Pediatric inguinal hernia
Pediatric inguinal hernia (indirect inguinal hernia) is a congenital condition that develops in the neonatal period due to failure to occlude the peritoneal sphincter during the descent of the testis during the embryonic period, and is more common in males, with the right side being 2 to 3 times more common than the left side, while bilateral cases are rare.
Disease overview
Oblique inguinal hernia (OIH) is one of the most common surgical disorders in pediatric patients.
Symptoms and signs
1. Typical symptoms are smooth, neat, slightly elastic, reversible swelling in the groin and (or) scrotum. When the child cries, stands, coughs or uses force to increase intra-abdominal pressure, the swelling appears or increases in size and has an inflated sensation of impact, which gradually shrinks to completely disappear after lying down. Fingers can also be used to gently press the swelling from the bottom upward to assist the swelling to return into the abdominal cavity. The sound of air passing over water can sometimes be heard during repositioning. After repositioning, the finger end is pressed into the outer ring, causing the child to cough, which is an impulsive sensation, and the swelling often reappears after the finger end leaves. On careful local examination, the inguinal region on the affected side is fuller than the contralateral side, the spermatic cord is thicker than the healthy side, and the scrotum is larger than the contralateral side.
2. Irreducible inguinal hernia can be clinically characterized by two conditions.
(1) simple irreducible hernia: that is, the hernia contents cannot be returned into the abdominal cavity, but there are no symptoms of intestinal obstruction. (1) Simple irreducible hernia: the hernia contents cannot be returned to the abdominal cavity without symptoms of intestinal obstruction. The hernia swelling is painless, elastic, and characterized by a sensation of impulsivity when coughing.
(2) Incarcerated hernia: i.e. the hernia contents cannot be returned and there are symptoms of intestinal obstruction or intestinal strangulation, and the swelling is painful with tenderness, hardness, and no impulse when coughing. In case of necrosis of strangulated intestine, there are symptoms of systemic toxicity, increase in body temperature and pulse rate, blood in stool in a few patients, and local redness, swelling, heat and pain in the hernia. If the embedded or strangulated organ is not the intestine but the omentum or ovary, the symptoms of intestinal obstruction may not appear, but there is localized pressure pain in the hernia.
Diagnostic tests
Laboratory tests: general symptoms and routine tests are normal, but if the disease is complicated by systemic toxicity, there may be infectious blood, significant increase in white blood cells, or even thrombocytopenia.
Other auxiliary examinations: B-ultrasound examination can be done to clarify the nature of the mass in the groin, and transillumination test and X-ray examination can be done to help diagnosis and differential diagnosis.
Diagnosis: There is no difficulty in the diagnosis of typical hiatal hernia with return phenomenon or history of return. In cases of non-return or partial retraction, the first step is to differentiate it from testicular syringomyelia, and the main method of differentiation is the reliable transillumination test. The transillumination test is performed by shining a flashlight bulb directly on the swelling, and if all the ovoid swelling is red and bright, it is a syringomyelia. If only the area touched by the bulb is red, the test is negative. In small infants with diagnostic difficulties, the first step is to perform an anal examination and try to find if there is a herniated intestine in the inguinal ring. If necessary, a tangential x-ray of the inguinal mass can be taken and a transparent x-ray of a pneumatized sac can be diagnosed as a hernia. Blind puncture tests are contraindicated.
The diagnosis of an incarcerated hernia is mostly uneventful. The diagnosis can be confirmed by the sudden failure of the hernia to return, immediate abdominal pain, crying, localized pressure pain, and frequent vomiting in the child. However, in children with advanced abdominal distension such as pediatric pneumonia or infantile diarrhea, functional intestinal obstruction symptoms such as vomiting and constipation can also occur suddenly, which can prevent the simultaneous hernia from retracting due to increased abdominal pressure, but in fact there is no incarcerated hernia, which must be differentiated. If an incorrect diagnosis of an incarcerated hernia is made and surgery is performed, it will add unnecessary surgical and anesthetic damage to the critically ill child and often aggravate the condition. Conversely, an incarcerated hernia may actually occur due to severe abdominal distension and high abdominal pressure, which can often delay treatment if the diagnosis is not made. The diagnosis of an incarcerated hernia should rely on systemic symptoms and symptoms of intestinal obstruction, but should also pay attention to local pressure pain, hardness, impulsive sensation and the time procedure of the appearance of each symptom for differentiation. In the late stage of strangulated hernia, children with severe toxicity, local redness, swelling and heat pain sometimes need to be differentiated from inguinal lymphadenitis, and a detailed history and clear symptoms of intestinal obstruction are often the key to diagnosis.
Treatment options
The etiology of pediatric hiatal hernia is mainly due to unclosed or incomplete atresia of the peritoneal sphincter and increased abdominal pressure, which can be cured with proper treatment of the hernia sac. The hernia may increase in size with age and may become entrapped or strangulated, so early surgical treatment is indicated.
In newborns and infants under 6 months of age, the hernia sac is thin and the anatomical relationship is unclear, so surgery is prone to hernia sac tearing and spermatic cord injury, and most people believe that if there is no recurrent entrapment, the age of surgery is more appropriate between 6 months and 6 years. If not treated, it may affect the child’s ability to participate in sports activities and may be detrimental to mental and physical development.
Newborns and small infants with incarcerated hernia should be operated immediately because they are often combined with torsion or compression of the spermatic cord, resulting in testicular necrosis. In larger infants and young children, if the incarcerated hernia lasts less than 12 hours, the general condition is good, the local hernia is not too tense and elastic, and the scrotum is not red or swollen, sedative drugs such as chloral hydrate, enema, and elevation of the buttocks can be used to try to reset the hernia manually, and the hernia can mostly be retracted. After repositioning of an incarcerated hernia, surgical treatment should be performed after 2-3 days, except for conditions that are not suitable for surgery. The hernia belt is not suitable for use in pediatric patients, as it can often compress the skin and there is a risk of subglottic herniation.
Prevention and prognosis
Prognosis: Generally, reversible hernias do not affect the growth and development of the child, and small hernias in infants less than 6 months of age may heal spontaneously. Uncomplicated hernias generally have no morbidity or mortality. If the hernia does not heal spontaneously or is left untreated, it gradually increases in size, hinders the movement of the child, and has the potential to become entrapped at any time, with the younger the child, the higher the rate of entrapment and the greater the risk.
Prevention: There are no definite preventive measures.
Precautions
There is no specific prevention method for this disease, early detection and early treatment.