CONGENITAL HERNIA AND HYDROCELE

congenital hernia

2. Congenital Inguinal HerniaCongenital Inguinal Hernia

Indirect Inguinal Hernia Indirect Inguinal Hernia

Continued patency of the Processus Continued patency of the Processus
Vaginalis Vaginalis

Patent PV sac is potential Patent PV sac is potential
hernia/hydrocoelehernia/hydrocoele

In hernia the sac is wider & contains an In hernia the sac is wider & contains an
intraabdominal structureintraabdominal structure

In hydrocoele the sac is narrow & contains In hydrocoele the sac is narrow & contains
only peritoneal fluidonly peritoneal fluid

3. Processus VaginalisProcessus Vaginalis . . . . . .

PV develops during12th wk of gestation PV develops during12th wk of gestation

Out pouching of the peritoneal cavity through the Out pouching of the peritoneal cavity through the
internal ringinternal ring

PV plays an integral role in the descent of testesPV plays an integral role in the descent of testes

PV obliterates spontaneously from the deep ring to the PV obliterates spontaneously from the deep ring to the
testistestis

possible role of CGRP in fusion of PVpossible role of CGRP in fusion of PV

Distal portion persists as tunica vaginalisDistal portion persists as tunica vaginalis

4. At birth PV is patent in up to 80% infants.At birth PV is patent in up to 80% infants.

6. IncidenceIncidence

0.8 – 4 %0.8 – 4 %

Highest in 1st year of lifeHighest in 1st year of life

Incidence in premature infants 16 – 25%Incidence in premature infants 16 – 25%

M:F is 6:1M:F is 6:1

Right 60%, Left 30%, Bilateral 10%Right 60%, Left 30%, Bilateral 10%

7. Factors contributing to development of Factors contributing to development of
herniahernia

Undescended testisUndescended testis

Increased peritoneal fluid :Increased peritoneal fluid :
Ascites, VP shuntAscites, VP shunt

Increased abdominal pressure :Increased abdominal pressure :
Severe ascites, Meconium peritonitis,Severe ascites, Meconium peritonitis,
post repair of Exomphalos / CDHpost repair of Exomphalos / CDH

Chronic respiratory disease :Chronic respiratory disease :
Cystic fibrosisCystic fibrosis

Connective tissue disorders:Connective tissue disorders:
Ehlers –Danlos, Marfans, MucopolysaccharidosisEhlers –Danlos, Marfans, Mucopolysaccharidosis

8. Clinical FeaturesClinical Features

Bulge in inguinal area extending towards / into Bulge in inguinal area extending towards / into
scrotum with crying / straining scrotum with crying / straining

may be present at birth or appear latermay be present at birth or appear later

reduces in size when the child is relaxed / asleepreduces in size when the child is relaxed / asleep

smooth soft-firm mass that emerges from the smooth soft-firm mass that emerges from the
external ring lateral and above pubic tubercle, external ring lateral and above pubic tubercle,
enlarges with increased abdominal pressureenlarges with increased abdominal pressure

9. 
Can be reduced with gentle pressure, may Can be reduced with gentle pressure, may
reduce with gurgling noisereduce with gurgling noise

Examine position of testis – undescended / Examine position of testis – undescended /
retractileretractile

Reappears on crying / valsalva (blowing a Reappears on crying / valsalva (blowing a
balloon / coughing ) preferably while balloon / coughing ) preferably while
standingstanding

Thickening & silkiness on palpating the cord Thickening & silkiness on palpating the cord
as it crosses pubic tubercle – as it crosses pubic tubercle – Silk Glove Silk Glove
signsign

If in doubt re-evaluate at second visitIf in doubt re-evaluate at second visit

10. ManagementManagement

Inguinal hernia does not resolve Inguinal hernia does not resolve
spontaneouslyspontaneously

Must be operated because of high risk Must be operated because of high risk
of incarcerationof incarceration

Operation : Operation :
HerniotomyHerniotomy - High suture ligation of the - High suture ligation of the
sac at the internal ringsac at the internal ring

Open technique / LaparoscopyOpen technique / Laparoscopy

11. Technique Technique

Anaesthesia:Anaesthesia:
In infants – ETGAIn infants – ETGA
Older children – facial or laryngeal maskOlder children – facial or laryngeal mask

Transverse groin skin crease incision Transverse groin skin crease incision

Open layersOpen layers

Incision in external oblique aponeurosis Incision in external oblique aponeurosis
lateral to external ring lateral to external ring

13. 
Fibres of cremasteric fascia are separatedFibres of cremasteric fascia are separated

Shiny glistening white hernial sac identified & Shiny glistening white hernial sac identified &
lifted with blunt forcepslifted with blunt forceps

In males the sac lies anterior & medial to vas In males the sac lies anterior & medial to vas
& vessels& vessels


Vas & vessels are never held with forceps, Vas & vessels are never held with forceps,
dissected off the sac with overlying areolar dissected off the sac with overlying areolar
tissuetissue

15. 
In females there are no significant structures other In females there are no significant structures other
than round ligament of uterusthan round ligament of uterus

Ensure there are no contents in the sac, divide Ensure there are no contents in the sac, divide
between clampsbetween clamps

Dissect proximally upto neck of the sacDissect proximally upto neck of the sac

Twist the proximal sac & transfix the neck at the level Twist the proximal sac & transfix the neck at the level
of deep ringof deep ring

Traction on the testis to return it to the scrotumTraction on the testis to return it to the scrotum

Closure in layers Closure in layers

16. Contralateral explorationContralateral exploration
Selected contralateral exploration:Selected contralateral exploration:

Age:Age: 40% contralateral hernias occur after unilateral surgery in 40% contralateral hernias occur after unilateral surgery in
children under 1 yrchildren under 1 yr

Side of hernia:Side of hernia: Left Left

Sex:Sex: Female Female

Patency of PV sac on opposite side:Patency of PV sac on opposite side: Herniography, Herniography,
intraoperative pnuemoperitoneum, Choledochoscope / intraoperative pnuemoperitoneum, Choledochoscope /
laparoscopelaparoscope

Conditions predisposing to hernia on the opposite side:Conditions predisposing to hernia on the opposite side:
VP Shunt, connective tissue disordersVP Shunt, connective tissue disorders

Poor risk for GAPoor risk for GA

17. Irreducible HerniaIrreducible Hernia
Incarcerated hernia: contents cannot be Incarcerated hernia: contents cannot be
easily reduced into peritoneal cavityeasily reduced into peritoneal cavity

Irritability, pain in the groin / abdomen, Irritability, pain in the groin / abdomen,
vomitingvomiting

Tense, tender, non fluctuant mass in the Tense, tender, non fluctuant mass in the
groin, may extend into scrotum, not groin, may extend into scrotum, not
transilluminanttransilluminant

Bilious vomiting, abdominal distension Bilious vomiting, abdominal distension
indicates obstruction of bowelindicates obstruction of bowel

18. Strangulated hernia: Tightly constricted at Strangulated hernia: Tightly constricted at
the neck resulting in ischemia of the neck resulting in ischemia of
contents.contents.

Pain intensifies, vomiting becomes bilious. Pain intensifies, vomiting becomes bilious.
Blood in stoolsBlood in stools

Mass is tender, edema & reddening of Mass is tender, edema & reddening of
overlying skin, feveroverlying skin, fever

19. Management:Management:

Non operative:Non operative: only when there is no only when there is no
e/o ischemiae/o ischemia

Under sedation & analgesia reduce the Under sedation & analgesia reduce the
hernia by gentle compressionhernia by gentle compression

Elective herniotomy after 48 hrs by Elective herniotomy after 48 hrs by
which time there is less edemawhich time there is less edema

20. 
Operative:Operative: When hernia cannot be When hernia cannot be
reduced or hernia is strangulatedreduced or hernia is strangulated

Hernial sac opened. Look for viability of Hernial sac opened. Look for viability of
bowelbowel

Deep ring can be enlarged by incising the Deep ring can be enlarged by incising the
arching fibres of conjoint tendon superiorlyarching fibres of conjoint tendon superiorly

Tell tale e/o ischemia – bloody or foul Tell tale e/o ischemia – bloody or foul
smelling fluid in the sac. Explore the smelling fluid in the sac. Explore the
abdomen abdomen

21. Complications of herniotomyComplications of herniotomy

Ascending / trapped testisAscending / trapped testis

Recurrence – 0.8%Recurrence – 0.8%

Injury to vasInjury to vas

Testicular atrophyTesticular atrophy

22. Congenital HydrocoeleCongenital Hydrocoele

Usually noted in early infancy, can occur at Usually noted in early infancy, can occur at
anytimeanytime

Often bilateralOften bilateral

Soft, bluish, fluctuant swelling surrounding the Soft, bluish, fluctuant swelling surrounding the
testistestis

Fluctuate in size: smaller at night when the Fluctuate in size: smaller at night when the
child is relaxedchild is relaxed

23. 
Neck of the hydrocoele narrows at the external Neck of the hydrocoele narrows at the external
ring & usually does not extend into the inguinal ring & usually does not extend into the inguinal
canalcanal

Hallmark: Brilliant transilluminationHallmark: Brilliant transillumination

In most children with congenital hydrocoele the In most children with congenital hydrocoele the
PV sac closes and hydrocoele resolves PV sac closes and hydrocoele resolves
between 12 – 24 monthsbetween 12 – 24 months

There is no e/o hydrocoele will evolve into There is no e/o hydrocoele will evolve into
herniahernia

25. ManagementManagement

Observation for first 2 years unless large, Observation for first 2 years unless large,
painfulpainful

Herniotomy if it persists > 2 yrsHerniotomy if it persists > 2 yrs