Pediatric ventral hernia, commonly referred to as pediatric hernia, is a protrusion of intra-abdominal organs or tissues through a weak point, defect, or gap in the abdominal or pelvic wall toward the body surface, where a protruding mass can be seen on the body surface. Inguinal hernia (inguinal hernia) is a common congenital developmental anomaly that can be classified as inguinal hernia or straight hernia. Almost all clinical cases seen are hiatal hernias, and straight hernias are extremely rare.
Incidence
The incidence of inguinal hernia in pediatric patients is 0.8%~4.4%, and the incidence in immature children is 4.8% in the literature. The incidence of inguinal hernia is 0.8%~4.4% in children and 4.8% in immature children.
[Etiology].
During embryonic development, the peritoneum has a pouch-shaped protrusion in the groin, called the peritoneal sphincter, which descends along the testicular lead, a cord that connects the testes in the posterior peritoneum to the bottom of the scrotum. The testis descends with the sheath and reaches the scrotum.
During normal development, the sphincter gradually atrophies and occludes around birth. The peritoneal sphincter attached to the testis is not occluded and forms the intrinsic testicular sheath cavity, which no longer communicates with the peritoneal cavity. In case of abnormal development, the peritoneal sphincter is not occluded, but still remains open or partially open, and the contents of the abdominal cavity enter it under some induced cause, which forms a congenital inguinal hernia. In boys, the right testicle descends more slowly than the left, and the right sphincter is occluded later than the left, so the incidence of right hernia is higher
If the sphincter is partially unoccluded or incompletely occluded, the sphincter becomes a narrow canal, and because the sphincter is small, abdominal organs cannot enter it, but fluid from the abdominal cavity can flow into it, which forms various types of syringomyelia. The cysts that occur in girls are called Nück cysts or round ligament cysts. A hernia does not always form after birth in children with a late closure of the peritoneal sphincter, but is only prompted by an increase in intra-abdominal pressure if it is accompanied by weak development of the abdominal wall muscles, or by frequent crying, prolonged coughing, constipation and difficult defecation, intra-abdominal masses, ascites, etc.
The process of occlusion of the sphincter may continue during the first 6 months of life, and inguinal hernias in children may heal spontaneously during the first 6 months of life, while the chance of occlusion after 6 months of life is extremely low.
[Pathology].
Pediatric inguinal hernia can be divided into two types according to the different occlusion of the peritoneal sphincter and the relationship between the hernia sac and the intrinsic testicular sheath cavity. One type is that the peritoneal sheath is completely unoccluded and the main part of the hernia sac is the intrinsic testicular sheath capsule and part of the spermatic cord sheath, with the testis inside the hernia sac, which is called testicular hernia. The other type is that the middle part of the peritoneal sheath is partially occluded and the spermatic cord is partially unclosed, and the hernia sac stops at the spermatic cord and does not communicate with the intrinsic sheath cavity of the testis, and the testis is not visible inside the hernia, which is called a spermatic cord hernia. Clinically, testicular hernias are less common and have been reported in about 5% of cases and spermatic cord hernias in 95% of cases.
In infants, most of the contents of the hernia are the small intestine; the cecum and appendix can sometimes enter the right hernia sac, and in older children, the greater omentum can sometimes enter the hernia sac. In women, the ovaries and fallopian tubes may be inside the hernia sac, and in a few cases, the cecum (including the appendix), bladder or ovaries form part of the wall of the hernia sac, creating a sliding hernia. However, because the abdominal wall of children is less developed, the tissue of the neck of the hernia sac is weak and elastic, the mesenteric vessels are more elastic, and the inguinal canal is shorter, intestinal necrosis occurs less frequently than in adults in the case of an incarcerated hernia, and most of them can be cured by resetting by manipulation.
Clinical manifestations
The typical symptom is a retractable swelling in the inguinal region, which can appear at the first cry at birth or 2-3 months or later after birth, mostly within 2 years of age. The swelling appears or increases in size when the child cries, stands or exerts effort, with small protrusions located in the external ring and the beginning of the scrotum and large ones descending into the scrotum (female to labia majora). The swelling can be returned to the abdominal cavity by gently pressing the swelling upward with the fingers. Sometimes a “gurgling” sound can be heard during the process of swelling rejection. After repositioning, the end of the finger is pressed against the external ring and the opening of the ring can be palpated and enlarged and relaxed.
In some children with a history of inguinal masses but no masses on examination, a careful local examination should be performed, comparing both inguinal areas, with the affected side being fuller than the contralateral side, and the affected scrotum may also be larger than the contralateral side. In addition, attention should be paid to whether other diseases such as contralateral hiatal hernia, cryptorchidism, spermatic sphincter effusion, and testicular spermatic sphincter effusion are present at the same time.
Diagnosis and differential diagnosis
The diagnosis of inguinal hernia can be made based on the intermittent appearance of a swelling in the groin or scrotum that can be returned into the abdominal cavity. It should be differentiated from the following diseases.
1, syringomyelia The swelling of syringomyelia is located in the scrotum, oval or cylindrical, cystic, with clear borders and positive transillumination test. Traffic syringomyelia is slowly shrinking after manual extrusion. In individual cases, the hernia and syringomyelia coexist, with the proximal end being the hernia sac and the distal end being the testicular or spermatic cord syringomyelia. The mass can disappear after the hernia is repositioned by manipulation, but the sphingomyelomeningocele cannot disappear.
2. Incomplete descent of the testicle The testicle stays in the inguinal canal or the upper part of the scrotum, where a mass may appear, which is substantial, hard, with clear borders, and distension and pain in the lower abdomen when lightly pressed. The scrotum on the affected side is usually hypoplastic and the testicle is not palpable. It may be combined with a hernia.
3. Testicular swelling The swelling in the scrotum is similar to inguinal hernia, and is substantial, heavy, and cannot be returned to the abdominal cavity.
Treatment
Theoretically, inguinal hernia in children has the potential to heal on its own, but most of them do not heal on their own. Currently, surgery is considered the best treatment for inguinal hernia. As a child grows older, the hernia gradually increases in size and can become ingrown and narrowed, so it should be treated early. 1-year-old children with hiatal hernia that does not heal spontaneously, or children with giant or ingrown hernia within 1 year of age should be treated surgically. Before surgery, the existing factors of increased abdominal pressure, such as chronic cough, urinary difficulty and constipation, should be cured.
1.Non-surgical treatment
If the “hernia belt” is not used correctly, it may cause impaction; injection therapy cannot close the hernia sac neck fundamentally, but may cause serious complications such as testicular atrophy, medical cryptorchidism, intestinal adhesion, intestinal necrosis and peritonitis. Therefore, it is considered inappropriate to use them.
Unlike adults, inguinal hernias in infants and children are congenital hernias, which are caused by congenital unclosed peritoneal sphincter and usually do not have local muscle weakness changes.
(1) Transinguinal hernia sac ligation: The child is placed in a supine position and a transverse incision of about 2~3 cm is made in the transversus abdominis of the skin on the affected side of the pubic bone. The skin and subcutaneous tissues are incised and bluntly peeled away to clearly reveal the tendon membrane of the extra-abdominal oblique muscle, the tendon membrane of the extra-abdominal oblique muscle is incised to enter the inguinal canal, the levator muscle is revealed and separated, and the hernia sac can be found in front of the spermatic cord, and the hernia sac is peeled away and separated from the inner ring so that it is completely separated from the surrounding tissues until the extra-peritoneal fat is exposed, and the hernia sac neck is ligated under direct vision at this site. The neck of the hernia sac is cut 0.5 cm from the ligature line, the excess hernia sac is removed, and then the spermatic cord and testis are repositioned and the incision is closed layer by layer. The external ring opening should be tightened if it is too large.
The surgery for girls is basically the same as that for boys. Since the round ligament is closely adherent to the wall of the hernia sac, it can be separated together with the hernia sac to the internal ring and removed together.
(2) Ferguson’s hernia repair For giant hernia with weak abdominal wall, an oblique incision along the inguinal canal is used, after performing high ligation of the hernia sac, the spermatic cord is reset, the joint tendon and the lower edge of the internal oblique abdominal muscle are sutured to the inguinal ligament in front of the spermatic cord, and then the tendon membrane of the external oblique abdominal muscle is sutured to reconstruct the subcutaneous ring, and this method focuses on strengthening the anterior wall of the inguinal canal.
(3) Sliding hernia surgery An intra-abdominal organ that slides downward through the inguinal canal orifice and forms part of the wall of the hernia sac is called a sliding hernia. It is rare in the pediatric population. There are sliding hernia of the cecum and sliding hernia of the fallopian tube. The contents of the hernia cannot be completely returned to the abdominal cavity. The posterior wall of the hernia sac should be cut on both sides of the distal cecum or fallopian tube to the neck of the hernia sac, the sliding organ should be reset, the hernia sac defect should be sutured, and the hernia sac neck should be sutured.
(4) Translaparoscopic hernia repair Laparoscopic high ligation of the hernia sac is performed under general anesthesia and artificial pneumoperitoneum. This procedure takes 10-15 minutes and has the following advantages: it does not destroy the anatomical structure of the inguinal canal, it shows the spermatic vas deferens clearly, it is not easily damaged, it is truly a standard high ligation, it can explore the contralateral side for occult hernias, it can deal with bilateral hernias and recurrent hernias at the same time, it is painless for the child and the hospital stay is short.
Incarcerated inguinal hernia
It is a common complication of pediatric inguinal hernia, which often causes strangulated intestinal obstruction and intestinal necrosis with serious consequences if not treated appropriately in time.
The incidence of incarcerated hernia accounts for 1/6 of all hernia cases, and blood circulation is obstructed when the small intestine enters the hernia sac and is clamped shut. However, the vascular elasticity of the pediatric population makes the progression of intussusception to intestinal necrosis slower, unlike in adults where strangulated necrosis can occur in 4 hours. However, prolonged intussusception can lead to intestinal necrosis. In infants and children, testicular infarction can be complicated by prolonged vascular compression of the spermatic cord, which is about 10%-15%.
Clinical manifestations
When an inguinal hernia is embedded, a painful mass appears in the groin and scrotum. Children show sudden crying, and the obstructive symptoms such as nausea, vomiting, stopping defecation and exhaustion can occur soon. On examination, a swelling in the groin is found to be elevated, hard, with red skin, tenderness, and no impulse when coughing, and the hernia contents cannot be returned to the abdominal cavity. If there is bloody stool with symptoms of poisoning, then there is mostly intestinal strangulation and necrosis.
Diagnosis and differential diagnosis
If there is a painful mass in the groin or scrotum that cannot be reset by itself, the first consideration should be an incarcerated hernia, and the diagnosis is more certain if there is a previous history of inguinal hernia. Since most incarcerated hernias occur in infants and young children, their medical history is often vague and therefore misdiagnosis is not uncommon. The following diseases are clinically confused with an incarcerated hernia.
1. testicular torsion or testicular adnexal torsion It also presents as a painful mass in the groin or scrotum and may be accompanied by gastrointestinal symptoms such as nausea and vomiting, but without progressive abdominal distention. If a testicle of normal size without pain can be palpated under the painful mass on local examination, then testicular or testicular adnexal torsion can be excluded.
2.Cryptorchidism complicated by torsion of spermatic cord Some children have severe pain and reflex vomiting, and a swelling in the inguinal region is found during physical examination, which is easily misdiagnosed as an incarcerated hernia. The testicle is located in the groin and is a substantial mass. The scrotum on the affected side is dysplastic and there is no testicle in the scrotum, which helps to differentiate.
3. Acute inguinal lymphadenitis Early on, the mass is hard with indistinct borders, localized skin redness and swelling, and tenderness in the well, much like a small incarcerated hernia. Individual cases are accompanied by fever, vomiting, and more easily confused with an incarcerated hernia, but without symptoms of intestinal obstruction.
Treatment
Pediatric incarcerated hernia should be treated urgently
For pediatric incarcerated hernia with a duration of about 12 hours, it is usually not urgent to operate, but to try to reset the hernia manually first. If the reset is successful, surgery will be performed after the edema has subsided for 24~48 hours. Contraindications to manual repositioning: (1) the time of incarcerated hernia has exceeded 1~2 hours and strangulation is suspected; (2) failure of manual repositioning; (3) the contents of incarcerated hernia in girls are often ovaries or fallopian tubes, which are mostly not easily repositioned; (4) the time of incarcerated hernia cannot be estimated in newborns; (5) the general condition of the child with incarcerated hernia is very poor, or there are signs of strangulation such as blood in stool.
Methods of manual repositioning
First, give appropriate amount of sedatives or sleeping pills. Make the child sleep quietly, and its abdominal muscles relax naturally. In the supine position with the head down and feet up, the hernia may reset itself within 1~2 hours. For those who cannot reset themselves, the hernia ring can be gently massaged with one hand and the hernia sac can be gently squeezed with the other hand. The hernia can almost always be repositioned within a few hours of onset. The operator can clearly feel the mass sliding into the abdominal cavity and disappearing during the reset. The likelihood of repositioning decreases with the duration of the disease. Do not use violence when performing manual resetting. If there is bloody stool, abdominal distension, abdominal muscle tension, fever or pneumoperitoneum, it indicates that the necrotic intestinal canal is reset, and the abdomen should be immediately dissected for investigation.
2.Surgical treatment The surgical method for incarcerated hernia is basically the same as that for inguinal hernia, and still focuses on high ligation of the hernia sac. During surgery, the operation should be operated carefully, and the anterior wall should be lifted when incising the hernia sac to avoid damaging the intestinal canal, and the contents of the hernia should be gently pressed when cutting the internal ring to prevent the difficulty in finding the return into the abdominal cavity. The hernia sac should be carefully examined for: ① the color of the intestinal canal; ② the tension of the intestinal canal; ③ the peristalsis of the intestinal wall; ④ the pulsation of the mesenteric vessels; ⑤ whether the exudate in the hernia sac is turbid and smelly. If necrosis of the intestinal canal is suspected, 5-10 ml of 0.25% procaine can be used to close the mesenteric root, cover the section with warm saline or put it into the abdominal cavity temporarily, and after 15-20 minutes of observation, if the intestinal canal is red, the mesenteric pulsation and intestinal peristalsis are good, the intestinal canal canal can be returned into the abdominal cavity only after normal vitality is determined. If the intestinal tube is necrotic or cannot be restored after the above treatment, intestinal resection, intestinal anastomosis or fistula should be performed, and after the intestinal tube is incorporated into the abdominal cavity, a high ligation of the hernia sac should be performed. In cases of severe bleeding of the greater omentum, it should be removed, and if the testis is necrotic, it should also be removed. In case of severe local contamination, rubber sheet drainage should be placed, and the drainage should be removed after 24-48 hours.