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Chapter 36. Inguinal Hernias >
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Pediatric Hernias
Most inguinal hernias in children are indirect, related to a persistent patent processus vaginalis.
Approximately 1 to 5% of children are born with or develop an inguinal hernia. However, the
incidence rises in preterm infants and those with low birth weights (13% of babies born before
32 weeks and 30% of babies with a birth weight less than 1000 g). 80 Overall, right-sided
hernias are twice as common as left-sided hernias, and about 10% of hernias diagnosed at birth
are bilateral, but this varies greatly on the basis of numerous risk factors, the most important of
which is age. The right-sided predominance is felt by most authorities to be related to the later
descent of the right testicle during gestation. 81,82 There are several conditions which
predispose a child to develop an inguinal hernia. (Table 36-13)
Table 36-13 Conditions Associated with an Increased Incidence of Pediatric Hernia

Family history
Undescended testis
Hypospadias/epispadias
Ventriculoperitoneal shunt
Peritoneal dialysis
Cryptorchism
Prematurity
Other abdominal wall defect
Cystic fibrosis
Ascites
Intersex conditions
Connective tissue disorders
Hunter-Hurler syndrome
Ehlers-Danlos syndrome
Infants or children may present with a mass in the groin or scrotum. The diagnosis may seem
obvious, but one must be careful to differentiate the mass from other cord and testicular
abnormalities such as a hydrocele, undescended testicle, varicocele, or even a testicular tumor.
Commonly, no hernia is able to be demonstrated when the patient presents to the surgeon. Some
surgeons rely on the so-called "silk glove sign," which reflects the way the hernia sac feels as it
is palpated over the cord structures. The finding is controversial and there is some evidence that
what is actually being felt is a hypertrophied cremaster muscle. 83 Overall, the diagnosis
commonly hinges on the observation of the referring physician or a parent. Most surgeons feel
that the risk:benefit ratio favors this as an acceptable indication for operation when the source
seems reliable, rather than taking the chance of incurring a strangulation.
Incarceration is a more serious problem in the pediatric patient than the adult, with large series
reporting rates of up to 20%. The patient presents with a hard, tender groin mass. Seventy-five to
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eighty percent of these can be successfully reduced, so the initial treatment consists of sedation,
Trendelenburg position, ice packs, and gentle taxis. A reasonable attempt at conservative
management of an incarcerated pediatric hernia before proceeding to emergency surgery is in the
patient's best interest, because the complication rate compared to elective herniorrhaphy is
increased 20-fold, including irreversible abnormalities such as testicular infarction or atrophy. If
no progress is made within 6 hours, or the patient exhibits signs of peritonitis or systemic
toxicity, immediate operation is appropriate.
Most pediatric inguinal hernias are repaired using the principle of high ligation of the sac. The
external oblique aponeurosis is opened for a short distance beginning at the external ring and
proceeding laterally. The sac is then gently dissected away from the cord structures proximally
until the internal ring is reached, then the sac is twisted, suture ligated, and amputated. If the sac
extends into the scrotum, it can be divided, leaving the distal sac in situ. Care must be taken to
exclude abdominal contents such as the tube and ovary before the suture ligation. Occasionally a
Marcy repair of the internal ring is added if the structure is unusually large.
Exploration of the opposite groin remains controversial. As an alternative, ultrasound
examination has become popular at some centers, but is largely dependent on the expertise of the
ultrasonographer. 84,85 The size of the internal ring and the presence of bowel or fluid in the
spermatic cord are diagnostic criteria indicative of a positive exam. Another alternative is
laparoscopy using either a rigid or a flexible endoscope through the contralateral hernia sac. The
accuracy is high for properly trained laparoscopists, such that it is considered the gold standard
in studies using both ultrasonography and laparoscopy. The disadvantage of laparoscopy is high
cost and potential intra-abdominal complications.
Hernia Accident (Incarceration, Bowel Obstruction, and Strangulation)
An incarcerated hernia is by definition an irreducible hernia. However, this does not constitute a
surgical emergency, as chronic states of incarceration are common because of the size of the
neck of the hernia in relationship to its contents or because of adhesions to the hernia sac. The
recommended treatment of an incarcerated hernia is surgical, but there is no urgency because
there is no life-threatening complication present.
A patient with an incarcerated inguinal hernia exhibiting signs of a bowel obstruction or one who
develops an acute incarceration that remains exquisitely tender represents a completely different
clinical scenario. Unlike adhesive small bowel obstructions, partial small bowel obstructions are
rare. Therefore most patients will have vomiting and absolute constipation (obstipation). In
Western countries, groin hernia ranks third after adhesive obstruction and cancer as the most
common cause of bowel obstruction. In other geographic areas, it remains the most prevalent. It
is common for it to be overlooked on clinical examination, and therefore must be kept in mind in
patients being evaluated for bowel obstruction.
Imaging studies are important in cases where there is the slightest question about the cause of the
patient's obstructive pattern. This is because a distal intestinal obstruction secondary to another
cause (e.g., adhesions) may result in distention of a coincidental nonobstructing groin hernia.
Should the examiner focus attention exclusively on the hernia, the stage is set for disaster when
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the hernia is repaired and the real cause of the obstruction is missed. Plain roentgenograms of the
abdomen will reveal the usual signs of an intestinal obstruction, such as dilated loops of bowel
with air-fluid levels, absence of bowel gas distal to the obstruction, and bowel shadows in the
region of the hernia. A lateral view is often useful to demonstrate this more clearly. Computed
tomographic (CT) scans reliably demonstrate the hernia with characteristic features of
obstruction, and should be considered if the clinical diagnosis is uncertain.
The initial treatment, in the absence of signs of strangulation, is taxis. Taxis is performed with
the patient sedated and placed in the Trendelenburg position. The hernia sac neck is grasped with
one hand, with the other applying pressure on the most distal part of the hernia. The goal is to
elongate the neck of the hernia so that the contents of the hernia may be guided back into the
abdominal cavity with a rocking movement. Mere pressure on the most distal part of the hernia
causes bulging of the hernial sac around the neck that can occlude the neck and prevent its
reduction (Fig. 36-1). Taxis should not be performed with excessive pressure. If the hernia is
strangulated, gangrenous bowel might be reduced into the abdomen or perforated in the process.
One or two gentle attempts should be made at taxis. If this is unsuccessful, the procedure should
be abandoned. Rarely, the hernia together with its peritoneal sac and constricting neck may be
reduced into the abdomen (reduction en masse). Reduction en masse of a hernia is defined as the
displacement of a hernia mass without relief of incarceration or strangulation. This diagnosis
must be considered in all cases of intestinal obstruction after apparent reduction of an
incarcerated hernia. Laparoscopy can be both diagnostic and therapeutic and therefore is a
particularly good option. Surgeon expertise may make laparotomy a better choice for some.
The most significant complication of either acute incarceration or intestinal obstruction is
strangulation. It is a serious, life-threatening condition because the hernia contents have become
ischemic and nonviable. The clinical features of a strangulated obstruction are dramatic. In
addition to the patient having developed an irreducible hernia and an intestinal obstruction,
clinical signs indicate that strangulation has taken place. The hernia is tense and very tender, and
the overlying skin may be discolored with a reddish or bluish tinge. There are no bowel sounds
present within the hernia itself. The patient commonly has a leukocytosis with a left shift, and is
toxic, dehydrated, and febrile. Arterial blood gases may reveal a metabolic acidosis.
Rapid resuscitation with intravenous fluids is essential, along with electrolyte replacement,
antibiotics, and nasogastric suction. Urgent surgery is indicated once resuscitation has taken
place. The initial surgical approach is to make an open inguinal hernia incision. If the bowel is
viable, it is reduced into the abdominal cavity prior to repairing the hernia. The neck of the
hernia is widened if any difficulty is encountered reducing the hernia. Although rare, the surgeon
must be cognizant of the possibility that a nonviable abdominal organ may have been reduced
into the abdominal cavity during the course of usual surgical maneuvers before it could be
visualized. If such a suspicion is present, the entire gastrointestinal (GI) tract must be evaluated.
If the bowel is found to be obviously gangrenous, more bowel must be pulled into the hernia so
that viable bowel can be transected and the gangrenous portion removed. In the ideal situation,
an end-to-end anastomosis is performed and the bowel is reduced into the abdominal cavity,
followed by hernia repair. The slightest suspicion that the entire process cannot be addressed
from the groin mandates exploratory laparoscopy or laparotomy to unequivocally prove that all
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nonviable tissue has been resected. In the case of a femoral hernia, it is frequently necessary to
incise the inguinal ligament anteriorly or the lacunar ligament medially to facilitate reduction.
Diagnosis
Physical Examination
Physical examination is the best way to determine the presence or absence of an inguinal hernia.
The diagnosis may be obvious by simple inspection when a visible bulge is present. The
differential diagnosis must be considered in questionable cases (Table 36-4). Nonvisible hernias
require digital examination of the inguinal canal (Fig. 36-12). This is best done in both the lying
and standing position. The examiner should place the tip of the index finger at the most
dependent part of the scrotum and direct it into the external inguinal ring. The patient is then
asked to strain. The ritual of having the patient cough is discouraged as it results in the
overdiagnosis of a hernia because of the difficulty of differentiating a normal expansile bulge of
muscle from a true hernia, especially in asthenic individuals.
Table 36-4 Differential Diagnosis of Groin Hernia
Malignancy
Lymphoma
Retroperitoneal sarcoma
Metastasis
Testicular tumor
Primary testicular
Varicocele
Epididymitis
Testicular torsion
Hydrocele
Ectopic testicle
Undescended testicle
Femoral artery aneurysm or pseudoaneurysm
Lymph node
Sebaceous cyst
Hidradenitis
Cyst of the canal of Nuck (female)
Saphenous varix
Psoas abscess
Hematoma
Ascites
Numerous authors have shown that the accuracy with which direct and indirect inguinal hernias
can be distinguished clinically before surgery is low. 28,29,30 However, classic teaching is that
an indirect hernia will push against the fingertip, whereas a direct hernia will push against the
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pulp of the finger. In addition, applying pressure over the mid-inguinal point (midway between
the anterior superior iliac spine and the pubic tubercle, and just above the inguinal ligament) with
the fingertip will control an indirect hernia and prevent it from protruding when the patient
strains. A direct hernia will not be affected with this maneuver.
A femoral hernia presents as a swelling below the inguinal ligament and just lateral to the pubic
tubercle. Femoral hernias are overdiagnosed because of the presence of a prominent femoral fat
pad, a so-called femoral pseudohernia. Thin patients commonly have prominent bilateral bulges
below the inguinal ligament medial to the femoral vessels. They are asymptomatic and disappear
spontaneously when the patient assumes a supine position. Surgery is not indicated. 21
Nonoperative Treatment
The term "watchful waiting" is used to describe this nonoperative treatment recommendation. It
is only applicable in asymptomatic or minimally symptomatic hernias. Patients are counseled
about the signs and symptoms of complications from their hernia so they might present promptly
to their physician in case an adverse event takes place. Definitive data that this recommendation
is safe are not available, and it is for this reason that surgical repair of all inguinal hernias at
diagnosis is recommended. However, a randomized controlled trial is currently underway which
should shed some light on this subject in the next few years.
A truss is a mechanical appliance consisting of a belt with a pad that is applied to the groin after
spontaneous or manual reduction of a hernia. The purpose is twofold: to maintain reduction and
to prevent enlargement. Whether either goal is achieved consistently is unknown, and it is
doubtful that the incidence of hernia accidents is reduced. What is clear is that symptomatic
relief is achieved in many patients. Most patients consider them cumbersome because of the
complicated system of elastic, Velcro, straps, and/or springs usually required to make them
effective. Some find them unacceptable because they are difficult to keep clean. Also, they are
not without complications. Atrophy of the spermatic cord has been described, and the clinical
experience of many surgeons is that an eventual hernia repair is made more difficult by the
constant mechanical pressure in the groin area that renders the tissue more difficult to dissect due
to atrophy and fibrosis. There are not enough valid studies to determine how effective trusses are
and whether they are as effective as operative treatment in controlling symptoms.
Indirect Inguinal Hernias
The so-called "saccular theory" of indirect inguinal hernia formation proposed by Russell
remains popular. 16 Russell's hypothesis that the "presence of a developmental diverticulum
associated with a patent processus vaginalis, was essential in every case" is still valid in the
minds of many surgeons today. Russell felt that increased intra-abdominal pressure might serve
to further stretch and weaken the internal ring, allowing additional intra-abdominal organs to
herniate through the orifice, but could not actually cause an indirect inguinal hernia. However,
this does not explain all cases of indirect groin hernias. First, a patent processus vaginalis can be
found at autopsy without clinical evidence of a hernia. 17 Second, there are patients with an
obliterated processus vaginalis who have an abdominal wall defect lateral to the epigastric
vessels. 18 Third, congenital structural malformations of the transversalis fascia and transversus
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abdominis aponeurosis can alter the strength and size of the internal inguinal ring. Denervation
of the internal oblique muscle by adjacent incisions (e.g., appendectomy) can also be associated
with the eventual development of an indirect inguinal hernia. 19
Excessive fatty tissue involving the cord or round ligament encountered by a surgeon during
elective herniorrhaphy has traditionally been referred to as a lipoma of the cord. This term is
unfortunate because it implies a neoplastic process, but a lipoma of the cord consists of normal
fatty tissue. The reason for the term lipoma is that the fatty tissue can easily be separated from
the cord structures and reduced into the preperitoneal space en masse, as if it were a tumor. A
lipoma of the cord is important from a clinical standpoint for the following reasons: (1) it can
cause hernia-type symptoms, although with less frequency than indirect hernias with a peritoneal
sac; (2) it is often difficult to distinguish at physical examination from an indirect hernia with a
peritoneal sac; and (3) it can be responsible for an unsatisfactory result because of an unchanged
physical examination after elective inguinal herniorrhaphy, especially when a preperitoneal
repair is utilized. 20 For the purposes of the large clinical trials referred to in other parts of this
chapter, a lipoma of the cord was classified as an indirect hernia. There is no peritoneal sac by
definition, because the contents of the indirect hernia (i.e., preperitoneal fat) come from the
preperitoneal space rather than the abdominal cavity.
Direct Inguinal Hernias
Two major factors are felt to be important in the development of direct inguinal hernias. The first
is increased intra-abdominal pressure associated with a variety of conditions listed in Table 36-2.
The second factor is relative weakness of the posterior inguinal wall. An abnormally high-lying
arch of the main body of the transversus abdominis muscle above the superior ramus of the pubis
that results in a large area at risk has been incriminated (see anatomy section). Similarly, a
limited insertion of the transversus abdominis muscle onto the pubis, weakness of the iliopubic
tract, limited insertion of the iliopubic tract aponeurosis into Cooper's ligament, or a combination
of these have been reported to contribute.
Etiology
The cause of an inguinal hernia is far from completely understood, but it is undoubtedly
multifactorial (Table 36-2). Familial predisposition plays a role. 5 There is increasing evidence
that connective tissue disorders predispose to hernia formation by altering collagen formation.
For example, lathyrism is associated with an increased incidence of inguinal hernia in animals,
and lathyrogens can be used in the laboratory to produce hernias. 12 Cannon and Read used
hydroxyproline concentration in the rectus sheath as a measure of collagen production to show it
was decreased in patients with inguinal hernias. They pointed out the importance of defective
collagen metabolism in cigarette smokers that causes hernia formation, and coined the term
metastatic emphysema. 13 A higher prevalence of inguinal hernias is well known among patients
suffering from certain congenital connective tissue disorders (Table 36-3). In children with
congenital hip dislocation, inguinal hernia occurs five times more often in girls and three times
more often in boys compared to children without this disease. 14 The role of physical exertion in
the development of inguinal hernia is probably less important than is commonly believed. The
cause-and-effect relationship between a specific lifting episode and the development of an
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inguinal hernia is present in less than 10% of patients, except in circumstances in which worker's
compensation issues are involved. 15 In addition, athletes, even weightlifters, do not seem to
have an excessive incidence of inguinal hernias.
Table 36-2 Presumed Causes of Groin Herniation
Coughing
Chronic obstructive pulmonary disease
Obesity
Straining
Constipation
Prostatism
Pregnancy
Birthweight less than 1500 g
Family history of a hernia
Valsalva maneuvers
Ascites
Upright position
Congenital connective tissue disorders
Defective collagen synthesis
Previous right lower quadrant incision
Arterial aneurysms
Cigarette smoking
Heavy lifting
Physical exertion (?)
Table 36-3 Connective Tissue Disorders Associated with Groin Herniation
Osteogenesis imperfecta
Cutis laxa (congenital elastolysis)
Ehlers-Danlos syndrome
Hurler-Hunter syndrome
Marfan syndrome
Congenital hip dislocation in children
Polycystic kidney disease
Alpha
1
-antitrypsin deficiency

Williams syndrome
Androgen insensitivity syndrome
Robinow syndrome
Serpentine fibula syndrome
Alport's syndrome
Tel Hashomer camptodactyly syndrome
Leriche's syndrome
Testicular feminization syndrome
Rokitansky-Mayer-Kuster syndrome
Goldenhar syndrome
Morris syndrome
Gerhardt syndrome
Menkes syndrome
Kawasaki disease
Pfannenstiel syndrome
Beckwith-Wiedemann syndrome
Rubenstein-Taybi syndrome
Alopecia-photophobia syndrome
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