Pediatric Inguinal Hernias
Inguinal hernias in the pediatric age group are almost always indirect, the result of persistent
patency of the processus vaginalis. The processus vaginalis is an out-pouching of the peritoneal
cavity that follows the inguinal canal down into the scrotum or the labium majora. The natural
tendency of this processus in the male is to become obliterated, forming a fibrous tract within the
spermatic cord. More distally, this area is called the tunica vaginalis of the testicle and the canal
of Nuck in females.
The processus vaginalis is still open in most newborns. It normally becomes fibrosed during
infancy, and by age 2 most are completely obliterated. The persistent processus in itself does not
indicate the presence of a hernia. Bowel or other intra-abdominal contents must come into the
processus for it to clinically become a hernia. The processus may close inconsistently, leading to
a funicular hernia, a scrotal hernia, or, if it remains open distally, a hydrocele (Figure 36).
Figure 36. Various degrees of closure of the processus vaginalis.
The persistence of the processus vaginalis seems to be more common on the right side, which
explains why right-sided hernias are twice as common as left sided hernias. Although persistence
of a processus is much less common in females than in males, it does occur and is usually
bilateral.
Diagnosis
Diagnosis of inguinal hernias in children can be difficult unless there is an obvious scrotal
hernia. Often the mother discovers the hernia when the child is coughing or crying. Confirming
the presence of a hernia is difficult through the inguinal canal because of its small size, and the
diagnosis is often made by history rather than by physical examination.
Once the diagnosis of an inguinal hernia is made in a child it should be repaired. Although some
authors disagree as to the advisability of operating on very young, premature infants, there may
be a higher incidence of incarceration or strangulation in these young children. In general, the
rule is to operate as soon as the clinical diagnosis is made. The question as to exploration of the
contralateral side is also somewhat controversial. If there is an obvious clinical hernia on the
opposite side, then there is no debate. Experts disagree, however, when no hernia is clinically
evident. Proponents of bilateral exploration (and those who favor laparoscopy) point to the
significant incidence of contralateral hernias that are found on exploration. Opponents of this
view believe that the risk of injury to the vas deferens or testicular vessels contraindicate routine
second-side exploration.[38,39]
Repair of Pediatric Hernias
Repair of most pediatric hernias requires ligation of the true neck of the sac through the internal
ring. The sac should be examined to rule out the presence of a sliding component. This is
especially important in female patients, as it may contain a Fallopian tube or ovary that could
inadvertently be ligated. In such cases, the sac should be freed, its excess removed, and the entire
remaining sac reduced into the abdomen. Since there are no cord structures in female patients,
the internal ring can be closed. Occasionally, in male patients with a very dilated internal ring,
suturing the transversalis fascia at the ring will narrow the ring.
Although they rarely occur, hematoma and infection can complicate repair of pediatric hernias.
Occasionally, an acute recurrence of a hernia occurs because the sac has not been ligated at its
true neck. High dissection and ligation of the sac are essential to prevent recurrence. While initial
repair of pediatric hernia usually remains successful, it is not uncommon for patients in mid or
later life to develop direct recurrent hernias.
In general, prosthetics should not be used in small children. However, hernias in full-grown
teenagers can be safely repaired with mesh. As in all patients, incarcerated or strangulated
hernias in children are true surgical emergencies. A gentle attempt should be made to reduce the
hernia, although this often is unsuccessful. If the incarcerated hernia cannot easily be reduced,
the patient should have surgery promptly. Of special concern with incarcerated hernias in girls is
that the ovary and tube may have a tendency to infarct. In boys, if the hernia is associated with a
undescended testicle, both the hernia repair and the orchidopexy should be done at the same
time, since hernia repair alone will cause scarring and make subsequent orchidopexy difficult to
perform.[40,41]
Authors and Disclosures
Author(s)
Arthur I. Gilbert, MD, FACS
Associate Clinical Professor of Surgery, University of Miami Medical School; Director of
Surgery, Hernia Institute of Florida, Miami, Fla.
Disclosure: Arthur I. Gilbert, MD, FACS, has disclosed that he is a surgical consultant for
Ethicon, Inc. He is President of the Florida Surgical Society and President of theAmerican
Hernia Society.
Michael F. Graham, MD, FACS
Hernia Institute of Florida, Consultant of Ethicon, Inc.
Disclosure: Michael F. Graham, MD, FACS, has disclosed that he holds consulting agreements
with Ethicon, Inc.
Walter J. Voigt, MD, FACS
Hernia Institute of Florida, Consultant of Ethicon, Inc.
Disclosure: Walter J. Voigt, MD, FACS, has disclosed that he holds consulting agreements with
Johnson & Johnson and Prolene Hernia System.
