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Pediatric hernias
Pediatric Hernias Joy L. Graf, Michael G. Caty, David J. Martin, and Philip L. Glick Indirect inguinal hernias, hydroceles, and umbilical hernias are extremely common in infancy and childhood. Less commonly encountered are femoral, direct inguinal, epigastric, and Spigelian hernias. Patient history and physical examination are usually sufficient for the diagnosis of a hernia. If the diagnosis is uncertain, ultrasound examination or herniograms are occasionally employed. Magnetic resonance imaging may be useful in diagnosing abdominal wall hernias in obese patients for whom physical examination is difficult.
Copyright 2002, Elsevier Science (USA). All rights reserved.
HE GONADS CAN BE identified in the fifth to sixth week of gestation. During the third month of gestation, a diverticulum of the peritoneum at the level of the internal ring protrudes outward, forming the processus vaginalis. In boys, as the gonads descend into the scrotum during the third trimester, the processus vaginalis is pushed ahead. Normally, the processus vaginalis obliterates, forming the tunica vaginalis. If the processus vaginalis remains patent, various types of infant and childhood hernias and hydroceles may form (Fig 1). In girls, a peritoneal outpocketing adjacent to the round ligament and known as the diverticulum of Nuck corresponds to the processus vaginalis, and if patent, predisposes the infant or child to hernia formation. The exact time that obliteration of the processus should occur is not known. If the entire processus remains widely patent, the patient has the potential to form an inguinoscrotal or inguinolabial hernia. If the patency is narrow, allowing only the passage of fluid distally, a communicating hydrocele results. If the proximal processus is obliterated, leaving fluid in the distal aspect, a cord or scrotal noncommunicating hydrocele results. The incidence of pediatric inguinal hernia has been reported to be between 0.8% and 4.4%. 1 However, as a result of improved neonatal intensive care and the survival of increasingly premature infants, the incidence has increased. Up to 30% of premature infants have an inguinal hernia. 2 The incidence is highest during the first year of life, peaking in the first month. Boys are 6 times more likely than girls to have a hernia. The right processus vaginalis obliterates later than the left, and consequently right-sided hernias are more common. Approximately 60% of hernias are on the right, 30% are on the left, and 10% are bilateral. Children with increased intra-abdominal press u r e - f o r example, those who undergo peritoneal dialysis or have ventriculo-peritoneal shunts--are prone to developing inguinal hernias. Because re-
T
pair is recommended for all pediatric inguinal hernias, this operation is one of the most commonly performed pediatric surgical procedures. Approximately 5% of patients diagnosed with a unilateral inguinal hernia will develop a contralateral hernia? Controversy abounds over the management of the asymptomatic groin. Proponents of bilateral groin exploration cite the risk of potential incarceration and a second anesthetic. Those who explore only the symptomatic side feel that the potential surgical risks of an exploration of an asymptomatic groin, especially to the vas deferens and cord vessels in a boy, is not win-ranted. Umbilical hernias are common in infancy and childhood. They are seen more frequently in low birth-weight infants and are 6 to 10 times more common in African American than Caucasian infants. Umbilical hernias develop when the umbilical ring fails to close spontaneously after the umbilical cord separates. This defect is typically easy to palpate and is most evident when the infant strains or cries. Unlike inguinal hernias, the natural history of more than 80% of umbilical hernias is spontaneous closure before the age of 3 to 5 years. The size of the defect may range from a few millimeters to several centimeters in diameter. Hernias > 2 cm or those that persist more than 4 years are unlikely to close spontaneously. The risk of incarceration and strangulation increases with age, and surgical repair is recommended for umbilical hernias that persist for more than 4 years. 4 Epigastric, femoral, and spigelian hernias are rare in children, accounting for less than 5% of
From the Departments of Pediatric Surgery and Radiology, The Children's Hospital of Buffalo, Buffalo, NY. Address reprint requests to Philip L. Gliek, MD, The Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222; e-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0887-2171/02/2302-0006535.00/0 do# l O.1053/sult.2002.31754
Seminars in Ultrasound, CT, and MRI, Vol 23, No 2 (April), 2002: pp 197-200
197
198
Bowel
GRAF ET AL
-----------~,~ Processns Vaginalis (obliterated)
Spermatic cord (Vas de~er~ & ~
Epldldlmis Testicle
v~Is)
A
Fig 1. Common variations of hernias and hydroceles arising from failure of complete obliteration of the processus vaginalis: (A) Normal gonad. (B) Inguinal hernia. (C) Inguinoscrotal hernia. (D) Communication hydrocele. (E) Hydrocele of the cord. Reprinted with permission. 6
hernias. An epigastric hernia occurs just superior to the umbilicus and presents as a small, localized, and occasionally tender mass. They are believed to arise from sites where blood vessels penetrate the fascia of the linea alba and frequently contain incarcerated but not strangulated epigastric fat. Femoral hernias account for less than 0.5% of pediatric hernias and are more commonly seen in girls. There is a sac of peritoneum that passes below the inguinal ligament and protrudes medially to the femoral vessels. The incidence of incarceration and strangulation is high, and treatment consists of early surgical repair. It is not uncommon that children with a femoral hernia have had a prior ipsilateral inguinal hernia repair. This implies that femoral hernias can be difficult to diagnose and can be missed at operation. Spigelian hernias are located at the lateral border of the rectus muscle at the junction of the semilunar line and the semicircular line of Douglas. These hernias typically present with a vague bulge, but like femoral hernias have a propensity for incarceration and should be repaired soon after diagnosis. 5
DIAGNOSIS The diagnosis of a hernia is almost exclusively clinical--based on patient history and physical examination. The condition is usually first ob-
served by a parent and is described as an intermittent bulge in the groin, scrotum, or labia. Usually asymptomatic, the hernia may be more prominent when the child is straining, such as during crying or bowel movement. A hydrocele may enlarge when the child is upright during daily activities and become smaller when the child is sleeping. If the hernia becomes incarcerated, it is very painful. An infant will be irritable, and an older verbal child will complain of pain. As time progresses, vomiting will ensue and the child will develop abdominal distension and eventually rectal bleeding. An incarcerated hernia should be viewed as an emergency, and a referral should be made immediately (within 2 hours) to a pediatric surgeon. On examination, the child will have a tender, possibly discolored bulge at the hernia site, and efforts should be made to gently reduce the hernia. If unsuccessful, the child should be taken immediately to the operating room for exploration. On occasion, the diagnosis of a hernia or hydrocele is unclear, and ancillary tests may be considered. Ultrasound is an excellent diagnostic tool for examining the inguinal area in infants and children. The internal and external rings, the vas deferens and vessels, and the testicle are clearly visualized. In a recent article by Chen et al, 6 ultrasound was found to accurately diagnose 97.9% of hernias compared to 84% by clinical assessment alone. These investigators suggested that determining the diameter of the internal ring could predict an inguinal hernia in boys. An internal ring diameter > 4 mm at any age was believed to represent an occult hernia. All patients with these findings were explored. Those patients with internal rings > 4 m m were found to have an inguinal hernia in 95% of cases explored. Ultrasound was also able to diagnose direct and femoral hernias that had been misdiagnosed as inguinal hernias on examination. Ultrasound differentiates a femoral hernia from an inguinal hernia by demonstrating the hernia passing beneath the inguinal ligament and medial to the femoral vessels. Direct hernias are suspected if the hernia is noted to bulge out from below the inferior epigastric vessels. Ultrasound is also useful for differentiating a hernia from a hydrocele. A hernia may contain bowel, ovary, bladder, and other abdominal viscera, whereas a hydrocele is a collection of fluid in various locations along the processus (Fig 2, 3). On occasion it can be difficult to
PEDIATRIC HERNIAS
Fig 2, Inguinal ultrasound showing a normal testis (a) surrounded by a hydrocele (b-- black area),
clinically differentiate an inguinal hernia from inguinal lymphadenopathy; an ultrasound can easily distinguish between them. Herniograms may be used to identify an inguinal or femoral hernia in a child with a typical history but an absence of physical findings on examination. Herniograms are also useful for patients who have had an inguinal hernia repaired and present with ipsilateral groin pain. In such patients, a herniogram may differentiate a recurrent hernia from other causes of groin pain. To perform a herniogram, the umbilical or infraumbilical skin is anesthetized using a small-gauge needle, and a small angiocatheter is then inserted into the abdominal cavity. A small volume of isotonic, halfstrength, water-soluble radiopaque contrast is injected. Serial radiographs of the inguinal area are taken at 5, 10, and 45 minutes after injection, and contrast in the hernia or hydrocele may be identified. A herniogram is not useful for diagnosing an
199
incarcerated hernia because the hernia sac will be occluded with the incarcerated viscus. Herniograms are not widely used for several reasons. It can be difficult to carry out the injection in a young and uncooperative infant or child. The contrast may be injected into the bladder or bowel, necessitating hospital admission and observation. 7'8 As such, a herniogram should be considered only if it is absolutely necessary to confirm the diagnosis; in all other cases, continued observation and reexamination should be used. Several methods may be used during surgery to identify a contralateral inguinal hernia. When the symptomatic side has been explored and the hernia sac identified, a small laparoscope may be inserted into the peritoneal cavity through the sac, and the opposite internal ring can be examined for the presence of a hernia. 9J° Similarly, the abdomen may have a pneumoperitoneum introduced via the hernia sac, and the opposite groin can be examined externally by palpation. With creation of a pneumoperitoneum, crepitence in the contralateral groin or scrotum represents air in the processus vaginalis and is considered a positive test; groin exploration is then performed. 11 To date, computerized tomography (CT) and magnetic resonance imaging (MRI) have not been used for the diagnosis of suspected pediatric inguinal hernias. There have been reports in the adult literature of the use of MRI for identifying ab-
Fig 3. Inguinal ultrasound showing a normal testis (a) and a hernia with an incarcerated bowel (b).
200
GRAF ET AL
d o m i n a l wall h e r n i a s - - f o r example, epigastric or Spigelian h e r n i a s - - i n obese persons for w h o m the diagnosis could not be m a d e b y physical e x a m i n a tion, but this has not b e e n d o c u m e n t e d in children. la W h e n considering the use of C T and M R I with infants a n d children, it is i m p o r t a n t to realize that small children are u n a b l e to cooperate for the procedure a n d will need either sedation or general anesthesia to obtain quality imaging. In view o f this a n d taking into account the risks associated
with sedation and/or anesthesia, the indications for these procedures m u s t be well considered.
CONCLUSION I n g u i n a l hernias are very c o m m o n in children, and diagnosis is usually based on patient history and findings o n physical examination. In patients for w h o m the diagnosis is uncertain, ultrasound e x a m i n a t i o n provides an excellent a d j u v a n t m o d e of evaluation.
REFERENCES
1. Rowe MI, Lloyd D: Inguinal hernia, in Welch K, Randolf J, Ravitch M, et al (eds): Pediatric Surgery. (ed 3) Chicago, Year Book Medical Publishers, 1986, pp 779-793 2. Harper RG, Garcia A, Sia C: Inguinal hernia: A common problem of premature infants weighing 1,000 grams or less at birth. Pediatrics 56:112-115, 1975 3. Tackett LD, Breuer CK, Luks FI, et al: Incidence of contralateral inguinal hernia: A prospective analysis. J Pediatr Surg 134:684-687, discussion 87-88, 1999 4. Rowe MI, O'Neill JA, Grosfeld JL, et al: Disorders of the umbilicus, in Rowe MI, O'Neill JA, Grosfeld JL (eds): Essentials of Pediatric Surgery. St Louis, Mosby, 1995, pp 1029-1043 5. Kapur P, Caty MG, Glick PL: Pediatric hernias and hydroceles, in Glick PL, Irish MS, Caty MG (eds): The Pediatric Clinics of North America, Philadelphia, WB Sannders, 1998, pp 773-789 6. Chen KC, Chu CC, Chou TY, et al: Ultrasonography
for inguinal hernias in boys. J Pediatr Surg 33:1784-1787, 1998 7. Butsch JL, Kuhn JP: Intramural hematoma of the small bowel: A possible lethal complication of herniography. Surgery 83:121-122, 1978 8. Ekberg O: Complications after herniography in adults. AJR Am J Roentgenol 140:491-495, 1983 9. Groner JI, Marlow J, Teich S: Groin laparoscopy: A new technique for contralateral groin evaluation in pediatric inguinal hernia repair. J Am Coll Surg 181:168-170, 1995 10. Zitsman JL: Transinguinal diagnostic laparoscopy in pediatric inguinal hernia. J Laparoendosc Surg; 6:$15-$20, 1996 (suppl 1) 11. Powell RW: Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: The Goldstein test. J Pediatr Surg 20:418-421, 1985 12. Spangen L: Ultrasound as a diagnostic aid in ventral abdominal hernia. J Clin Ultrasound 1975:3:211-213.
Copyright 2002, Elsevier Science (USA). All rights reserved.
HE GONADS CAN BE identified in the fifth to sixth week of gestation. During the third month of gestation, a diverticulum of the peritoneum at the level of the internal ring protrudes outward, forming the processus vaginalis. In boys, as the gonads descend into the scrotum during the third trimester, the processus vaginalis is pushed ahead. Normally, the processus vaginalis obliterates, forming the tunica vaginalis. If the processus vaginalis remains patent, various types of infant and childhood hernias and hydroceles may form (Fig 1). In girls, a peritoneal outpocketing adjacent to the round ligament and known as the diverticulum of Nuck corresponds to the processus vaginalis, and if patent, predisposes the infant or child to hernia formation. The exact time that obliteration of the processus should occur is not known. If the entire processus remains widely patent, the patient has the potential to form an inguinoscrotal or inguinolabial hernia. If the patency is narrow, allowing only the passage of fluid distally, a communicating hydrocele results. If the proximal processus is obliterated, leaving fluid in the distal aspect, a cord or scrotal noncommunicating hydrocele results. The incidence of pediatric inguinal hernia has been reported to be between 0.8% and 4.4%. 1 However, as a result of improved neonatal intensive care and the survival of increasingly premature infants, the incidence has increased. Up to 30% of premature infants have an inguinal hernia. 2 The incidence is highest during the first year of life, peaking in the first month. Boys are 6 times more likely than girls to have a hernia. The right processus vaginalis obliterates later than the left, and consequently right-sided hernias are more common. Approximately 60% of hernias are on the right, 30% are on the left, and 10% are bilateral. Children with increased intra-abdominal press u r e - f o r example, those who undergo peritoneal dialysis or have ventriculo-peritoneal shunts--are prone to developing inguinal hernias. Because re-
T
pair is recommended for all pediatric inguinal hernias, this operation is one of the most commonly performed pediatric surgical procedures. Approximately 5% of patients diagnosed with a unilateral inguinal hernia will develop a contralateral hernia? Controversy abounds over the management of the asymptomatic groin. Proponents of bilateral groin exploration cite the risk of potential incarceration and a second anesthetic. Those who explore only the symptomatic side feel that the potential surgical risks of an exploration of an asymptomatic groin, especially to the vas deferens and cord vessels in a boy, is not win-ranted. Umbilical hernias are common in infancy and childhood. They are seen more frequently in low birth-weight infants and are 6 to 10 times more common in African American than Caucasian infants. Umbilical hernias develop when the umbilical ring fails to close spontaneously after the umbilical cord separates. This defect is typically easy to palpate and is most evident when the infant strains or cries. Unlike inguinal hernias, the natural history of more than 80% of umbilical hernias is spontaneous closure before the age of 3 to 5 years. The size of the defect may range from a few millimeters to several centimeters in diameter. Hernias > 2 cm or those that persist more than 4 years are unlikely to close spontaneously. The risk of incarceration and strangulation increases with age, and surgical repair is recommended for umbilical hernias that persist for more than 4 years. 4 Epigastric, femoral, and spigelian hernias are rare in children, accounting for less than 5% of
From the Departments of Pediatric Surgery and Radiology, The Children's Hospital of Buffalo, Buffalo, NY. Address reprint requests to Philip L. Gliek, MD, The Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222; e-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0887-2171/02/2302-0006535.00/0 do# l O.1053/sult.2002.31754
Seminars in Ultrasound, CT, and MRI, Vol 23, No 2 (April), 2002: pp 197-200
197
198
Bowel
GRAF ET AL
-----------~,~ Processns Vaginalis (obliterated)
Spermatic cord (Vas de~er~ & ~
Epldldlmis Testicle
v~Is)
A
Fig 1. Common variations of hernias and hydroceles arising from failure of complete obliteration of the processus vaginalis: (A) Normal gonad. (B) Inguinal hernia. (C) Inguinoscrotal hernia. (D) Communication hydrocele. (E) Hydrocele of the cord. Reprinted with permission. 6
hernias. An epigastric hernia occurs just superior to the umbilicus and presents as a small, localized, and occasionally tender mass. They are believed to arise from sites where blood vessels penetrate the fascia of the linea alba and frequently contain incarcerated but not strangulated epigastric fat. Femoral hernias account for less than 0.5% of pediatric hernias and are more commonly seen in girls. There is a sac of peritoneum that passes below the inguinal ligament and protrudes medially to the femoral vessels. The incidence of incarceration and strangulation is high, and treatment consists of early surgical repair. It is not uncommon that children with a femoral hernia have had a prior ipsilateral inguinal hernia repair. This implies that femoral hernias can be difficult to diagnose and can be missed at operation. Spigelian hernias are located at the lateral border of the rectus muscle at the junction of the semilunar line and the semicircular line of Douglas. These hernias typically present with a vague bulge, but like femoral hernias have a propensity for incarceration and should be repaired soon after diagnosis. 5
DIAGNOSIS The diagnosis of a hernia is almost exclusively clinical--based on patient history and physical examination. The condition is usually first ob-
served by a parent and is described as an intermittent bulge in the groin, scrotum, or labia. Usually asymptomatic, the hernia may be more prominent when the child is straining, such as during crying or bowel movement. A hydrocele may enlarge when the child is upright during daily activities and become smaller when the child is sleeping. If the hernia becomes incarcerated, it is very painful. An infant will be irritable, and an older verbal child will complain of pain. As time progresses, vomiting will ensue and the child will develop abdominal distension and eventually rectal bleeding. An incarcerated hernia should be viewed as an emergency, and a referral should be made immediately (within 2 hours) to a pediatric surgeon. On examination, the child will have a tender, possibly discolored bulge at the hernia site, and efforts should be made to gently reduce the hernia. If unsuccessful, the child should be taken immediately to the operating room for exploration. On occasion, the diagnosis of a hernia or hydrocele is unclear, and ancillary tests may be considered. Ultrasound is an excellent diagnostic tool for examining the inguinal area in infants and children. The internal and external rings, the vas deferens and vessels, and the testicle are clearly visualized. In a recent article by Chen et al, 6 ultrasound was found to accurately diagnose 97.9% of hernias compared to 84% by clinical assessment alone. These investigators suggested that determining the diameter of the internal ring could predict an inguinal hernia in boys. An internal ring diameter > 4 mm at any age was believed to represent an occult hernia. All patients with these findings were explored. Those patients with internal rings > 4 m m were found to have an inguinal hernia in 95% of cases explored. Ultrasound was also able to diagnose direct and femoral hernias that had been misdiagnosed as inguinal hernias on examination. Ultrasound differentiates a femoral hernia from an inguinal hernia by demonstrating the hernia passing beneath the inguinal ligament and medial to the femoral vessels. Direct hernias are suspected if the hernia is noted to bulge out from below the inferior epigastric vessels. Ultrasound is also useful for differentiating a hernia from a hydrocele. A hernia may contain bowel, ovary, bladder, and other abdominal viscera, whereas a hydrocele is a collection of fluid in various locations along the processus (Fig 2, 3). On occasion it can be difficult to
PEDIATRIC HERNIAS
Fig 2, Inguinal ultrasound showing a normal testis (a) surrounded by a hydrocele (b-- black area),
clinically differentiate an inguinal hernia from inguinal lymphadenopathy; an ultrasound can easily distinguish between them. Herniograms may be used to identify an inguinal or femoral hernia in a child with a typical history but an absence of physical findings on examination. Herniograms are also useful for patients who have had an inguinal hernia repaired and present with ipsilateral groin pain. In such patients, a herniogram may differentiate a recurrent hernia from other causes of groin pain. To perform a herniogram, the umbilical or infraumbilical skin is anesthetized using a small-gauge needle, and a small angiocatheter is then inserted into the abdominal cavity. A small volume of isotonic, halfstrength, water-soluble radiopaque contrast is injected. Serial radiographs of the inguinal area are taken at 5, 10, and 45 minutes after injection, and contrast in the hernia or hydrocele may be identified. A herniogram is not useful for diagnosing an
199
incarcerated hernia because the hernia sac will be occluded with the incarcerated viscus. Herniograms are not widely used for several reasons. It can be difficult to carry out the injection in a young and uncooperative infant or child. The contrast may be injected into the bladder or bowel, necessitating hospital admission and observation. 7'8 As such, a herniogram should be considered only if it is absolutely necessary to confirm the diagnosis; in all other cases, continued observation and reexamination should be used. Several methods may be used during surgery to identify a contralateral inguinal hernia. When the symptomatic side has been explored and the hernia sac identified, a small laparoscope may be inserted into the peritoneal cavity through the sac, and the opposite internal ring can be examined for the presence of a hernia. 9J° Similarly, the abdomen may have a pneumoperitoneum introduced via the hernia sac, and the opposite groin can be examined externally by palpation. With creation of a pneumoperitoneum, crepitence in the contralateral groin or scrotum represents air in the processus vaginalis and is considered a positive test; groin exploration is then performed. 11 To date, computerized tomography (CT) and magnetic resonance imaging (MRI) have not been used for the diagnosis of suspected pediatric inguinal hernias. There have been reports in the adult literature of the use of MRI for identifying ab-
Fig 3. Inguinal ultrasound showing a normal testis (a) and a hernia with an incarcerated bowel (b).
200
GRAF ET AL
d o m i n a l wall h e r n i a s - - f o r example, epigastric or Spigelian h e r n i a s - - i n obese persons for w h o m the diagnosis could not be m a d e b y physical e x a m i n a tion, but this has not b e e n d o c u m e n t e d in children. la W h e n considering the use of C T and M R I with infants a n d children, it is i m p o r t a n t to realize that small children are u n a b l e to cooperate for the procedure a n d will need either sedation or general anesthesia to obtain quality imaging. In view o f this a n d taking into account the risks associated
with sedation and/or anesthesia, the indications for these procedures m u s t be well considered.
CONCLUSION I n g u i n a l hernias are very c o m m o n in children, and diagnosis is usually based on patient history and findings o n physical examination. In patients for w h o m the diagnosis is uncertain, ultrasound e x a m i n a t i o n provides an excellent a d j u v a n t m o d e of evaluation.
REFERENCES
1. Rowe MI, Lloyd D: Inguinal hernia, in Welch K, Randolf J, Ravitch M, et al (eds): Pediatric Surgery. (ed 3) Chicago, Year Book Medical Publishers, 1986, pp 779-793 2. Harper RG, Garcia A, Sia C: Inguinal hernia: A common problem of premature infants weighing 1,000 grams or less at birth. Pediatrics 56:112-115, 1975 3. Tackett LD, Breuer CK, Luks FI, et al: Incidence of contralateral inguinal hernia: A prospective analysis. J Pediatr Surg 134:684-687, discussion 87-88, 1999 4. Rowe MI, O'Neill JA, Grosfeld JL, et al: Disorders of the umbilicus, in Rowe MI, O'Neill JA, Grosfeld JL (eds): Essentials of Pediatric Surgery. St Louis, Mosby, 1995, pp 1029-1043 5. Kapur P, Caty MG, Glick PL: Pediatric hernias and hydroceles, in Glick PL, Irish MS, Caty MG (eds): The Pediatric Clinics of North America, Philadelphia, WB Sannders, 1998, pp 773-789 6. Chen KC, Chu CC, Chou TY, et al: Ultrasonography
for inguinal hernias in boys. J Pediatr Surg 33:1784-1787, 1998 7. Butsch JL, Kuhn JP: Intramural hematoma of the small bowel: A possible lethal complication of herniography. Surgery 83:121-122, 1978 8. Ekberg O: Complications after herniography in adults. AJR Am J Roentgenol 140:491-495, 1983 9. Groner JI, Marlow J, Teich S: Groin laparoscopy: A new technique for contralateral groin evaluation in pediatric inguinal hernia repair. J Am Coll Surg 181:168-170, 1995 10. Zitsman JL: Transinguinal diagnostic laparoscopy in pediatric inguinal hernia. J Laparoendosc Surg; 6:$15-$20, 1996 (suppl 1) 11. Powell RW: Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: The Goldstein test. J Pediatr Surg 20:418-421, 1985 12. Spangen L: Ultrasound as a diagnostic aid in ventral abdominal hernia. J Clin Ultrasound 1975:3:211-213.