Abdominal hernias

• Abdominal wall hernias


  • Inguinal hernias
  • Hydrocoele
  • Umbilical hernias
  • Femoral hernias
• Inguinal hernias


  When obliteration of processus vaginalis fails - inguinal hernia results
• Embryology of inguinal hernias

  1. Processus vaginalis: Outpouching of peritoneum attached to testicle / round ligament in girls

  2. Trails behind as it descends retroperitoneally into scrotum / labium majora

  3. When obliteration of processus vaginalis fails - inguinal hernia results
• Inguinal hernias


  • Always indirect inguinal hernias
• Incidence: 2 - 5% in male children, 0.2% in female children
• Prognosis after operation of uncomplicated hernia

  Very good
• An incarcerated or strangulated hernia can lead to severe morbidity or even death
• Importance of early operation
• Processus vaginalis


  Not obliterated
• Clinical picture of inguinal hernia


  • History: intermittent visible swelling in the inguino-scrotal region in boys, inguino-labial region in girls
  • Swelling: after crying or straining, resolves while the baby is sleeping
  • Examination: Palpable swelling, can be reduced
• Treatment of uncomplicated inguinal hernia


  1. Book on elective list

  2. When you make the diagnosis, give date for operation
• Uncomplicated inguinal hernias never close spontaneously, operation always needed
• Operation for inguinal hernia


  1. Cord structures separated from hernial sac

  2. Hernial sac is clamped, transsected and ligated

  3. Inguinal incision in the region of external meatus

  4. Mobilise hernial sac

  5. Reconstruction of the inguinal canal as in adults - rarely necessary in children
• Incarcerated inguinal hernia


  The bowel become swollen, oedematous, engorged and trapped outside the abdominal cavity
• Incarceration is common cause of bowel obstruction in babies and children
• Clinical picture of incarcerated hernia

  • History of a painful swelling in the inguinal region
  • Examination: Tender firm mass in the inguinal canal or scrotum, child may be fussy, unwilling to feed, and crying, overlying skin may be oedematous, erythematous, and discoloured
  • Signs of bowel obstruction
• Treatment of incarcerated hernia

  1. Attempt of reduction should be made, if successful, it will convert an emergency into an elective situation: Sedate the child and then put it in Trendelenburg position on the mother's lap

  2. If this procedure is not successful within 2 hours, the child should be referred for emergency surgery
• Strangulated inguinal hernia


  Entrapment becomes so severe as to compromise blood supply of bowel
• It is not always easy to differentiate between incarceration and strangulation
• Treatment of strangulated hernia

  1. Resuscitate: Drip, nasogastric tube

  2. Refer for emergency operation, Pain meds

  3. Operation: Inguinal incision as for elective uncomplicated hernia, Hernial sac opened, bowel evaluated, If necrotic bowel - Resection and primary anastomosis
• Hydrocele


  Painless, non-reducible swelling of the scrotum or inguino-scrotal region
• Sonar might be very helpful in differentiating a hydrocele from a hernia
• Transillumination does not help: Fluid filled bowel also transilluminates!
• Hydroceles


  Often congenital, can close spontaneously
• Treatment of hydrocele


  Expectant treatment is warranted if the hydrocele persists beyond age 1 to 2y, Operative resection indicated
• Umbilical hernias


  Majority does not cause any problems, does not cause abdominal pain
• Most common reason for chronic abdominal pain in preschool children?
• Management of umbilical hernias


  1. Many regress: defect closes spontaneously by age of 5 years

  2. Operation indicated if: Hernia has not closed by the age of 5y, In the rare event of incarceration of contents: worms, stones in child with pica, Meckel's diverticulum, Very large defect (> 2cm): will not close
• Femoral hernias


  Rare in children (around 0.2%), often missed on physical examination because femoral region below inguinal ligament is not examined, High risk for incarceration / strangulation
• Treatment of femoral hernias


  Must be treated aggressively: Surgery ASAP even if not incarcerated / strangulated