Pediatric Hernias

“Hernias, hernias
everywhere - what to
do about them?”
Colin D. Gause, MD
Pediatric Surgery
Providence Health & Services
Conflicts of interest
• Planning Committee & Faculty Disclosure: The Planning
Committee and Faculty have no relevant financial
relationships with commercial interests to disclose.
Goals/Questions
• What are the types of pediatric hernias, and how common
are each?
• Which pediatric hernias should be referred and when?
• What the concerns with each type of hernia?
• How are pediatric hernias repaired?
• What are long-term concerns and expectations?
Inguinal Hernia
• History
• Greek, Hellenistic (323-31 BC)
terracotta figures1
• Treatment radical excision2,3
• Ramses V (1156-1152 BC),
mummy with hernia sac4
• 900 BC: Phoenician statue with
tight fitting bandages
Inguinal Hernia
• Galen (200 AD)5 & Paul of Aegina (700 AD)6 described IH
as well
• Paul recommended ligature of the hernia sac with
amputation of the testicle7; regression in treatment
• Albucasis (1013-1106 AD) removed testicle during hernia
surgery8
• William of Salicet (1210-1277 AD) rejected removal of
testicle. Described reduction in Trendelenburg9
Inguinal Hernia
• Ambroise Pare included an entire chapter on hernias in
The Apologie and Treatise. Described hernia reduction and
closure of peritoneum. Strongly recommended against
castration10
• Kaspar Stromayr distinguished between direct and indirect
hernias (1559 AD)
• Hasselbech describes eponymous triangle and iliopubic
tract (1814 AD)
Inguinal Hernia
• 1870/1871: Lister introduces antiseptic surgery
• 1876: Czerny describes high ligation of the sac
• 1881: Lucas-Championniere splits the external oblique
and imbricates the hernia floor
• 1896: Halsted introduces gloves
• Mortality remains high, 2-7%; and recurrence near 100%
• Bassini sutures transversus abdominus and external
oblique to inguinal ligament11-13
Inguinal Hernia
• Background
• Most common elective pediatric surgical procedure
• Right 2x > Left
• More common in premature infants
• Associated with undescended testicle, abdominal wall
defect, connective tissue disease
• Failure of obliteration of processus vaginalis (testicle,
round ligament)
Inguinal Hernia
• Direct inguinal hernia bulges through
floor medial to inferior epigastric
vessels, while indirect hernia bulges
lateral to inferior epigastric vessels
Inguinal Hernia
• Presentation
• Asymptomatic or asymptomatic groin swelling that may
extend to scrotum or labia
• Crying or straining makes more prominent
• Fortunately, most are asymptomatic
• Rarely, present with incarceration, obstruction or
strangulation
Inguinal Hernia
• Examination Tips!
• Stand on contralateral side, palpating along
inguinal canal at external ring
• Valsalva maneuvers (coughing, sit-ups)
• Although subtle, a thickened cord (silk glove
sign) suggests presence of hernia sac
• Examine for undescended testicles (UDT)
• Home pictures at end of day
Inguinal Hernia
• Diagnosis
• Physical examination is nearly always all that is
needed
• US if cannot distinguish between hernia and hydrocele, or
in rare cases, lymph node
• Transillumination!
Inguinal Hernia
• Incarcerated hernias cannot be reduced. More common
in infants.
• Almost always be reduced with proper technique
• Straightening canal, constant, directed pressure
• Trendelenburg position, pain medication and
sedation can help
• If reduced, should be repaired semi-urgently/electively
• If failed reduction, immediate surgery
Inguinal Hernia
• Surgery
• Do NOT heal spontaneously
• Must be repaired due to risk of incarceration (17%
right, 7% left)
• Elective repair – 11% ED visit by 30 days after dx (ED
utilization, HC resources, parental concern)
• 50% of incarcerations in first 6 months of life, 2/3 in
children <1 year
Inguinal Hernia
• If asymptomatic, parents do not need to reduce hernia, but
should be educated on how to do so, and counseled
on signs/symptoms of incarceration
Inguinal Hernia
• Timing (AAP Section on Surgery)
• NICU: 63% repair before discharge, 18% at specific
corrected age, 5% when convenient
• Outpatient: 53% repair when convenient, 27% wait until
between 38-60 cGA (mean 53.1 weeks)
• Risk of apnea in premature babies
• 5% at 48 weeks cGA, 1% at 54 weeks cGA
• Need 12-24 (preferred) inpatient monitoring earlier
Inguinal Hernia
• Operative repair
• Open
• High ligation of hernia sac
• Consider reconstruction of inguinal floor, Bassini repair
if weakened
Inguinal Hernia
• Operative repair
• Laparoscopic
• High ligation of hernia sac
without excision
• Modern studies suggest similar
hernia recurrence as with open
repair
Inguinal Hernia
• Complications
• Testicular atrophy (1-2%), vas deferens injury (<2%),
wound infection (<1%), recurrence (1-5%)

• Follow-up
• 1 office, phone or televisit
• 6 months, examine testicles for iatrogenic UDT which
would require orchiopexy
Umbilical Hernia
• Background
• Common
• Gender ratio equal
• May be more common in African-
Americans
• Increased in Beckwith-Wiedemann
syndrome, trisomies 13, 18 and 21
Umbilical Hernia
• Presentation
• Asymptomatic bulge that increases with valsalva
• Symptoms are rare
• Obstruction is extremely rare/nearly non-existent
• No medical treatment (binders/taping are historical interest
only)
Umbilical Hernia
• Surgery
• Smaller (<1 cm) more likely to close than >1.5 cm
• No large population studies
• Most close at 4-5 years of age, 85-90%
• Theory that transition from abdominal wall to
diaphragmatic breathing at this age may contribute
• Symptomatic repair at time of diagnosis
• Should repair, will enlarge, risk of complications
Umbilical Hernia
• Operative repair
• Curvilinear incision below umbilicus
or vertical through umbilicus
• Separation of hernia sac from
umbilical skin
• Fascia closed with interrupted
absorbable sutures
Umbilical Hernia
• Complications
• Bleeding, infection and recurrence are rare, all ~2%
• Injury to viscera during repair is very rare

• Follow-up
• Routine follow-up is offered but not essential
• Telephone/televisit is reasonable
Epigastric Hernia
• Background
• Hernia through midline/linea alba,
between xiphoid and umbilicus
• Small mass, usually with
incarcerated preperitoneal fat
• Different than diastasis recti
Epigastric Hernia
• Presentation
• More often symptomatic, with intermittent pain
• Midline, epigastric bulge
• May be adjacent to umbilicus and thus difficult to
distinguish from umbilical hernia
• Congenital, defect in anterior fascia; only preperitoneal
fat. Very rarely full thickness, thus almost never
incarcerated viscera
Epigastric Hernia
• Surgery
• Should be repaired because they do not resolve

• Operative repair
• Mark beforehand! Hard to find when anesthetized
• If concern for umbilical hernia as well, supraumbilical
curvilinear incision permits repair of both
• Preperitoneal fat excised or reduced, hernia closed
Epigastric Hernia
• Complications
• Bleeding, infection rare
• Recurrence very rare

• Follow-up
• Routine follow-up is offered but not essential
• Telephone/televisit is reasonable
Spigelian Hernia
• Background
• Defect at junction of rectus
abdominus and aponeurosis of the
internal oblique at the linea
semiluminaris
• Inferior to arcuate line, where there
is no posterior sheath
• Associated with skeletal anomalies
Spigelian Hernia
• Presentation
• Pain or a bulge at the lateral
border of the rectus muscle,
beneath the umbilicus
• Because the defect is posterior
sheath, a bulge may not be
obvious, even with incarceration
• US or CT can be very useful
Spigelian Hernia
• Surgery
• Should be repaired because they do not resolve, can
become incarcerated

• Operative repair
• Transverse incision over defect with excision of sac and
closure of defect
• Mesh may be needed in larger defects
Lumbar Hernia
• Background
• Congenital, very rare

• Presentation
• Bulge in area bordered by 12th rib,
sacrospinalis muscle, internal oblique
• Typically contain preperitoneal fat
• Soft mass
Lumbar Hernia
• Surgery
• Advised because will not resolve and incarceration is
theoretically possible

• Operative repair
• Primary closure. Prosthetic mesh may be needed because
the tissue is often weak or absent when adjacent to bone
• Absorbable mesh in children, decrease risk of scoliosis
Diaphragmatic Hernia
• History
• First language description in 1754 by
McCauley
Diaphragmatic Hernia
• 1827: Cooper; 1834: Laennec both describe CDH
• Bochdalek (1801-1883) speculates hernia results from
rupture of membrane separating the pleuroperitoneal
cavity into 2 cavities
• 1888: Naumann; 1890: O’Dwyer make first efforts to repair
• 1901: Aue, first successful repair in adult
• 1905: Heidenhaim, first successful repair in child
• Hedblom’s review shows that 75% of 44 infants died
Diaphragmatic Hernia
• 1940: Ladd and Gross show consistent, successful repair
(9/16 patients)
Diagphragmatic Hernia
• Background
• Incidence around 1/200
• True incidence likely underestimated due to
spontaneous or elective abortion
• 1/3 die as stillbirth, often with other severe anomalies
• 80% left sided
• 90% posterolateral “Bochdalek”; 10% anterior
“Morgagni”
Diagphragmatic Hernia
• Background
• Cardiopulmonary disease
• Pulmonary hypoplasia, with underdeveloped airways,
decreased lung weight, decreased number of
bronchioles and overall bronchiole cross-sectional
area, alveolar count and volume
• Pulmonary vascularization is abnormal, with resulting
pulmonary hypertension
Diagphragmatic Hernia
• Diagnosis
• Prenatal US, most can be seen in 2nd trimester
• Polyhydramnios, bowel within chest, MS shift
• Lung:head ratio (LHR) predicts survival
• LHR >1.35 100%; 1.35-0.5, 61%; <0.6, no survival
• LHR should be calculated as observed/expected as
the normal ratio changes during gestation
• Fetal MRI great for morphologic, volumetric measurements
Diagphragmatic Hernia
• Presentation
• Respiratory distress is typical
• Tachypnea, chest wall
retractions, grunting, cyanosis,
pallor
• Scaphoid abdomen
• CXR confirms bowel within chest
Diagphragmatic Hernia
• Management
• Endotracheal intubation, severe cases (some intubate all)
• Orogastric decompression
• Aggressive resuscitation, targeting preductal SaO2 85-
95% (cerebral!) with permissive hypercapnea to maintain
low PIP
• ECMO may be needed. CDH accounts for 25% of all
infants needing ECMO
Diagphragmatic Hernia
• Surgery
• Historically performed emergently
• We now understand that the defect itself is not the issue,
but the resulting pulmonary hypoplasia and pHTN.
Immediate procedures prior to stabilization can
exacerbate pHTN and hypoxemia beyond medical
correction, resulting in death
Diagphragmatic Hernia
• Operative repair
• Open or minimally invasive from either abdomen or chest
• Patch may be needed for larger defects
Late-Presenting Diagphragmatic Hernia
• Most often discovered due to non-specific GI or
respiratory symptoms prompting work-up
• Complications rare, prognosis favorable
• Symptomatic should be repaired immediately
• Asymptomatic, most would repair electively – some would
not repair if small and no digestive tract herniation
• Small, right sided defects can avoid repair entirely if covered
by liver, especially in high-risk patients
Take Home Points
• Inguinal hernia
• Common. Should be repaired due to the risk of
incarceration
• Outpatient repair should be delayed until 54-60 weeks cGA
due to anesthetic risks
• Open and laparoscopic repairs have similar recurrence
• Follow-up should focus on testicle location and
characteristics in boys
Take Home Points
• Umbilical hernia
• Do not need to be repaired until age 4-5 in the absence of
symptoms due to the high rate of spontaneous closure.
• Incarceration is very rare.
• Epigastric hernia
• Should be repaired because they do not resolve and are
often symptomatic
Take Home Points
• Spigelian hernia
• Very rare
• Found lateral to rectus muscles and below umbilicus
• Most present with symptoms at some point, and should be
repaired
• Lumbar hernia
• Very rare
• Should be repaired due to risk of incarceration
Take Home Points
• Diaphragmatic hernia
• Diagnosed prenatally with US and MRI
• LHR predicts survival
• Morbidity and mortality related to pulmonary hypoplasia
and pulmonary hypertension
• Repair in neonatal period when diagnosed
• Timing of repair of late-presenting CDH should be
individualized base on symptoms, risk, and size
Questions?
• Phone number: 503-216-6050
• Fax: 971-282-0102
• Epic code for internal referrals: St. Vincent - REF84BB;
Clackamas - REF84H