Inguinal hernias in children are mostly congenital hiatal hernias. The prevalence of inguinal hernia in children has been reported to be the first of all birth defects in children, and inguinal hernia repair in children is the most common procedure performed in pediatric surgery. Globally, the prevalence of inguinal hernias in children ranges from 0.8% to 4.4% in different age groups and can reach 30% in premature infants.
Causes of morbidity
In early embryonic life, the peritoneum protrudes outward at the internal inguinal ring, forming the peritoneal sheath. Under normal circumstances, the sphincter wraps around most of the testis and descends with the testis under the traction of the testis, eventually reaching the base of the scrotum. After birth, the sphincter gradually atrophies and becomes occluded. If an obstruction occurs during this process, the sphincter canal remains open and once an abdominal organ enters, an inguinal hernia is formed. This disease can develop at any age, especially in infants and children. In boys, the right testicle descends later, so inguinal hernias occur more often on the right side than on the left, and rarely bilaterally. The inguinal hernia can also occur in girls with unclosed sphincter, but significantly less than in boys, with a male to female incidence of approximately 15:1. The most common hernia contents are the small intestine and ileocecal region, and in older children, the greater omentum, while in girls, herniation of the genital appendages is more common. The occurrence of inguinal hernias in children is the result of a combination of congenital (genetic) and acquired (environmental) factors.
Diagnosis and differential diagnosis
Like adult inguinal hernias, inguinal hernias in children are characterized by a “reducible” mass in the inguinal region. When the abdominal pressure increases (e.g., standing, jumping, crying, coughing, constipation, etc.), a mass may appear in the inguinal region; it may disappear after lying down. Since children under 2 years of age cannot express their symptoms accurately, the possibility of inguinal hernia should be considered when the child is crying continuously and no cause can be found. Inguinal hernia in children should be differentiated from the following diseases: spermatic syringomyelia, testicular syringomyelia, traffic syringomyelia, cryptorchidism, etc.
Treatment
1. Non-surgical treatment, i.e. hernia belt therapy: some children within 1 year of age still have the possibility of self-closing of the peritoneal sphincter and can be treated with hernia belt or cotton gauze girdle to compress the inguinal area. This method is simple, non-invasive and suitable for children without recurrent inguinal hernias, but requires a specialist to determine the location of the internal ring opening. This treatment can be continued until the child is about 1 year old, and if the symptoms do not disappear, the child is no longer likely to heal spontaneously and should be treated surgically. Children over the age of half a year who have had recurrent inguinal hernias should also receive surgery as soon as possible to avoid risks.
2. Surgery: Children with no possibility of self-healing or recurrent ingrown hernia and children with large hernia sacs should be treated surgically. It is recommended that surgery be performed in a qualified medical unit. The timing of surgery is usually chosen after the age of 1 year, and surgery should be performed in time if intussusception occurs frequently, while older children should be actively operated.
At present, the following surgical methods are commonly used in clinical practice.
1.Traditional open hernia sac high ligation surgery
Pediatric inguinal hernia is caused by congenital non-closure of the peritoneal sphincter and therefore can be treated by high ligation of the hernia sac alone. The traditional surgical method involves incision of the extra-abdominal oblique tendon membrane, separation of the hernia sac to reach the hernia sac neck and high ligation of the hernia sac when extra-peritoneal fat is seen, and the child usually needs to be bedridden for 3-5 days.
2.Minimally invasive laparoscopic hernia sac ligation
Along with the development of minimally invasive surgical techniques, laparoscopic surgery has now been applied to the treatment of pediatric inguinal hernia. Laparoscopic high ligation of the hernia sac does not require dissection of the inguinal canal and stripping of the spermatic cord tissue, thus effectively avoiding the trauma and corresponding complications caused by the traditional surgical route, and because of its advantages such as intraoperative detection of contralateral occult hernia, small and aesthetic incision, mild postoperative pain, minimal trauma, no need for bed rest, and wide indications for surgery (treatment of hiatal hernia, recurrent hernia, incarcerated hernia, and straight hernia have been reported), it has been more widely used in It has been more widely used in clinical practice. Currently, in our hernia surgery department, this procedure is used in children under 6 years of age.
Modern “individualized” treatment of inguinal hernia in children
Although inguinal hernia is a common disease in children with similar symptoms and a large number of children, in fact, the condition of each child is different, so only one or two methods of treatment for inguinal hernia is far from enough. Based on years of clinical experience, our department has developed a set of “individualized” clinical protocols for the treatment of inguinal hernia in children and has achieved satisfactory results. For children’s hernia under 6 years old, we adopt laparoscopic high ligation of hernia sac, which is less traumatic, faster recovery, lower recurrence rate after surgery, and no obvious incision scar, and can achieve minimally invasive cosmetic effect. For children aged 7 to 18 years, the size of the hernia needs to be treated on a case-by-case basis. For children with a small hernia sac, laparoscopic high ligation of the hernia sac is still an option if the hernia ring defect is not large, while for children with a large hernia sac, simple high ligation of the hernia sac is not effective and the recurrence rate is high. Therefore, the posterior wall of the inguinal canal should be repaired and reinforced after high ligation of the hernia sac, and a new absorbable biopatch is currently used in our hernia surgery department for open surgical repair of these children.
Advantages of surgical treatment of inguinal hernia in children during the summer
The biggest advantage of surgical treatment for children during the summer is that it does not delay the child’s study time and allows for adequate rest and recovery after surgery, and after a holiday break, the child can start normal studies and sports after school.
The general procedure of inguinal hernia surgery for children and several points to note
1. 1-2 weeks before surgery, the child should avoid symptoms of cold, cough and fever.
2. The child can visit the hernia surgery clinic and basically be hospitalized and undergo preoperative examination on the same day, and can be operated on the next day (except holidays).
3. The cost of minimally invasive laparoscopic hernia sac ligation for children is about RMB 3500-4000.
4.The surgery is performed under intravenous general anesthesia and takes about 10-15 minutes. No urinary catheter is needed before the surgery and no drip is needed after the surgery.
5. One week, one month and three months after surgery, children should avoid excessive crying and strenuous activities.