INTRODUCTION
Inguinoscrotal swellings in children form a majority of pediatric surgical conditions requiring treatment. Indirect inguinal hernia is one of the most common congenital malformations seen in children. It results from persistence of patent processus vaginalis.[1] The incidence of inguinal hernia is estimated to be 1%–3% in full-term newborns and could be as high as 30% in prematures.[2] Inguinal herniotomy (surgical closure of patent processus vaginalis) is the most frequently performed operations in the pediatric age group.[1] This encouraged us to comprehend a clinical audit (the assessment of morbidity and mortality statistics) of pediatric patients with inguinal hernias and hydroceles and analyze their clinical outcomes.
Aims and objectives
To analyze the clinical presentation and outcomes of a large series of pediatric inguinal hernias and hydroceles from a tertiary care institute.
SUBJECTS AND METHODS
A single center, retrospective study was performed from January 1983 to December 2014. The study included cohort of all pediatric patients, aged <16 years with: (a) inguinal hernia, (b) inguinal hydrocele, and (c) hydrocele of cord admitted to our department of a tertiary care institute. In cases of inguinal hernia, we have agreed on the policy of recommending herniotomy only when the hernia is clearly evident. In the case of a hydrocele, age above 2 years was agreed as the standard (lower limit) for surgical intervention. Furthermore, cases of tense hydroceles under 2 years were also subjected to operation.
The operative procedures were performed on an in-door basis, requiring total hospital stay of about 24–72 h. A policy of unilateral inguinal hernia repair without contralateral exploration in patients having a unilateral inguinal hernia without evidence of contralateral hernia. The herniotomy was usually performed under inhalational anaesthesia. All operations were performed by senior pediatric surgeon or under his strict supervision. The surgery was performed through the standard inguinal incision. The division of the external oblique aponeurosis and dissection of the sac from the surrounding cord structures with high ligation was performed with nonabsorbable sutures (Gross and Fergusson procedure).[3]
The clinical and operative records of these patients were analyzed. Charts were reviewed according to age at presentation, sex, clinical findings, location of hernia, investigations undertaken, operative procedure, intraoperative and postoperative complications and final outcomes. All patients were assessed at 1 month follow-up. Late complications were not evaluated in our study. All statistical data analysis was obtained with SPSS Statistics for Windows, version x.0 (SPSS Inc., Chicago, Ill., USA).
RESULTS
There were 8000 pediatric patients admitted for inguinal herniotomy with the diagnosis of either inguinal hernia or hydrocele. There were 7350 (91.875%) males and 650 (8.125%) females (M:F = 11.3:1). Age ranged from 3 days (youngest) to 15 years (oldest). Patients were subdivided into 8 age groups [Table 1]. Among these groups, only 60 (0.75%) were in neonatal age group and collectively, 1770 (22.125%) were infants. Maximum patients, i.e., 1838 (22.975%) were in ≥5 years to <10 years of age group. The right side pathology was present in 4950 (61.875%), left side in 2790 (34.875%) while bilateral disease was present in 260 (3.25%) cases [Figure 1]. Out of 8000, 170 (2.125%) patients presented with incarcerated inguinal hernia [Table 1]. These cases required surgical intervention on emergency basis.
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Table 1: Demographic details of the patients in the study (n=8000)
Figure 1: Preoperative clinical photographs showing bilateral inguinal hernia in a male child (a), left inguinal hernia (red arrow) in a female child (b), and left inguinal hernia in a male child (c)
A total of 8260 herniotomies were performed which included 260 cases with bilateral disease. All procedures were performed by experienced pediatric surgeon or under their supervision. Inguinal hernia constituted 6195 (75%) patients and hydrocele was present in 2065 (25%) cases. The details of individual anomaly and the sex distribution are described in Table 2. Out of 8260 herniotomies, 170 (2.06%) herniotomies were performed for incarcerated or strangulated inguinal hernia [Figure 2]. Among this group, 101 (1.22%) patients were <1 year of age. In 13 patients, bowel ischemia/gangrenous changes and or perforation were present [Figure 2]. These 13 patients required resection anastomosis of intestines in addition to herniotomy.
Table 2: Operative details of the patients in the study (n=8260)
Figure 2: Clinical and operative photographs showing inflamed red hemi scrotum (white arrow) with incarcerated inguinal hernia (a), on inguinal exploration (black arrow) (b), sigmoid colon (blue arrow) in the incarcerated inguinal hernial sac (c), and perforated ileum (green arrow) in the inguinal hernial sac (d)
Amyand’s hernia was appreciated with appendix and caecum as content of sac in 7 (0.09%) patients [Figure 3]. In 2 patients, Amyand’s hernia presented as incarcerated inguinal hernia with appendicular lump and features suggestive of appendicitis [Figure 3]. Inflamed appendix along with caecum was found to be lying within it, with adhesions to the sac. In these patients, adhesiolysis, dissection of lump, appendectomy (through inguinal incision) and reduction of caecum into the peritoneal cavity was performed. Out of 5 patients, the right side was involved in four (reduction of caecum with appendix was done), while left side in one patient (appendectomy and reduction of caecum was performed). In all 7 cases, caecum was mobile and fixation abnormality was evident in the form of nonfixation to the retroperitoneum, as caecum was reaching the scrotum along with the vermiform appendix.
Figure 3: Clinical and operative photographs showing incarcerated inguinal hernia (a), appendix and caecum (red arrow) as the content of inguinal hernial sac (b), appendicular lump (green arrow) in the inguinal hernial sac (c) and dissection of the appendix (green arrow) in Amyand’s hernia (d)
Associated genital anomalies and abdominal wall defects were present in 252 (3.15%) cases. Undescended testes were the most common association, present in 82 (1.03%) cases [Table 3]. In 80 (1%) patients, additionally ipsilateral orchiopexy was performed for unilateral undescended testis 76 (0.95%) and unilateral ectopic testis 4 (0.05%) as shown in Table 3.
Table 3: Associated genital and abdominal wall pathology of the patients in the study
Inguinal hernia was of sliding variety in 67 (0.8%) cases. The viscera forming the lateral wall of the sac included bladder (16), sigmoid colon (11) fallopian tube (13) and fallopian tube with ovary (25), uterus with fallopian tube, i.e., hernia uterus inguinale (HUI)[2] as shown in Figure 4. In all these cases, hernia sac was ligated distal to the visceral contents and divided; the proximal sac was then invaginated into the peritoneal cavity through the internal ring. The internal ring was then closed in the female patients while in male patients, adequate narrowing was performed.
Figure 4: Clinical and operative photographs showing inguinal hernia in a female child (a), hernia uterus inguinale with ovary (black arrow) and uterus (red arrow) (b); ovary (black arrow) and fallopian tubes (green arrow) as content of inguinal hernial sac (c and d)
Postoperative complications were present in 48 (0.6%) cases only [Table 4]. Forty-five were minor requiring wound care and short course of antibiotics for 1 week along with supportive care. In three cases, repair of vas deferens was done with 6–0 absorbable sutures at the time of surgery, as there was injury to vas deferens. Recurrence was seen in only 2 (0.03%) cases. Both occurred through unrecognized tears in the base of the friable sac. Re-exploration and ligation of the hernial sac was successfully accomplished.
Table 4: Postoperative complications of the patients in the study (n=48)
DISCUSSION
Approximately 400 years ago, a French surgeon, Ambroise Pare, described the etiology, i.e., congenital origin of pediatric hernia, taxis maneuver, and surgical management. Congenital inguinal hernias are related to the abnormalities of descent of testis and failure of obliteration of processus vaginalis.[4] The counter part of patent processus vaginalis in females is “Canal of Nuck.”
Hernia is defined as a protrusion of a viscus or part of it through a normal or an abnormal opening in the wall of its containing cavity.[4] Inguinal herniotomy is undoubtedly the most common operation performed in pediatric surgical practice. The procedure may look to be simple, but is technically demanding in neonatal age group.[4] In our series, all hernias were indirect type.
According to earlier studies, one-third of all children with hernias present before 6 months of age. In our center, <14 (22.125%) patients reported for surgery before 1 year of age. This delayed presentation may be due to lack of education and poor socio-economic status of the population. Most hernias occur in males, with a male to female ratio of 6:1 (range from 3:1 to 10:1).[5] In our case, M:F ratio was 11.3:1. In recent series from India, M:F ratio was 11.5:1.[4] Approximately 60% of hernias are right sided, while in our case, the right side was involved in 61.875% cases.[4,5] In our study, bilateral involvement was present in 3.25% cases, while it was high (18.2%) in a recent series.[4,5]
Maximum children present with nontender readily reducible intermittent swelling in the inguinal region, which may extend to the scrotum (males) and to the labial region (females). Incarcerated inguinal hernia presents as firm, tender inguinal swelling (possibly extending to the scrotum) which is not readily reducible with pressure. The child is extremely irritable and there is unwillingness to eat; this is followed by features of intestinal obstruction. In our series, incarceration was rare (2.125%). In similar studies, incarceration was present in 4%–4.7% patients; though it may range from 3% to 16% of cases.[1–4] Incarceration is the most common in the 1st year of life as seen in 59.41% (101 out of 170) patients in our series. Delay in diagnosis and treatment leads to loss of testis, ovaries or portion of bowel to incarceration or strangulation.[2,4,5]
The differential diagnoses (d/d) for uncomplicated inguinal hernias include hydrocele, undescended or retractile testicle and lymphadenopathy. In case of incarcerated hernia d/d includes inguinal lymphadenitis, torsion of the testicle and acute hydrocele. The bowel, ovaries or fallopian tubes are the organs that are most commonly incarcerated. It may progress quickly to strangulation and infarction of the incarcerated contents.[2,5]
Sliding inguinal hernia is infrequent in pediatric patients. They are more common in girls than in boys. Ovaries and fallopian tubes are present in the sacs in as many as 15% of the hernias in girls. The structures which are present in the sliding hernia are caecum, appendix, bladder, sigmoid colon and rarely, the uterus. Inguinal hernia containing both uterus and its adnexa is an extremely rare condition. It is known as HUI and is seen in infants.[6] In our series, HUI was present in 0.02% (2) patients. Undescended testes were present in 1.03% cases, which was less than other studies.[4,7]
Most inguinal hernia repairs may be performed electively soon after the diagnosis is made. In preterm infants, there is a greater possibility for an incarcerated hernia and surgery should be carried out, if possible within 1 week of diagnosis. Reduction of an incarcerated hernia (taxis maneuver) should be tried with or without sedation; if successful, the herniotomy should be undertaken (in the admitted patient) after 48 h, i.e., following resolution of edema. If reduction fails, emergency surgery is essential to prevent further morbidity. Emergency operation for incarcerated hernia (as seen in 2.125% patients in our series) is challenging because of the edematous cord structures and hernial sac making the dissection challenging.[1]
Amyand’s hernia is an inguinal hernia with hernial sac containing the vermiform appendix. It occurs in approximately 1% of the cases.[8] This hernia is named Amyand to honor Dr. Claudius Amyand, Sergeant Surgeon to King George II of England, who first described this phenomenon in 1735. The patient was an 11-year-old boy who presented with an enterocutaneous fistula due to the perforation of the appendix by a pin within an inguinal hernia sac. The appendix may be noninflamed or inflamed (perforated) within an inguinal hernia.[8] Right-sided Amyand’s hernia are more common than left-side because of the normal anatomical position of the appendix and also right-sided inguinal hernia is more common than left. Left-sided Amyand’s hernia has been reported with situs inversus, intestinal malrotation or a mobile cecum. In all our seven cases the cecum was mobile and fixation abnormality was present.[8,9] The management of Amyand’s hernia is based on the intraoperative findings. If the appendix is normal in right-sided Amyand’s hernia of pediatric age group, appendectomy is not recommended. On exploration, if appendicitis or perforated appendix is present, appendectomy is essential. Appendectomy is also preferred in case of (a) left-sided Amyand’s hernia as the cecum is mobile, (b) situs inversus, and (c) intestinal malrotation. It is done to prevent diagnostic dilemma of appendicitis in future owing to its atypical clinical presentation and also as a part of Ladd’s procedure.[9,10]
The Canadian Pediatric Surgeons Guidelines for optimal timing of surgical hernia repair recommend that inguinal hernia should be operated 1 week after the diagnosis.[11] Authors suggest that inguinal hernia must be operated as soon as possible following its diagnosis due to its risk of incarceration.[4]
A hydrocele is a collection of fluid in the scrotum without a recognizable inguinal hernia. It is observed shortly after birth as a unilateral or bilateral, nontender, fluid filled, transilluminant, and fluctuant swelling in the scrotum. It may sometimes be very tense. Hydroceles that persist or appear beyond 2 years of age are unlikely to resolve spontaneously and should, therefore, undergo elective surgical repair. In our series, 25% of patients were having hydrocele, while in similar studies, it ranged from 17% to 32%.[4,12]
Complications seen are wound infections, bleeding, recurrence, testicular atrophy and injury to the vas deferens. The most common complication was scrotal hematoma (0.3%) in our series. Authors recommend minimal mobilization of the cord structures and posterior floor of the inguinal canal. Recurrence was seen in 0.02% patients in present series. In a similar large series from northern Africa, recurrence was seen in 0.5% of pediatric patients, though it may be as high as 2.5%.[13,14]
The present study has quite a few strengths. Mainly, the database comprises a relatively large pediatric population. The limitations are that our study was retrospective; our data only included participants who were covered in our institute. However, our data are reliable as the coverage rate of our hospital is large portion of the population. Nevertheless, the precise number of untreated children is unknown.
Surgery within a small period after diagnosis of inguinal hernia is recommended. The aim of the pediatric surgery centers for these operations should be both successful surgery and a minimum rate of complications. The complication rate is low if the surgical procedure is performed by an experienced pediatric surgeon or under his or her strict supervision.
CONCLUSIONS
Inguinal hernia is a common cause of congenital inguinoscrotal swelling in pediatric patients. It is frequently seen in male children and right side involvement is common.
All the inguinal hernia in pediatric age group is of indirect type, which is due to patent processus vaginalis in males and “Canal of Nuck” in females. Early surgical intervention with inguinal herniotomy is the treatment of choice in inguinal hernia in children. Complications associated with inguinal hernias including those presenting with incarceration and strangulation are rare if they are managed in time and under the supervision of an experienced pediatric surgeon. We recommend a yearly clinical audit (assessment of morbidity and mortality statistics) of pediatric inguinal hernias and hydroceles managed with inguinal herniotomy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We are sincerely thankful to the faculty Department of Paediatric Surgery and Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India.
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