Inguinal hernias and congenital hydroceles in infants and children

A baby's processus vaginalis is usually open at birth, and closes before he is two. If it is not completely obliterated it can have any of the abnormalities in Fig 14-15.

When you see him, his hernia may be present, or it may have reduced itself, so you have to depend on his mother's history that he has a lump which comes and goes, and gets larger when he cries. If you want to see it, find some way to make him cry.

Inguinal hernias in a child are always indirect. Unlike umbilical ones, they do not become smaller spontaneously as he grows older. They seldom strangulate, but they often become obstructed, especially in the first year. The smallest ones strangulate most easily and are most easily missed. You can usually reduce an inguinal hernia by taxis, as described below. Repairing them is one of the most common operations in paediatric surgery, but it is not easy. The sac is thin, delicate, and difficult to find, and a baby's vas is small and easily injured.

At birth the canal is short, and if his hernia is large, his external ring may lie directly over his internal one, which is convenient, because it allows you to dissect out the sac, without opening his external oblique aponeurosis. In young children, simply excise the sac.

Wait to operate until a baby is 3 or preferably 6 months old, when anaesthesia will be easier. All you usually need to do is to dissect out the sac carefully (making sure that you do not damage his spermatic vessels or his vas), to transfix its neck at his external ring, and to excise it. There is no need to open the inguinal canal of a young child, but if he is more than five years old, you will have to open it. You may occasionally need to narrow the internal ring of an older child. Don't try to shift any muscles, and don't apply a truss.

In principle, the repair of an inguinal hernia in a child is the same as in an adult, as described in Section 14.2. Only the differences are described here. You may find a sliding hernia of his bladder or colon, or of a girl's adnexae. If you operate in the morning, a child can be up and about in the afternoon, as soon as he has recovered from the anaesthetic.

Hydroceles in children are formed in a different way from those in adults, and need different treatment: (1) In adults fluid is secreted by the tunica vaginalis, so this has to be excised or inverted as in Section 23.23. (2) In a child they are the result of fluid passing from his peritoneal cavity to his tunica vaginalis, through a narrow (2 to 10 mm) connection between them (a persistent processus vaginalis, C, in Fig. 14- 15). If you divide this, fluid will not reform. So, find the processus vaginalis, dissect it out, and divide it between ligatures.

INGUINAL HERNIAS [s8]AND CONGENITAL HYDROCELES IN CHILDREN DIFFERENTIAL DIAGNOSIS. A hydrocele in a child is difficult to distinguish from a hernia, because they both transmit the light of a torch, so they are both considered together here. The distinction is not critical, because most hydroceles need to be operated on.

Suggesting a hydrocele[md]a swelling which cannot be reduced and does not have a cough impulse. Its size varies, but much less so than a hernia.

TAXIS [s7]FOR INGUINAL HERNIAS IN CHILDREN If a child's hernia is irreducible, so that its contents will not return to his abdomen, sedate him, and put him into gallows traction (78.2). There is a 50% chance that it will reduce spontaneously, or with a little help. If taxis succeeds, put him on the waiting list, and operate as soon as it is convenient. If it fails, operate without delay.

HERNIOTOMY [s7]IN YOUNG CHILDREN INDICATIONS. (1) If he is a neonate, or very young, don't operate until he is 3 to 6 months old, when anaesthesia will be easier. If he is fortunate, his hernia may occasionally resolve spontaneously while he is waiting. (2) All inguinal hernias in children over 6 months old.

ANAESTHESIA. (1) Ketamine (A 8.1). (2) General anaesthesia. Don't use local anaesthesia.

INCISION. Make a 5 cm incision in the skin crease above his inguinal ligament, from above his mid-inguinal point (found by palpating his femoral artery) to the medial aspect of the swelling of his hernia.

Cut through his subcutaneous tissues, and pick up his small superficial epigastric and external pudendal vessels with 3/0 plain catgut or monofilament. Expose his external oblique aponeurosis, and his external ring, which lies above and lateral to his pubic tubercle.

Find the hernial sac, which should be anterior to his cord, and apply haemostats to its edge. Dissect it away with scissors from his spermatic vessels and vas. Use blunt gauze dissection to separate any light connective tissue. In this way separate his cord from the sac.

Open the sac between haemostats, as if you were opening the peritoneum for an abdominal operation. Enlarge the opening and apply 4 haemostats conveniently placed on its circumference. If it is big enough, insert the index finger of your left hand as you dissect down to its neck.

CAUTION ! (1) Free the sac completely before you open it. In this way you are less likely to split it. (2) A girl's Fallopian tube and ovary may slide into the sac[md]don't remove them as part of it. (3) If you meet the appendix, don't remove it. (5) A boy's vas is very small, don't mistake it for a piece of fibrous tissue.

Transfix the neck of the sac with 3/0 chromic catgut, and tie it off. If the sac does not continue into his scrotum excise it. If it continues to become the tunica vaginalis of his testis (common), cut this across about 1 cm above his testis and tie it. In doing so you restore his normal anatomy. A hydrocele does not reform in a child, as it does in an adult.

CAUTION ! (1) Make sure you are cutting the sac only. You can easily cut his vas, because it is adherent to the posterior surface of the sac. (2) Don't split the sac. (3) Don't use blunt dissection, except on very light connective tissue. It may lead to the formation of a haematoma.

If he is older than five years, assess the size of his internal ring. Try to put your finger though it into his peritoneal cavity. If it is big enough to take the tip of your little finger, it probably needs repair. If his internal ring is more than 1.5 cm across, close it as described below.

INGUINAL HERNIAS [s7]IN OLDER CHILDREN First do a herniotomy as described above.

The internal ring of an older child is no longer under his external one. It will have started to migrate laterally, as in an adult. Open his inguinal canal for about 2 cm. Cut upwards and laterally from his external ring, in the direction of the fibres of his external oblique aponeurosis. Then isolate and tie the sac as above, but do it at his internal ring.

REPAIR OF THE INTERNAL RING. If his internal ring is more than 1.5 cm across, repair it. Retract his cord laterally. Put the tip of your finger through the hole in which the stump of the sac has retracted. Feel the margins of the hole, put a haemostat on its medial margin, and lift it forwards. Bring the fine upper and lower edges together with 2 to 4 sutures of 3/0 chromic catgut or monofilament, so as to ''snug' his transversalis fascia round his cord. You should still be able to pass the tip of your forceps through the ring alongside his cord. Close his inguinal canal with 3/0 catgut or monfilament.

CONGENITAL HYDROCELES [s7]IN INFANTS AND CHILDREN Proceed as above for a congenital hernia. At operation it will be obvious that a child has a hydrocele rather than an inguinal hernia, because his tunica vaginalis will be swollen with fluid, and there is no obvious neck to the swelling. Confirm it by aspirating a little fluid.

When you follow his hydrocele proximally it will finally disappear into his processus vaginalis. Find it in close relation to his spermatic vessels and his vas, and divide it between ligatures. There is no need to open his tunica vaginalis.

CAUTION ! His vas is very small (2 mm in diameter) and is thin-walled.

If you have difficulty, aspirate more of the contents of the hydrocele, and instil some Bonney's blue or gentian violet. Massage the fluid and it may demonstrate his patent processus vaginalis.

Close his subcutaneous tissue with 3/0 plain catgut and his skin with 3/0 monofilament.

DIFFICULTIES [s7]WITH INGUINAL HERNIAS IN CHILDREN If he has a HERNIA and a HYDROCELE, gently draw the mass upwards, and dissect off its outer coverings down to the hydrocoele sac, so as to expose it. Don't disturb his testis. Do a herniotomy for the hernia. To do this you will have to divide his processus vaginalis. If you can find it, tie it; if you cannot find it, this is not important.

If his SAC SPLITS up to and perhaps through his inguinal ring, this is inconvenient. Be specially careful, as you search for something to sew together, that you don't tie his vas.

If his TESTIS ATROPHIES later, you have probably interfered with its blood supply. This is one of the commonest complications. His parents, who may have difficulty accepting that one testis can function as efficiently as two, will not be pleased. His other testis should however be normal, so reassure them.

If his hernia RECURS (unusual), try to refer him. If you are inexperienced, re-operation can be difficult.