first thread, the hernial ligature is removed and tied subcutaneously.
Extracorporeal method using a Reverdine needle
Extracorporeal
method with Reverdin needle
R. Shalaby [17] (Fig. 13 a, b, c)
Rice. 13. Extracorporeal method using a Reverdine needle.
A Reverdine needle with a hernial ligature at the end is passed under the peritoneum of the lateral portion of the internal inguinal ring over the vas deferens and testicular vessels. The ligature is left in the abdominal cavity. By repeatedly injecting the Reverdine needle into the medial part of the internal inguinal ring, the thread is pulled out and tied subcutaneously.
Subcutaneous endoscopically assisted ligation with hydrodissection and double thread placement
SEAL with hydrodissection and dual encirclage
Saranga Bharathi K. [18] (Fig. 14 a, b)
Rice. 14. Subcutaneous endoscopically-assisted ligation with hydrodissection and double thread placement.
A preperitoneal injection of a small volume of saline solution (NaCl) is performed in the projection of the elements of the spermatic cord. An atraumatic needle with a hernial ligature is inserted percutaneously into the projection of the lateral part of the internal inguinal ring and carried extraperitoneally, including over the elements of the spermatic cord, and brought out. Making the reverse movement, the rear part of the needle is brought out into the injection hole. The hernial ligature is tied subcutaneously.
Extracorporeal hook method
Extracorporeal
hook method
K. Lee [19]; C. Yeung [20] (Fig. 15 a, b, c)
Rice. 15. Extracorporeal hook method.
A Herniotomyhook device is used, which has a hole at the end into which the thread is placed. A hook containing a hernial ligature is inserted percutaneously into the projection of the lateral aspect of the internal inguinal ring and is passed extraperitoneally, including over the elements of the spermatic cord. After puncturing the peritoneum, the ligature is removed using an endoscopic clamp and remains in the abdominal cavity. Repeated insertion of the hook from the medial side is accompanied by the capture of the thread and its extraction out.
Extracorporeal method using the Endoneedle needle
Extracorporeal
method with Endoneedle
M. Endo, E. Ukiyama [21, 22] (Fig. 16 a, b)
Rice. 16. Extracorporeal method using an Endoneedle needle.
Using a special needle, the ligature is passed over the vas deferens and testicular vessels. Then the ligature is removed into the abdominal cavity and, by repeated injection from the medial side of the internal inguinal ring, it is captured and removed outward.
Lasso technique using hydrodissection
Hydrodissection
- lassotechnique
O. Muensterer, K. Georgeson [23] (Fig. 17 a, b)
Rice. 17. Lasso technique using hydrodissection.
An extraperitoneal injection of a small volume of physiological solution (NaCl) is performed in the projection of the elements of the spermatic cord. A needle with a ligature inserted into the lumen of the needle in the form of a loop is injected from the outside medially of the internal inguinal ring, passed under the peritoneum, bypassing the components of the spermatic cord, and punctured laterally from them. The loop remains in the abdominal cavity. Repeated injection of a similar needle, also with a thread threaded through it, which is a hernial ligature, is performed on the other side of the internal inguinal ring. A thread in the form of a loop is placed in the first loop and, when pulled out, is tied subcutaneously.
Laparoscopically-assisted extraperitoneal release of the hernial sac and its ligation
L
AP -assisted micro-incision extraperitoneal division and ligation
S. Kim, T. Hu [24] (Fig. 18)
Rice. 18. Laparoscopically-assisted extraperitoneal isolation of the hernial sac and its ligation.
A micro-incision is made in the groin area above the internal inguinal ring. A mosquito-type clamp is placed into the incision, the end of which is advanced inward until the extraperitoneal space is reached. Using an atraumatic endoscopic clamp, an extraperitoneal bypass of the neck of the hernial sac is performed using a mosquito clamp. The mobilized part of the hernial sac is removed out, where a hernial ligature is placed around the neck and tied.
Laparoscopically-assisted suturing and obliteration of the internal inguinal ring using an epidural catheter
Laparoscopically Assisted Simple Suturing Obliteration (LASSO) of the internal ring using an epidural catheter
S. Li [25] (Fig. 19)
Rice. 19. Laparoscopically-assisted suturing and obliteration of the internal inguinal ring using an epidural catheter.
A Tuohy needle with a silk ligature inserted into the lumen of the needle in the form of a loop is injected externally lateral to the internal inguinal ring, passed under the peritoneum, bypassing the components of the spermatic cord, and punctured medially. The needle is removed leaving the ligature in the abdominal cavity. Another ligature is tied to the end of the epidural catheter, which is a “loop catcher”. An epidural catheter with a “loop catcher” at the end is inserted into the Tuohy needle. The device is reinserted from the medial side of the internal inguinal ring. The hernial ligature is immersed in the “loop catcher” and removed out.
How is surgery for inguinal hernia performed on children?
Conservative methods of treating the disease are practically not used, since the effectiveness of such methods is extremely low, and the risk of strangulation of the hernia is high. The only correct solution is surgical removal of the formation.
There are two options for hernioplasty:
- open access;
- using laparoscopic equipment.
The optimal method of surgery is chosen by the doctor based on examination data, the child’s age and possible risks. The type of intervention determines how long the operation for an inguinal hernia in a child lasts. The operation time can vary from 30 minutes to an hour, taking into account anesthesia. Regardless of the chosen method, deletion occurs according to a certain algorithm:
- incision of the hernial sac and restoration of the anatomically correct location of internal organs and tissues;
- suturing of the hernial orifice;
- strengthening the inguinal canal or the patient’s own tissues.
All manipulations are performed under general anesthesia.
In modern pediatric surgery, laparoscopic hernioplasty is considered the preferred method of treatment. It is less invasive: minimal blood loss and small incisions reduce the risk of complications and shorten the recovery period. In some cases, it is possible to perform an open operation on a child to remove an inguinal hernia in the scrotal area. The doctor determines the method of performing the operation individually in each specific clinical case.
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.
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.
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.
Symptoms of the disease
The initial stages of pathology development and small formations are not accompanied by any signs. Symptoms of an inguinal hernia can be detected in children when the size of the formation is large during crying, screaming, or physical tension of the muscles of the abdominal wall. In rare cases, the condition is accompanied by minor pain.
In boys, the swelling can spread to the scrotum area, in girls - to the labia majora. When pressed, the swelling is easily reduced and does not manifest itself in any way at rest.
Characteristic signs in children are accompanied only by strangulation of the inguinal hernia - a dangerous condition that requires immediate surgical treatment. Symptoms of infringement include:
- sharp pain in the area of the protrusion;
- severe flatulence, bloating;
- constipation;
- inability to reduce swelling;
- general intoxication.
In infants, pathology can be suspected by expressed anxiety, attempts to take a forced position, crying, and moodiness.
Further development of strangulation can lead to peritonitis, which is accompanied by nausea, vomiting, fever, and loss of consciousness. Such signs may indicate internal bleeding and the development of necrosis, which can threaten not only the health, but also the life of the child.