Inguinal Hernia and Hydrocele in Infants and Children

Symposium on Pediatric Surgery

Inguinal Hernia and Hydrocele in Infants and Children Marc I. Rowe, M.D., * and Michael B. Marchildon, M.D.t

Although inguinal hernia repair is one of the most common operations performed in the pediatric age group, even the most experienced pediatric surgeon is almost daily confronted by difficult decisions concerning management of the infant and child with an inguinal hernia. As we reviewed the literature we became convinced that most articles championed a particular point of view. It occurred to us that it might be valuable to question senior pediatric surgeons whose individual experience with inguinal hernias numbered in the thousands and find how they handled some of the common problems associated with inguinal hernias. Six broad areas were covered: (1) diagnosis, (2) surgical technique, (3) hydrocele, (4) the contralateral side of a clinically apparent inguinal hernia, (5) incarceration, and (6) inguinal hernia in the premature baby. We chose 40 senior pediatric surgeons and by telephone or personal interview discussed 48 different questions. All the surgeons had Certificates of Special Competence in Pediatric Surgery of the American Board of Surgery and were members of the American Pediatric Surgical Association. Many were on the faculty or chiefs of approved training programs in pediatric surgery. Sixty per cent had full-time university positions; 40 per cent were in private practice exclusively. The average years of clinical practice was 17, with a total of 680 physician years of pediatric surgical practice.

DIAGNOSIS OF INGUINAL HERNIA

A common and frustrating problem faced by all pediatric surgeons is the course to follow when an excellent history of an inguinal hernia is obtained, but the physician is unable to demonstrate the pathology during an office visit. 1. If a parent describes an inguinal hernia perfectly but you are unable to demonstrate it in your office, what do you do? (a) Schedule the child for operation, 45% (b) See the patient in the office for a second visit, 55%

*Professor of Pediatric Surgery, University of Pittsburgh School of Medicine; Surgeon-in-Chief, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania tAssistant Professor of Pediatric Surgery, University of Miami School of Medicine, Miami, Florida

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2. If a pediatrician is the one who diagnoses the hernia but you are unable to demonstrate it, what do you do? (a) Schedule for operation, 65% (b) See patient in the office, 35%

Comment. Many surgeons rely on the history of the mother if they think she is conscientious and intelligent. Many said that they would accept the pediatrician's diagnosis and operate if the pediatrician is well known to the surgeon and his or her judgment can be trusted. Ten per cent of the surgeons questioned replied that a good history but inability to demonstrate a hernia by physical examination was an indication for a herniagram. 3. If there is a clear history but you are unable to demonstrate a bulge by routine examination, what special procedures do you employ to make the diagnosis? (a) Almost all surgeons ask older children to strain or cough, most feel that it is helpful to examine the child standing as well as lying down. In order to increase intraabdominal pressure in a baby, the surgeon frequently stimulates the baby to bring on crying. (b) Thirteen per cent of the surgeons have the child blow up a balloon in order to increase intra-abdominal pressure. (c) One surgeon asks the mother to observe the child at home. When she sees a bulge, she is instructed to photograph it with a Polaroid camera, "since every home in 1981 has a Polaroid camera." (d) One surgeon believes that reexamination of the child after voiding is helpful.

SURGICAL TECHNIQUE 1. What technique do you use for skin closure? (a) Subcuticular, 100%

2. What sutures do you use for skin closure? (a) (b) (c) (d)

Catgut, 20% Polyglactin acid, 50% Silk or cotton, 15% Plastic sutures, 15%

3. What is your routine preoperative skin preparation? (a) Povidone iodine, 75% (b) Povidone iodine and alcohol, 27% (c) Alcohol, 3%

4. Do you do more than a high ligation of the sac in a repair of an average size inguinal hernia? (a) No, 80% (b) Yes, 20%

Comment. Most of the surgeons who perform more than a high ligation utilize a Ferguson repair, simultaneously bringing down the external oblique fascia and internal oblique muscle to Pouport's ligament. Others tighten the internal ring by placement of one or two silk sutures.

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5. Do you routinely cut the external oblique fascia in boys? (a) Yes, 92% (b) No, 8%

Comment. The 8 per cent who do not cut the external ring perform the entire dissection of the cord and sac through the external ring. Fifty-four per cent of the entire group cut the external oblique fascia through the external ring, and 38 per cent cut the external oblique fascia up to, but not including, the external ring. 6. In the boy with a large scrotal sac, do you remove the entire distal portion of the sac? (a) No, 100%

Comment. All the surgeons questioned would leave the distal sac in place and open. Some would trim the portion that is easily accessible. 7. Do you routinely open the hernial sac before ligation in a boy? (a) No, 95% (b) Yes, 5%

8. Do you routinely open the hernial sac in a girl? (a) Yes, 60% (b) No, 40%

Comment. The difference in approach between the male and the female paient is explained by most surgeons by the possible presence in the female of a liding hernia. They want to be sure that the fallopian tube is completely reduced before they ligate and excise the sac to avoid injury. 9. In the repair of an inguinal hernia in a girl, do you close the internal ring? (a) Yes, 30% (b) No, 70%

10. In the repair ofan inguinal hernia in a girl, do you close the external ring? (a) Yes, 50% (b) No, 50%

11. How do you manage a sliding hernia in a girl that contains either the allopian tube or the ovary? (a) Invert the sac by a pursestring suture, then close the internal ring, 65% (b) Dissect the structures off the sac, reduce them into the peritoneal cavity, and perform a high ligation of the sac, 20% (c) Create a flap by incising the sac on either side of the tube, turn the flap into the peritoneal cavity, and close the open sac with a pursestring suture (Potts-Goldstein operation), 15%

12. In a girl with a bilateral inguinal hernia, do you look inside the peritoneal avity for a gonad or other female organs to rule out intersex problems? (a) No, 75% (b) Yes, 25%

Comment. Two surgeons routinely perform rectal examinations to check for he presence of a uterus. 13. If, in the course of an inguinal hernia repair, you find a mobile testicle that

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comes up into the groin wound during the dissection of the cord and sac, do you fix the testicle within the scrotum at the completion of the operation? (a) No, 50% (b) Yes, 50%

Comment. Half of the surgeons who fix the testicle pass a suture through the testicle and scrotal skin and secure the suture over a button or dental roll. The remainder place the testicle in a dartos' pouch. 14. Will you perform a circumcision during a routine inguinal hernia repair? (a) Yes, 85% (b) No, 15%

15. Would you perform an umbilical hernia repair during the course of an inguinal hernia repair? (a) Yes, 85% (b) No, 15%

16. Do you do more than a high ligation of the sac during the repair of a large inguinal hernia? (a) Yes, 30% (b) No, 70%

17.' Do you do more than a high ligation in a patient who has a ventriculoperitoneal shunt and an inguinal hernia? (a) Yes, 65% (b) No, 35%

Comment. In both instances, most of the surgeons who do more than a high ligation would either tighten the internal ring or do some type of formal inguinal hernia repair. 18. How do you handle a recurrent indirect inguinal hernia? (a) High ligation only, 85% (b) Formal inguinal hernia repair, 15%

Comment. The vast majority of surgeons said that an indirect recurrence was due to a technical error in ligation of the sac or to missing the sac at the initial procedure. Therefore, they believed that only a high ligation rather than an extensive musculofascial repair was warranted.

HYDROCELES 1. At what age do you operate on a hydrocele? (a) (b) (c) (d)

Under 6 months, 5% Six to 12 months, 30% Over 12 months, 40% Other, 25%

Comment. Five per cent of the surgeons who did not operate on hydroceles at any age believe that they frequently will not recur following a simple aspiration.

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Many surgeons said that if the hydrocele is very large or freely communicated, it should be operated on at any age. 2. How do you handle the hydrocele sac? (a) High ligation of the patent processus and partial excision or incision of the sac, 95% (b) Bottle procedure, 5%

3. Do you explore the contralateral side after operating on a unilateral hydrocele? (a) No, 57% (b) Yes, 43%

4. Do you believe that a hydrocele can develop into an inguinal hernia? 70% yes

{(a) (b) (c) (d) (e)

Yes, personally have observed this, 8% Yes, a hydrocele is a hernia by definition, 18% Yes, 45% No, 23% Don't know, 7%

Comment. There was a good deal of discussion about this question. Some surgeons said that it was a matter of semantics, since they believe that almost all pediatric hydroceles are communicating and therefore by definition are hernias. Three surgeons reported that they had personally seen patients with hydroceles and no clinically apparent hernias later develop incarcerated inguinal hernias.

THE OPPOSITE SIDE A good deal of controversy still rages about the value of exploring the side opposite a clinically apparent inguinal hernia. In a survey of frequently cited articles on pediatric inguinal hernias from 1960 to 1981, we found that 39 per cent of the papers discussed the contralateral side. Even more surprising was the fact that in recent years, 22 per cent of the articles on inguinal hernias dealt with the use of herniagrams. We thought that it would be of particular interest to discuss this problem with experienced surgeons to find out what they actually did in practice. 1. In a boy with a clinically apparent unilateral inguinal hernia, do you explore the other side? (a) Yes, 80% (b) No, 20%

2. In a girl? (a) Yes, 90% (b) No, 10%

3. Is the side of the clinically apparent hernia a factor in your decision? (a) No, 90% (b) Yes, 10%

Comment. Some surgeons stated that if there were a left-sided inguinal hernia, the right side should be explored. 4. If you routinely explore the opposite side, is age a factor? (a) Yes, 100%

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5. Up to what age do you routinely explore the contralateral side of the clinically apparent hernia? (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k)

Up Up Up Up Up Up Up Up Up Up Up

to 3 months, 3% to 6 month, 7% to 2 years, 310/0 to 3 years, 7% to 4 years, 7% to 5 years, 100/0 to 6 years, 3% to 7 years, 7% to 10 years, 7% to 12 years, 3% to 15 years, 14%

Comment. This question had the widest spectrum of responses in the entire survey. Although most surgeons agreed that they would explore the opposite side regardless of the sex of the patient or the side of the clinically apparent hernia, they differed greatly on what age they would stop exploring the opposite side. We were unable to determine the reason for the particular age group chosen. Forty-three per cent of the respondents will explore only up to two years; the other 57 per cent varied up to the adolescent age group. 6. Do you utilize any technique to check for a contralateral patent processus vaginalis during repair of a clinically apparent inguinal hernia? (a) No, 920/0 (b) Yes, 8%

Comment. Two surgeons passed a DeBakey dilator through the open hernia sac of the opposite groin and one injected air into the peritoneum through the hernia sac. 7. Do you use herniagrams? (a) (b) (c) (d)

Never, 78% Just a few times, 14% Occasionally, 50/0 Routinely, 3%

Comment. Twenty-two per cent of the surgeons have used herniagrams some time in their practice, but only 3 per cent use them routinely. Those that use the procedure believe that is is safe and accurate when performed by an experienced radiologist. Some surgeons volunteered that they utilized herniagrams in the past frequently, but because of complications and inaccurate readings they have abandoned the procedure.

INCARCERATION 1. Do you attempt to reduce an incarcerated inguinal hernia in a clinically stable patient without signs of peritoneal irritation? (a) Yes, 100%

2. Do you use sedation to aid in non-operative reduction? (a) Yes, 75% (b) No, 25%

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3. Do you use elevation? (a) Yes, 55% (b) No, 45%

4. Do you use ice over the hernia mass? (a) Yes, 18% (b) No, 82%

5. Do you attempt to reduce the hernia by gentle manual manipulation? (a) Yes, 95% (b) No, 5%

6. Do you think that a rectal examination is helpful in differentiating an incarcerated inguinal hernia from such conditions as a hydrocele of the cord? (a) Yes, 52% (b) No, 40% (c) Unsure, 8%

7. Is the total time that the hernia has been incarcerated an important factor in your decision of whether to attempt nonoperative reduction of an incarcerated inguinal hernia? (a) No, 80% (b) Yes, 20%

Comment. Most surgeons said that the history of time of incarceration was unreliable and more weight should be placed on physical findings, such as abnormal vital signs, erythema of the groin, or signs of peritoneal irritation. 8. Would you attempt a non operative reduction if a child has abdominal distention and x-ray evidence of intestinal obstruction but no signs of peritonitis? (a) Yes, 75% (b) No, 25%

9. Do you explore the opposite side during an operation on a stable patient without bowel compromise who has had an irreducible inguinal hernia? (a) No, 70% (b) Yes, 30%

10. During operation for an incarcerated inguinal hernia, if the testicle appears to be infarcted, what do you do? (a) Remove the testicle, 8% (b) Leave the testicle in place, 92%

Comment. Most surgeons will leave the testicle in place after performing a capsulotomy. A few said that they would consider re-exploration of the testicle after 48 hours. 11. If an apparently irreducible inguinal hernia reduces once the child has been anesthetized, but before the incision is made, what do you do? (a) Proceed to repair the hernia, 95% (b) Cancel the operation, 5%

12. If the incarcerated bowel slips back into the peritoneal cavity before the sac is opened and the bowel inspected, what do you do?

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(a) Repair the hernia without attempting to visualize the bowel, 82% (b) Attempt to identify the bowel through the open hernia sac, 18%

13. If the gangrenous segment of the bowel is discovered during the course of an operation for incarcerated inguinal hernia, should it be resected through the hernia sac? (a) Yes, 50% (b) No, 50%

Comment. Half of the surgeons felt that a separate incision should be made in the right lower quadrant or that the hernia wound should be extended and the peritoneal cavity entered by cutting through the muscles above the inguinal canal. 14. If you reduce an incarcerated inguinal hernia in the emergency room, do you always admit the patient to the hospital? (a) Yes, 65% (b) No, 35%

15. After nonoperative reduction of an incarcerated inguinal hernia, when do you schedule repair? (a) Next day, 50% (b) Within three days, 42% (c) When convenient, 8%

PREMATURITY There is an increased incidence of inguinal hernias in premature infants. With the higher survival rates of low birth weight babies, many pediatric surgeons now are called in consultation concerning the timing of hernia repair in hospitalized premature babies. 1. When would you schedule operation for a three-week-old infant weighing 1500 gm who has completely recovered from hyaline membrane disease and has a large, easily reducible inguinal hernia? (a) Before the infant leaves the hospital, 70% (b) Schedule electively after discharge, 30%

Comment. Many surgeons, because of the fear of incarceration, will operate on the infant in spite of his or her small size before discharge. The surgeons who choose to operate on a child after the initial discharge are willing to wait for periods up to as long as three to six months before scheduling operation. Several felt that the patient must attain a weight of at least 2500 gm before operation. The decision to allow the patient to go home without repair appears to be strongly influenced by the reliability of the parents and the ability of the doctor to have a close patient follow-up.

COMMENT As could be expected, almost all the pediatric surgeons questioned agree that high ligation of the hernia sac is the key to an effective hernia repair even if there

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is a large or recurrent hernia. Most agreed on the method of managing a hydrocele, and all believe that an attempt should be made to nonoperatively reduce an incarcerated inguinal hernia in a pediatric patient who is clinically stable. Most routinely explore the contralateral side of an inguinal hernia but do not agree on what the age cut-off should be. What surprised us about this survey is the lack of agreement on so many of the questions. In only 4 of 48 questions was there 100 per cent agreement. If one defines a clear majority as a vote of more than two-thirds toward one particular position, we found that this level of agreement was not reached in answering 33 per cent of the questions. Since each individual surgeon has a large experience in treating inguinal hernias and would continue to do only what he has found to be safe and successful, this points out that more than one approach may be effective in managing problems associated with inguinal hernia in the pediatric age group and that rigid policies are unwarranted. Department of Surgery 125 De Soto Street Children's Hospital Pittsburgh, Pennsylvania 15213