Pediatric hernias and hydroceles

Hernias and hydroceles are common conditions of infancy and childhood, and inguinal hernia repair is one of the most frequently performed pediatric surgical operations. As a result of improved neonatal intensive care, more and more premature babies are being delivered, and consequently the incidence of neonatal inguinal hernia is increasing. The most important aspect of the management of neonatal inguinal hernias relate to its risk on incarceration, and emphasis is placed on this point. This article covers the embryology, incidence, clinical presentation, and treatment of groin hernias and hydroceles, as well as dealing with abdominal wall hernias other than umbilical hernias. This article places special emphasis on when a patient with a hernia or hydrocele should be referred to a pediatric surgeon.     

Strength and functional recovery following repair of flexor digitorum superficialis in zone 2

Since 1989 we have performed 21 endoscopic hernia repairs in 19 female patients. One recurrent hernia occurred 3 months after laparoscopic preperitoneal patch repair using a single layer of resorbable mesh. Hernioscopy was developed as the transcutaneous endoscopic CO2-gas dissection and subsequent inspection of the preperitoneal hernial sac. Hernioscopic stuffing of the preperitoneal hernial sac using resorbable patch material was performed in seven direct inguinal hernias and in one femoral hernia. Postoperative pain was minimal and convalescence was short. No recurrent hernia occurred during a 1-9-month follow-up.     

B-Myb, a repressed trans-activating protein

From April 1990 to November 1996, 313 inguinal and 14 femoral hernias were repaired in 295 subjects with a mean age of 74 years (66 to 97). Concomitant diseases increasing the operative risk were present in 206 subjects (70 per cent). A mesh repair was performed with "tension-free" or "plug" techniques in all but 23 inguinal and 2 femoral herniorrhaphies where the Bassini or the Shouldice procedures were adopted. Fifty-two inguinal hernias were recurrent, 11 emergency herniorrhaphies were performed for strangulation. Almost all operations (305), including 9 emergency herniorrhaphies, were carried out under local anaesthesia. There was no perioperative mortality. Acute intestinal bleeding occurred after surgery in a subject with colon diverticulosis. One urinary retention following emergency hernia repair under general anaesthesia and 2 following elective hernia repair under local anaesthesia in 2 subjects with hypertrophy of the prostate were observed. Some episodes of hypotension and/or bradycardia were observed either during or after surgery. Local complications following inguinal hernioplasty were 5 (1.5%) scrotal hematomas, 3 (0.9%) wound infections and 1 case (0.4%) of orchitis with atrophy after repair of a recurrent hernia. There were 1 recurrence after Bassini, 1 after Shouldice, and 1 (0.4%) after mesh inguinal hernioplasty. Using local anaesthesia and a mesh repair elective surgery of inguinal and femoral hernias can be safely and effectively performed in elderly patients. Consequently, early elective surgery should be recommended to avoid the risk of an emergency operation.     

Musculo-aponeurotic flap in the treatment of inguinal hernias, apropos of 1,600 operations

Morbidity, absention and duration of cares are important factors for the treatment of groin hernias. Deep and tension free cure is a key element to decrease the rate of recurrence. Utilization of prosthesis cannot provide a rate of 100%. This must be taken into consideration for indications. Beside we must take into account specific risks of each technique. Hernia treatment cannot be unique. This parietal surgery must remain a technique with low morbidity. As for treatment of unilateral hernia, we have qualified a technique of hernioplastia depending upon theses criteria, by inguinal incision, without prosthesis. Our technique includes: A complete dissection of the inguinal canal. The resection of the sac of the hernia at the internal ring. A deep cure of the fascia transversalis. A systematic incision of discharge on the anterior face of the rectus sheath. This incision is extremely internal and constitutes a large musculo-aponeurotic flap of 8 to 12 cm that makes this cure tension free possible. In the term of 10 years, our recurrence rate is below 1% for type I or II hernias in Nyhus classification. Consequently we discuss the indications for prosthesis. They must be reserved for hernias with high recurrence risk, bilateral hernias of for recurrent hernias.     

Longitudinal follow-up of blood lymphocyte subpopulations from birth to 1 year of age

The features of the rare interstitial hernia, as seen in four children, are described. All were boys ranging in age from 7 days to 7 years. The presenting sign was swelling in the right side of the abdomen associated with undescended testis. The hernias arose at the deep inguinal ring and expanded superiorly between the internal and external oblique muscles. Repair involved a standard herniotomy and orchidopexy through an oblique inguinal incision-except in one patient with a vanishing testis. The importance of being aware of this rare type of hernia is stressed.     

Femoral hernia: the dire consequences of a missed diagnosis

Femoral hernia has always presented more difficulty in diagnosis than other external abdominal hernias. The incidence of incarceration and strangulation is higher in our series than the published literature would suggest. A retrospective study was performed at our institution from February 1990 to June 1995. In that period, 22 patients were operated on for femoral hernia. There were 16 women and 6 men, average ages 51 and 48 years, respectively. The men weighed on average 209 lb, and the women, 154 lb. Three of our patients had elective repair of their hernias (16%); 19 were performed urgently or emergently (86%). Of the emergency repairs, 3 had strangulated small bowel requiring resection (16%), 1 had a strangulated vermiform appendix with abscess formation (5%), 3 had strangulated omentum requiring excision (16%), giving a total of 7 patients with strangulation and necrosis of the hernial contents (36%). The remainder had viable contents in the hernia sac. The time from the onset of symptoms to presentation at the hospital varied from 1 day to 3 years. The time from strangulation to presentation was between a few hours and 4 days. Surgery was performed on the day of admission (within 24 hours) on all but 2 of our patients. Procedures performed were McVay repair, 13; Bassini, 4; laparoscopic with Marlex mesh, 1 patient; drainage of a groin abscess in 2 patients with later repair; and on 2 patients the type of repair was not specified. One of the patients died. Postoperative wound infection occurred in 2 heavily contaminated patients, and 3 had pneumonia. Patients with no regular physician and no routine physical examinations are at higher risk for developing strangulation of femoral hernias. Emergency physicians and general practitioners are in the best position to diagnose these hernias early, when treatment can be elective.     

The features of contralateral manifestations after the repair of unilateral inguinal hernia

BACKGROUND/PURPOSE: Routine contralateral exploration in infants and children with unilateral clinical inguinal hernia is performed by many surgeons in a selected population of patients based on a presumed high incidence of patent processus vaginalis. Our purpose is to report the actual incidence of contralateral manifestations in infants and children after the repair of unilateral inguinal hernia. METHODS: From July 1985 through December 1995, 1,052 infants and children with unilateral inguinal hernia or hydrocele were treated in our hospital without contralateral exploration. Among them, 1,001 patients (95.2%) were followed up for 1 to 11 years to determine if contralateral hernia developed after unilateral inguinal herniorrhaphy. RESULTS: The overall incidence of contralateral hernia was 11.6% (116 of 1,001). In boys, the incidence was 13.1%, 13.7%, and 11.7% in those under 1 year, under 2 years of age, and in total, respectively. In girls, the incidence was 9.6%, 13.9%, 11.3%, in those under 1 year, under 5 years of age, and in total, respectively. The side of the initial repair did not influence the subsequent development of contralateral inguinal hernia. In children with hydrocele, the incidence of contralateral hernias was lower (7.6%). In girls with sliding hernias the contralateral occurrence was 12.5%. CONCLUSION: Given this low incidence of contralateral hernia after unilateral inguinal herniorrhaphy, the authors do not recommend contralateral exploration for infants and children with unilateral inguinal hernia.     

Laparoscopic evaluation for a contralateral patent processus vaginalis: part III

OBJECTIVES: Between May 1, 1992 and August 1, 1996, 759 consecutive children younger than 10 years of age were evaluated and treated for known inguinal hernia. These children were participating in a prospective investigation of the potential role of diagnostic laparoscopy in the evaluation of the contralateral inguinal anatomy. The initial two series of data (parts I and II of this three-part series) were previously presented at the 1993 and 1995 American Academy of Pediatrics meetings. METHODS: Of 759 patients, 100 children were diagnosed with bilateral inguinal hernias and therefore did not undergo laparoscopy. Thirty-two patients did not undergo laparoscopic evaluation due to technical difficulties or complicated clinical situations. The patient's contralateral inguinal region was carefully examined under anesthesia, and predictions were made regarding the likelihood of contralateral patent processus vaginalis (CPPV). Six hundred twenty-seven children underwent diagnostic laparoscopy to confirm the presence or absence of CPPV. Laparoscopy was initially exclusively performed through the umbilicus prior to repair of the known hernia, but over the last 26 months, 250 children successfully underwent laparoscopy through the ipsilateral hernia sac. RESULTS: Of patients younger than 1 year of age, 114 were diagnosed with both a known unilateral hernia and CPPV, whereas 132 had a unilateral hernia only (46% versus 54%). Among children older than 1 year of age, 148 (39%) were diagnosed with unilateral hernia and CPPV, and 233 (61%) were diagnosed with a unilateral hernia alone. After examination under anesthesia, 233 of the 627 patients were suspected of having a CPPV, and 107 were confirmed at laparoscopy (46%). The remaining 394 patients were not believed to have a CPPV. Normal inguinal anatomy was confirmed in 234 patients (59%), but 160 patients were found at laparoscopy to have a CPPV (41%). CONCLUSIONS: A contralateral patent processus vaginalis may be present in a surprising number of young patients being evaluated for a known inguinal hernia. Laparoscopy can be performed without a separate incision when the ipsilateral hernia sac is of sufficient width to allow passage of the scope. Laparoscopy is the best method for evaluating the contralateral inguinal region, particularly in younger children, as it prevents unnecessary inguinal exploration and it decreases the risk that the child will later present with a clinical contralateral hernia.     

Routine bilateral exploration for inguinal hernia in infancy and childhood

Whether to explore the contralateral side is a real question regarding the management of unilateral inguinal hernias in infants and children. The surgeon can easier make a decision if he knows the true incidence and prevalence of the bilateral involvement in different ages. During the years 1982 to 1991 the authors could find 138 contralateral hernias developed after unilateral herniorrhaphy in 2554 children (5.4%). Fifty-five percent of these children (76 patients) were younger than 1 year of age, 74% of them (102 patients) were younger than 3 years of age at the time of the initial repair. The interval between the operations was less than 1 year in 54% of the cases. To get more precise data, we explored 148 children younger than 3 years of age bilaterally during 1992. The result was positive in 104 cases (70.3%). The bilateral involvement was most frequent under the first 6 months of life (83.5%), then it dropped gradually. We found a patent processus vaginalis on the asymptomatic side in 74.3% of girls and in 61.1% of boys. The overall contralateral involvement of unilateral hernias was 64.8%, independently of which side the hernia had appeared on. The patent processus vaginalis can be regarded as a precursor of indirect hernias, so the contralateral exploration can prevent the development of a later hernia. The authors conclude that bilateral exploration is mainly justified during infancy, but in case of girls they suggested applying it until three years of age.     

Ultrasonography for inguinal hernias in boys

BACKGROUND/PURPOSE: History taking and physical examination alone no longer meet the surgeon's need in the diagnosis of inguinal hernia. Ultrasonography (US) provides a good and safe diagnostic tool for inguinal hernias in boys. METHODS: From 1995 to 1997, 244 boys with inguinal hernias (41 bilateral and 203 unilateral), received preoperative US on both groins to confirm the diagnosis. Those with positive US findings, such as viscera or fluid in inguinal canal or widening of the internal inguinal ring, underwent surgery. RESULTS: The accuracy of diagnosis with US and clinical assessment were 97.9% and 84%, respectively. More than 95% of widening of internal inguinal rings (>4 mm) proved to be hernias. There were two direct inguinal hernias and two femoral hernias, which were misdiagnosed by clinical examination, but proved to be diagnosed correctly by US. CONCLUSIONS: US serves as a noninvasive and highly accurate diagnostic tool for inguinal hernias in boys. Using 4 mm as the upper limit of the normal diameter of the internal inguinal ring, an occult inguinal hernia can be easily detected before surgery.     

Classification systems for groin hernias

All groin hernia classifications are somewhat arbitrary and artificial. Currently, there is no consensus among either general surgeons or hernia specialists as to a preferred system. A survey by Zollinger in 1998 of hernia specialists in North American and Europe showed, that although the Nyhus, Gilbert, and Schumpelick-Arit systems were commonly used, the majority of these specialists still used the traditional classification for groin hernias. It is apparent that only the traditional classification of groin hernias has stood the test of time. As stated by Fitzgibbons, "the primary purpose of a classification system for any disease is to stratify for severity so that reasonable comparisons can be made between various treatment strategies." Given the multiplicity of operative techniques and approaches for the repair of groin hernias, it appears that no one classification system can satisfy all. With time, it is likely that we surgeons will settle upon a given operation for a specific type of inguinal hernia. For that given operation to be accepted as proven best, however, it is essential the competing operations be applied to simliar (classified) groups of groin hernia patients.     

Laparoscopic herniorrhaphy in girls

BACKGROUND/PURPOSE: Laparoscopy has been used to evaluate the contralateral side in inguinal hernias. Once a hernia was identified in such procedures, laparoscopy was terminated and a conventional groin exploration was undertaken. This study presents a purely laparoscopic approach using miniature instruments without the use of a groin incision. METHODS: The technique was applied in 14 girls (median age, 6.5 years). The laparoscope was inserted via the umbilicus. Two 1.7- or 2-mm instruments were advanced (without a trocar) trough the abdominal wall for intraabdominal suturing of the open inguinal rings by the placement of two to three Z-sutures. RESULTS: With this procedure the diagnosis is easy, although the placing of miniature suturing needs practice. When there is doubt about an inguinal ring during laparoscopy, an open processus vaginalis also can be sutured using the same approach. There were no recurrences or complications. The longest follow-up period is 1 year. CONCLUSIONS: A purely laparoscopic approach using miniature instruments combines diagnosis and immediate treatment without the need for conversion to another technique. There is rapid recovery and excellent cosmetic results.     

Lichtenstein inguinal hernia repair in a primary healthcare setting

BACKGROUND: Given the generally accepted poor outcome of inguinal hernia repair when using nylon darn, and the recent interest in low-tension mesh repair, an attempt was made to demonstrate the feasibility, outcome and patient perception of providing Lichtenstein inguinal hernia repair, using local anaesthesia, wholly within the primary healthcare sector. METHODS: A prospective study reviewed clinical outcome and patient perception in 100 adults referred with inguinal hernia only. No selection was made regarding age, sex, American Society of Anesthesiologists status or previous repairs. Recurrence, pain, infection, return to full function and associated complications were assessed at 24 h, 1 and 6 weeks, and 1 year. Local Community Health Councils assessed patient perception. RESULTS: In the first 100 patients (age range 21-83 (mean(s.d.) 60(14.7)) years; 58 of employable age; 92 men; ten recurrent hernias), no recurrences have occurred at 1 year. Infection rate was 3 per cent. Pain was maximal in the first 24-48 h (median visual analogue scale 5, range 0-10) and reduced rapidly (median 1) at 1 week. Mean time to return to work or full normal activity was 8 days. Some 85 operations were performed within 1 month of diagnosis. In all, 86 patients returned the patient satisfaction questionnaire and 98 per cent of these were 'very pleased' with the service. CONCLUSION: In highly motivated primary healthcare centres, inguinal hernia repair can be undertaken effectively, providing high patient satisfaction, minimal complications and low recurrence rates using the Lichtenstein technique.     

Surgical treatment of postop abdominal hernia in elderly and geriatric patients

The results were summarized on surgical treatment of 56 patients, ageing 60-85 years, for femoral hernia using two methods--according to Bassini and original one stipulated for femoral ring strengthening using implant made of poliuretane in hernial sac tunic fixed without tension to inguinal and public ligaments. Recurrence of hernia in the late follow-up period have occurred in 13.6% of patients operated on according to Bassini and was never observed after operation performed using original method.     

When and how we perform surgery for inguinal hernia in children

In the course of 15 years in the authors department 4,694 operations of inguinal hernias and hydrocele were performed in children at the age of 0-15 years. Most frequently children aged 2-5 years were involved (45%). There were 4.5 times more boys than girls and the lateral distribution was also consistent with data in the literature. A relapse of hernia occurred in 33 children (i.e. 0.7%) operated in the authors department and in 19 children originally operated elsewhere. The total percentage of relapses in the group is 1.1%. In 25 children factors were identified which predispose for relapses. Relapses were most frequent in children operated before the age of one year (52%). The authors recommend therefore that operations of these children should be entrusted to a paediatric surgeon.     

Transitional cell neoplasm of the bladder in childhood: presentation of a clinical case

The authors report their experience with the use of loco-regional anaesthesia for the surgical treatment of inguinal and femoral hernias. Their series includes 1730 operations, 235 of which for hernia relapses, performed exclusively in the outpatient department. In the authors opinion, with loco-regional anaesthesia it is possible to treat any type of inguinal-femoral hernia, reducing the risks related to total anaesthesia and the complications arising from bedrid. Excellent results were achieved especially in the elderly and high risk patients like cardiopathic or those affected by respiratory and hepatorenal insufficiency with a complete absence of mortality and morbidity.     

Organization and results of ambulatory surgery for inguinal hernia]

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.     

The use of Mersilene mesh in adult inguinal and femoral hernia repairs: a comparison with classic techniques

A retrospective review of both mesh classic inguinal hernia repairs performed under the guidance of a single surgeon showed that Mersilene mesh is safe to use and that the recurrence rate is significantly improved by using the mesh for repair. Mersilene mesh is easier to use than other types of mesh and should be used routinely in the repair of inguinal and femoral hernias.     

Classification systems and groin hernias

The once simple division of groin hernias into indirect and direct inguinal and femoral components is no longer adequate to reflect a more sophisticated understanding of the pathophysiology and management of these lesions. Similarly, the availability of a concise, easy-to-use, logical, and recognizable classification scheme would facilitate a better understanding of modern repair techniques and confirmation of operative results.