What is an inguinal hernia? It is a hernia. This is a congenital sagging of the peritoneum that extends along the inguinal canal to the testicle compartment. A hernia occurs in every 50th boy and every 200th girl. Gender distribution boys: girls is 80%: 20%. Most hernias are recognized before the 6th month of life. Premature babies are more likely to have an inguinal hernia: 15% to 20% of infants with a birth weight of less than 1500 g have an inguinal hernia.
Our statistics show: Inguinal hernia on the right side 60%, inguinal hernia on the left side 25%, inguinal hernia on both sides 15%. 50% of all childhood hernias occur in children under 1 year. The hernia is combined with a groin testicle in 7% to 9% of all boys. An inguinal testicle is an incorrect position of the testicle, which is not localized in the testicular compartment, but in the inguinal canal, in the abdominal wall or in the abdominal cavity. Every 8th inguinal hernia is trapped at the time of diagnosis. Pinching is a painful condition of an inguinal hernia in which the tube, intestine, appendix or, in girls, the tube, ovary or parts of the uterus are immovable and there is a risk of circulation. Pinching on the right side is twice as common as on the left. This is due to the fact that the right testicle, compared to the left side later in the development phase, migrates from the abdominal cavity into the testicle compartment and the passage through which the testicle moves into the testicle compartment later closes compared to the opposite side.
Between 81,000 and 85,000 inguinal hernia operations are performed annually in Germany.
In children over 3000 g, hernias can be operated on an outpatient basis if they are not pinched and if it is not a relapse procedure (operation after a previous hernia).
Inguinal hernia surgery is a very difficult surgical procedure in infancy and childhood. Professor Dr. F. Rehbein (Bremen) particularly pointed this out. There is a risk of injury to the vas deferens, the artery and the vein that supply the testicles, as well as an overlook of the inguinal hernia with subsequent surgery required later.
The inguinal hernia is a protuberance of the abdominal cavity (peritoneum or peritoneum) along the inguinal canal (indirect inguinal hernia) or through a muscle gap through the abdominal wall (direct inguinal hernia). The inguinal canal runs obliquely through the abdominal wall. Only in newborns does the inguinal canal run straight (vertical) through the abdominal wall. A distinction is made between the hernial sac and the hernial sac contents. The hernial sac is a non-anatomically defined protuberance of the abdominal cavity through the abdominal wall. In boys it can extend into the testicle compartment, in girls it can extend into the outer labia. The hernia sac contents are organ structures that are components of the abdominal cavity: small intestine, appendix, network, adrenal glands, ovary, fallopian tubes, parts of the uterus. The hernial sac can also be filled with fluid (water breakage) or with lymph fluid (chylocele).In rare cases there is an anatomical connection between the spleen and the testicle in the testicular compartment (splenogonal fusion), which must be removed by surgery.
The trapping of abdominal viscera in the hernial sac is more common in infants because the inguinal canal runs straight through the abdominal wall. This allows the pressure in the abdominal cavity to propagate through the abdominal wall in a straight line when screaming and pressing and thus pushing abdominal viscera directly into the inguinal canal.
Fine tissue microscopic examinations (Professor Dr. R. R. Lehmann) have shown that the wall structure of the hernial sac consists of connective tissue, small bundles of nerve fibers, small arteries and veins and individual striated muscle fibers. A thickening of the hernial sac indicates repeated occurrence of abdominal viscera in the hernial sac. The thickness of the hernial sac wall varies and averages 1 mm.
In boys and girls there is the following classification of inguinal hernias:
The hernia in the child is congenital and either follows the anatomical structure of the inguinal canal (indirect hernia) or penetrates the abdominal wall at muscle weak spots or muscle gaps in a straight direction (direct hernia). The hernia in adults is related to an undetected hernia in childhood. Inguinal hernias in adults can also result from physical exertion, injuries or metabolic diseases along predetermined anatomical structures (inguinal canal, abdominal wall gaps, previous operations in the abdominal wall).
Adverse factors in childhood that can lead to a hernia:
Suspicion of a hernia is suspected by the observation and the related information from adults who look after the child: permanent or changeable swelling in the groin area, changeable pain, irritation of the general condition.
The doctor, who then examines the child and palpates it from the abdominal wall, determines the swelling, which can either be pushed back into the abdomen or which causes great pain to the child when touched. In this case it is a pinched hernia, which necessitates an urgent operation.
The inguinal hernia itself can be felt by the doctor with the finger when the contents of the hernial sac have been pushed back into the abdominal cavity, whereby a displaceable part of the tissue under the skin that corresponds to the inguinal hernia can be determined. This is referred to as the "silk phenomenon".
The ultrasound is an additional aid with which the hernial sac or hernial sac contents can be determined without any problems. With the help of so-called "Doppler sonography", the blood flow conditions in the spermatic cord structures and thus in the testicles can be checked.
The usual examination and finding of an inguinal hernia by touching and inserting the testicle compartment with the index finger towards the abdominal cavity is unsuitable for adults. This examination is not expedient in children because the diameter of the inguinal canal is smaller than the diameter of the examining finger.
There is no healing of a hernia once it has been identified. Exceptions can be so-called "water breaks", where the fluid empties into the abdominal cavity and the hernial sac walls stick together. However, this only happens in rare cases.
There is also a congenital muscle weakness in infants and toddlers, especially in those areas of the abdominal wall where there is an opening.
Coughing, pressing and screaming can result in a bulge-like protrusion. This abdominal muscle weakness, however, regresses in the course of development.
Children should not wear trusses, as this tends to widen the hernia and overlook jams.
Once an inguinal hernia is diagnosed, an operation should be performed. This is best done within the first year of life, since this is the greatest risk of trapping. If an inguinal hernia cannot be “repositioned” (the contents of the hernia cannot be pushed back into the abdominal cavity), then an urgent surgical intervention is necessary. In such a case, the otherwise required period of non-consumption of food need not be observed, since there is an increased risk of circulatory disorders in organs that are in the hernial sac.
An inguinal hernia that keeps getting stuck and spontaneously regresses is said to be so-called "postponed urgency", i.e. can be operated within a short time after diagnosis after appropriate preparation.
Inguinal hernias in girls who, after having been diagnosed accordingly, have an incident of the ovary, the tube (fallopian tube) must be treated as an urgent surgical intervention. Otherwise the tube may be blocked or the ovary may malfunction.
Double sided hernias - frequency 5% - can be removed in one operation. Preventive surgery on the opposite side in the event of a unilaterally determined inguinal hernia should only be carried out in rare and justified exceptional cases. However, after the operation of a unilateral hernia and after the hernia has been closed on the opposite side, a hernia that did not previously exist can occur at a later time. The frequency is 0.5% to 1%.
It is often discussed whether the inguinal hernia found in premature babies and infants with a birth weight of less than 2500 g needs surgery. On the one hand, the risk assessment when deciding when the surgical intervention should be carried out may have anesthetic risks, operational special features with an increased post-operative rate and special post-operative follow-up care. On the other hand, there is a high risk of inguinal hernia, especially in infants.
In most cases where there is no acute pinching, a body weight of 2500 g to 3000 g should be reached before the operation is carried out, for safety reasons the infants should be monitored under close clinical supervision by a pediatrician.
In a few exceptional cases there is a postponement of the operation, which cannot, however, be viewed as a contraindication. This is the case if the children have an infection, have a threatening metabolic disorder, have heart defects, lung or kidney diseases.
There is no contraindication to the hernia operation in the case of a pinched hernia in the girl or boy.
After the diagnosis and examination have been carried out by the pediatric surgeon, an explanation and declaration of consent to the planned surgical procedure is given. Exceptions that may occur are also discussed. A further examination by the anesthetist with a corresponding declaration of consent is necessary. If desired, it is possible and desirable for a parent to be taken along in most hospitals. The surgical intervention is preferably scheduled early on the respective surgical program in order to keep the sobriety period as short as possible and to enable a daily surgical intervention.The individual surgical steps are discussed by the respective surgeon with the parents, depending on the available findings (is there a water break, indirect or direct inguinal hernia?): Surgery through skin incision or with the help of so-called "keyhole surgery" i.e. endoscopic surgery. It is crucial to remove the hernia sac and seal it while protecting the artery, vein and spermatic duct. If the testicle is incorrectly positioned, it should be moved to the testicle compartment and, if necessary, fixed there.
A so-called “hernia sac” caused by injection treatment can destroy the vas deferens and vessels and thus lead to a testicular dysfunction. Therefore, sac fracture in children is not indicated.