Inguinal Hernias and Hydroceles

Pediatric Surgery, AlSadik Hospital, Qatif, Saudi Arabia


17.1 Introduction

  • Hippocrates used the Greek hernios for bud or bulge to describe abdominal hernias.

  • Abdominal wall hernias are protrusions of abdominal contents through a defect or weakness in the abdominal wall.

  • Abdominal wall hernias are among the most common of all surgical problems in infants and children.

  • There are several different types of abdominal wall hernias in infants and children including:

    • Inguinal hernia

    • Umbilical hernia

    • Paraumbilical hernia

    • Epigastric hernia

    • Femoral hernia

    • Spigelian hernia

    • Lumbar hernia

    • Incisional hernia

    • Other rare hernias

  • The management of abdominal wall hernias are different and depend on the type of hernia, age of the patient and mode of presentation.

  • All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as inguinal hernia incarceration or strangulation.

17.2 Inguinal Hernia

17.2.1 Incidence

  • The exact incidence of indirect inguinal hernia in infants and children is unknown.

  • The incidence of hernias is about 10–20 per 1,000 live births and is much more common in prematures.

  • Indirect inguinal hernias are more common on the right side and about 60 % of hernias occur on the right side (Figs. 17.1 and 17.2).


    Figs. 17.1 and 17.2
    Clinical photographs showing a large right and left inguinal hernia

  • Premature infants are at increased risk for inguinal hernia, with incidence rates of 2 % in females and 7–30 % in males.

  • Approximately 5 % of all males develop a hernia during their lifetime.

  • Inguinal hernias are much more common in males than in females.

  • The male-to-female ratio is estimated to be 4–8:1.

  • Moreover, the risk of incarceration of inguinal hernia is more than 60 % in prematures.

  • Inguinal hernias:

    • 60 % are on the right side.

    • 30 % are on the left side.

    • 10 % are bilateral (Figs. 17.3 and 17.4)


      Figs. 17.3 and 17.4
      A clinical photograph showing bilateral inguinal hernias

    • Anatomically speaking, indirect and direct inguinal hernias differ in that the direct hernia bulges through the inguinal floor medial to the inferior epigastric vessels and the indirect hernia arises lateral to the inferior epigastric vessels.

    • Inguinal hernia can be complete where the whole sac descends into the scrotum and surrounds the tesis (Scrotal hernia) or incomplete where the hernial sac ends up in the inguinal canal above the testis (Inguinal hernia) (Fig. 17.5).


      Fig. 17.5
      Diagrammatic representation of the classic inguinal hernia and inguinal hernia extending into the scrotum (scrotal hernia)

17.2.2 Etiology

  • Inguinal hernias are congenital.

  • Embryologically, the processus vaginalis is an outpouching of peritoneum attached to the testicle that trails behind as it descends retroperitoneally into the scrotum.

  • Normally, the processus vaginalis obliterates.

  • When obliteration of the processus vaginalis fails to occur, inguinal hernia results.

  • Increased intra-abdominal pressure is seen in a variety of conditions and also contribute to the appearance of inguinal hernia.

  • Elevated intra-abdominal pressure is associated with chronic cough, ascites, increased peritoneal fluid from biliary atresia, peritoneal dialysis or ventriculoperitoneal shunts, intraperitoneal masses or organomegaly, and constipation.

  • Other conditions with increased incidence of inguinal hernias are:

    • Exstrophy of bladder.

    • Neonatal intraventricular hemorrhage.

    • Myelomeningocele.

    • Undescended testes.

  • The following conditions are associated with an increased risk of inguinal hernia:

    • Prematurity and low birth weight.

    • Urologic conditions:

      • Cryptorchidism

      • Hypospadias

      • Epispadias

      • Exstrophy of the bladder

      • Ambiguous genitalia

      • Cloacal exstrophy

    • Patent processus vaginalis, which may be present because of increased intraabdominal pressure due to ventriculoperitoneal shunts, peritoneal dialysis, or ascites

    • Abdominal wall defects

      • Gastroschisis

      • Omphalocele

    • Family history

    • Meconium peritonitis

    • Cystic fibrosis

    • Connective tissue disease

    • Mucopolysaccharidosis

    • Congenital dislocation of the hip

    • Ehlers-Danlos syndrome

    • Marfan syndrome

    • Fetal hydrops

    • Liver disease with ascites

    • Ventriculoperitoneal shunting for hydrocephalus

17.2.3 Clinical Features

  • The parents of infants and children with an inguinal hernia present with the history of a swelling that is commonly intermittent, in the inguino-scrotal region in boys and inguino-labial region in girls.

  • The swelling commonly occurs after crying or straining.

  • Sometimes, they present with an obvious swelling at the inguinal region or sometimes within the scrotum in boys (Fig. 17.6).


    Fig. 17.6
    A clinical photograph showing an incarcerated right inguinal hernia. Note also the left hydrocele

  • The hernia may be bilateral (Figs. 17.7 and 17.8)


    Figs. 17.7 and 17.8
    Clinical photographs showing bilateral incarcerated inguinal hernia

  • The swelling is painless and reducible in a simple inguinal hernia.

  • The presence of a painful swelling suggests an incarcerated inguinal hernia.

  • Patients with an incarcerated hernia generally present with a tender firm mass in the inguinal canal or scrotum that is irreducible.

  • Silk sign: When the hernia sac is palpated over the cord structures, the sensation may be similar to that of rubbing two layers of silk together.

  • This finding is known as the silk sign and is highly suggestive of an inguinal hernia.

17.2.4 Variants of Hernia

  1. 1.

    Indirect inguinal hernia:

    • Indirect inguinal hernias occur when the abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels.

    • It is caused by failure of embryonic closure of the processus vaginalis.


  2. 2.

    Direct inguinal hernia:

    • This type of inguinal hernia, enters through a weak point in the transversalis fascia of the abdominal wall, and its sac is noted to be medial to the inferior epigastric vessels.

    • Direct inguinal hernias may occur in males or females, but males are ten times more likely to get a direct inguinal hernia.

    • These hernias are capable of exiting via the superficial inguinal ring but, unlike indirect inguinal hernias, they cannot descend into the scrotum.


  3. 3.

    Littre’s hernia (Fig. 17.9):


    Fig. 17.9
    Diagrammatic representation of a Littre’ hernia

    • A Littre’s hernia is a hernia containing a Meckel’s diverticulum.

    • Littre’s hernia was first described by the French surgeon Alexis Littré in 1700.

    • He described three cases from cadaverous studies of incarcerated femoral hernias containing a diverticulum of the small bowel.


  4. 4.

    Sliding inguinal hernia:
Jul 10, 2017 | Posted by in UROLOGY | Comments Off on Inguinal Hernias and Hydroceles

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