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.
Can an inguinal hernia be operated on as an outpatient / day surgery?
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.
Information about the anatomy of the inguinal hernia
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.
Why is the risk of trapping a hernia in infancy particularly common compared to adolescents and adults?
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.
What is the hernial bag made of?
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.
What are the different hernias?
In boys and girls there is the following classification of inguinal hernias:
- Indirect hernia. It runs in the inguinal canal.
- Direct hernia. It runs almost straight through the abdominal wall.
- Testicular hernia (scrotal hernia). This is an indirect hernia where the hernia extends to the testicles. The technical terminology describes this condition as "open vaginal process".
- Water break. This is a hernia that is filled with fluid due to its connection to the abdominal cavity (hydrocele). The water break can be chambered. Its connection to the abdominal cavity can become sticky. Then it is a chambered water quarry that cannot be expressed. In rare cases, the water break can stick together, so that it does not appear externally when touched.
- Femoral hernia. This is a fracture that can be seen as a bulge below the groin in the area of the thigh and is located in the immediate vicinity of the femoral artery, femoral vein and leg nerve.
Are there differences between hernias in adults and hernias in children?
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:
- Increased pressure in the abdominal cavity. Illnesses with pressure in the abdominal cavity can cause an inguinal hernia: whooping cough, recurrent lung diseases, constipation, colonic passage disorders, obesity. The long-term increased pressure in the abdominal cavity is crucial. Children who received a drainage of the cerebral fluid into the abdominal cavity through an operation show an 8x more frequent occurrence of a hernia and a risk of being pinched by approx. 20%.
- Metabolic disorders. Disrupted fat metabolism, sugar metabolism and protein metabolism can lead to a disturbance of the collagen and muscle building and thus to a thinning of the abdominal wall. Diet-related disorders can also be a trigger factor for hernias.
- Changes to the inner inguinal ring. In the area of the inguinal canal towards the abdominal cavity there is a functional locking mechanism that is triggered by muscle activity and a connective tissue loop. In rare cases, this locking mechanism can be disturbed or it can be missing. This can lead to indirect hernias.
- Strike or bump on the stomach due to an accident - no connection with increased hernia. Injury to the inner groin ring does not cause a groin hernia. The defect in the muscles is usually healed in a few days. A weak point in the abdominal wall can only result in the most severe injuries with extensive muscle destruction. A causal connection between blunt abdominal trauma and the development of inguinal hernias is rather unlikely in children.
What symptoms, what complaints do the children have?
- Swelling in the groin area, which is noticed by the parents, grandparents, kindergarten teachers or by the doctor. The swelling can vary in intensity, or can occur and regress depending on where the hernial sac is located and whether it is filling with liquid or not.
- Failure to thrive in infants and children due to irritation caused by pulling on the peritoneum. It can also lead to an impairment of general well-being with flatulence, restlessness and screaming.
- Pain in the groin area caused by the occurrence of abdominal viscera in the hernia sac or by massive swelling of the testicle compartment due to fluid accumulation.
- Missing testicle in the testicle compartment, triggered by the testicle sticking to the hernial sac wall.
- Permanent swelling in the groin area, which is difficult or impossible to "express".
How do you identify 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.
Is there spontaneous healing of the inguinal hernia?
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.
When is surgery necessary?
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%.
Inguinal hernia surgery in infants weighing less than 2500 g.
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.
Is there a contraindication to the hernia operation?
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.
My child needs surgery - what happens to him?
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.
- Adrenal tissue on the spermatic cord: when the adrenal gland develops, small adrenal nodules can migrate from the abdomen to the groin area with the gonads. The millimeter-sized nodules are to be removed and examined histologically. Frequency 0.5% - 0.8%
- Lymph fluid (chylocele) can flow from the abdominal cavity into the hernia sac for various reasons. In this case, the connection of the inguinal hernia to the abdominal cavity is to be closed as in the case of an inguinal hernia and the cause of the secretion of lymphatic fluid into the abdominal cavity is to be examined at a later time.
- Connection of the spleen to the testicle (splenogonal fusion): this is a strand that pulls from the spleen to the testicle. This strand is removed so as not to impede intestinal motility in the abdomen.
- Missing or partially occluded vas deferens: this occurs in children with cystic fibrosis, kidney malformation and after rubella infections. This finding should be photo-documented intraoperatively.
- Littre's hernia: this is a fracture that lies between the individual layers of the abdominal wall. A testicle may be located in the wrong position at the tip of the hernia sac.
What should be considered after the operation?
- The wound dressing should be left on for the first 24 hours. If no bandage has been applied, it must be ensured that the wound is kept dry and clean. An open treatment can then be carried out. The risk of infection after 48 hours is low.
- If a suture has to be removed, this can be done between the 7th and 10th day after the operation.
- In older children, attending kindergarten / school can be resumed after 1 week. Sports activities can be carried out after 3 weeks. If possible, activities that are frequently associated with abdominal dreams should be avoided.
- A bruise manifests itself in a swelling after the operation in the groin area or in the testicle compartment with a bluish, later greenish discoloration of the skin. As a rule, this completely disappears after 14 days. Local ointment therapy can positively influence and accelerate the resolution of the bruise in the wound area. In any case, it is advisable to show this change to a doctor at an early stage after the operation.
- A wound infection manifests itself through redness, swelling and local overheating, as well as through fever. Wound infections usually occur between the 5th and 8th day after the operation by the above-mentioned. Symptoms in appearance. In any case, the surgeon should look at the wound. In most cases, the inflammation resolves spontaneously, antibiotic therapy is occasionally necessary. In rare cases, the wound should be spread after previous pain therapy so that bacteria, infected wound fluid and pus can drain away.
Renewed inguinal hernia (relapse)
Around one to five out of 100 patients have a new inguinal hernia in the same place some time after the operation (recurrent hernia). Recurrence is less common when using a plastic net. Whether there is a new break depends on many factors. The patient can influence some of them through his / her behavior: For example, quitting smoking can improve wound healing. In addition, it is important to adhere to the given therapy recommendations for diseases such as diabetes mellitus or kidney disease. If a new inguinal hernia is operated on, doctors usually choose a different surgical method than for the first operation (if the first operation was an open one, the second operation is laparoscopic, and vice versa).
Inguinal hernia in children
Inguinal hernias are almost always congenital in children. Five out of 100 newborns have an inguinal hernia. Children born prematurely, in particular, are at increased risk for this. Inguinal hernias are much more common in boys than in girls. The parents often notice a mostly painless protrusion in the groin area. Sometimes this can only be seen when crying, coughing, or pressing. In boys, swollen scrotums or in girls thickened labia may also be noticeable. Occasionally, however, it can also happen that the parents do not notice a hernia and the pediatrician discovers one as part of a mother-child pass examination. Most children are then operated on immediately to avoid complications. Because babies and toddlers can also have a pinched fracture: If the child suddenly becomes very restless, cries or vomits or has a fever, immediate medical help is necessary!