Inguinal Hernia

Inguinal hernia

The patient with a swollen and/or painful scrotum will usually not go unnoticed. We have previously discussed testicular torsion and the association of the acute scrotum and HSP.  We have also discussed the presentation of Varicoceles. Now let us look another commonly encountered cause of the acute scrotum: the Indirect Inguinal Hernia.

Inguinal Hernia – Basics

  • Most congenital abnormality requiring surgery
  • Occurs in 0.2% of live births
  • Rates are highest amongst premature infants
    • 7-10% of infants born less than 36 weeks gestastional age will have inguinal hernias. (Boocock, 1985)
  • Inguinal hernias are more common in boys.
  • They are more common on the right side.

 

Inguinal Hernia – Presentation

  • Often present within 1st year of life.
  • May present as an asymptomatic bulge in the groin or scrotum.
    • May resolve when calm and supine.
  • Can become complicated by incarceration or strangulation.
    • 7-30% of hernias
    • When incarcerated the child will become uncomfortable / irritable.

 

Inguinal Hernia – Manual Reduction

  • Strangulation of the hernia is contra-indication of manual reduction.
    • Classic teaching states that gangrenous bowel will not reduce…
      • This is not necessarily true, so just because you were successful at the reduction, doesn’t mean everything is good. (Strauch, 2002)
      • Close observation with good anticipatory guidance is required if you send the child home.
    • Signs of strangulation:
      • Severe pain
      • Bilious emesis
      • Blood in Stool
      • Signs of peritonitis
      • Redness and edema overlying the affected side of the scrotum
    • Manual Reduction Steps (suggested)
      • GIVE PAIN MEDICATIONS
        • The child will be uncomfortable as you attempt the reduction.
          • The discomfort will be counterproductive to your efforts.
          • One study showed that more than half of the kids with incarcerated hernias DID NOT receive ANY medications. (Al-Ansari, 2008)
          • Don’t be a brut.
        • Consider IV or Intranasal
      • Place in Trendelenburg position (let Gravity help you!)
      • Align the Hernia Sac
        • Instead of just pushing on the intestinal mass, which is likely swollen and slightly larger than the external inguinal ring…
        • Use gentle traction on the scrotum to help align the hernia sac with the external ring.
        • While keeping gentle traction, you can begin to attempt to decompress the contents from that bowel segment by gentle squeezing from distal to proximal.
      • Open the Internal and External Rings
        • Using the other hand, now apply pressure laterally with the index and thumb along each side of the hernia neck and inguinal canal.
        • Imagine you are trying to stretch open the rings.
      • Gently add more pressure distally and help reduce the hernia.
      • BE PATIENT!
        • This process can take several minutes.
        • Some have documented up to 40 minutes (Davies, 1990)
      • For some pictures see – NETS.ORG.AU

 

References

Al-Ansari K1, Sulowski C, Ratnapalan S. Analgesia and sedation practices for incarcerated inguinal hernias in children. Clin Pediatr (Phila). 2008 Oct;47(8):766-9. PMID: 18490664. [PubMed] [Read by QxMD]

Strauch ED1, Voigt RW, Hill JL. Gangrenous intestine in a hernia can be reduced. J Pediatr Surg. 2002 Jun;37(6):919-20. PMID: 12037764. [PubMed] [Read by QxMD]

Davies N1, Najmaldin A, Burge DM. Irreducible inguinal hernia in children below two years of age. Br J Surg. 1990 Nov;77(11):1291-2. PMID: 2101598. [PubMed] [Read by QxMD]

Boocock GR, Todd PJ. Inguinal hernias are common in preterm infants. Arch Dis Child. 1985 Jul;60(7):669-70. PMID: 4026366. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

5 Responses

  1. DONELLA FLORENCE says:

    Really important topic to point out. thanks for sharing

    Medical Books Store

  2. Dr sathish nayak says:

    Very useful article.

  1. December 23, 2016

    […] children. Clin Pediatr (Phila). 2008;47(8):766-769. [PubMed] 4. Inguinal hernias. pedemmorsels. http://pedemmorsels.com/inguinal-hernia/. Published January 22, 2015. Accessed December 21, […]

  2. August 25, 2017

    […] Inguinal Hernia […]

Leave a Reply

Your email address will not be published. Required fields are marked *