Hernias Paediatric Surgery by Adnan Akram

8/14/2019 Hernias Paediatric Surgery by Adnan Akram

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Hernias

Adnan AkramRiga 2009


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As defined in 1804 by Astley Cooper, " a hernia as aprotrusion of any viscus from its proper cavity " Theprotruded parts are generally contained in a sac-like

structure, formed by the membrane with which the cavity isnaturally lined

Definations

Protrusion of an organ beyond its normal confines istermed as hernia.


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EtiologyAny condition that increases the pressure in the intra-

abdominal cavity may contribute to the formation of a hernia Marked obesity Heavy lifting Coughing Straining with defecation or urination Ascites Peritoneal dialysis Ventriculoperitoneal shunt Chronic obstructive pulmonary disease (COPD)

Family history of hernias


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Types of Hernias (location)

1. Inguinal hernia2. Femoral hernia

3. Umbilical hernia4. Incisional hernia


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Inguinal Hernia

An inguinal hernia follows the tract through the inguinal canal.

This results from a persistent process vaginalis.

Contents of this hernia thenfollow the tract of the testicle

down into the scrotal sac.

Every year in UK, 70,000surgical operations arerequired to repair inguinal

hernias


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Femoral Hernia

The femoral hernia follows the tract below the inguinal ligamentthrough the femoral canal. The canal lies medial to the femoralvein and lateral to the lacunar (Gimbernat) ligament. Becausefemoral hernias protrude through such a small defined space,

they frequently become incarcerated or strangulated.These are less common than inguinal hernias, occurring in 16out of every 100,000 people in England. Around three quartersof cases of femoral hernias occur in women.


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Femoral Hernia


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Umbilical Hernia

The umbilical hernia occurs through the umbilical fibromuscularring, which usually obliterates by 2 years of age. They arecongenital in origin and are repaired if they persist in childrenolder than age 2-4 years.

These are very common in young children, with as manyas one in six children being affected.


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Incisional Hernia

occurs in 2-10% of all abdominal operations secondary tobreakdown of the fascial closure of prior surgery. Even afterrepair, recurrence rates approach 20-45%.


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Mortality/Morbidity

Morbidity is secondary to missing the diagnosis of the hernia orcomplications associated with management of the disease. A hernia can lead to an obstructed bowel.

The hernia also can lead to strangulated bowel with acompromised blood supply. Reduced strangulated bowelleads to persistent ischemia/necrosis with no clinicalimprovement. Surgical intervention is required to preventfurther complications such as perforation and sepsis.

Ensuing surgery to repair the hernia or its complicationsmay leave the patient at risk for infection, future hernias, orintra-abdominal adhesions.


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Clinical

Patients with hernias present to the emergency department

(ED) secondary to a complication associated with the hernia. Presents as a swelling or fullness at the hernia site Aching sensation (radiates into the area of the hernia)

No true pain or tenderness upon examination Enlarges with increasing intra-abdominal pressure and/orstanding

Nausea, vomiting, and symptoms of bowel obstruction(possible)


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DD

EpididymitisHidradenitis SuppurativaHydroceleLymphogranuloma Venereum

Testicular Torsion


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Diagnostics

Complete blood count Results from CBC are nonspecific. Leukocytosis with left shift may occur with strangulation.

Urinalysis: This test assists with narrowing the differentialdiagnosis of genitourinary causes of groin pain in the settingof associated hernias.


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Investigations

Imaging Studies Ultrasonography can be used in differentiating masses in

the groin or abdominal wall or in differentiating testicularsources of swelling.

CT scanning or ultrasonography may be necessary in thefollowing cases:o To diagnose a spigelian or obturator herniao Inability to obtain a good examination because of body

habitus


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Treatment

Analgesic(IM Morphine)

Antibiotic Cefoxitin (Mefoxin)

Pediatric80 mg/kg/d IV divided into 4 equal doses q6h

SurgeryOpenSurgeryLaparoscopic (keyhole) surgery


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Hydrocele

A hydrocele is a collection of fluid within the processusvaginalis (PV) that produces swelling in the inguinal region orscrotum.


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Etiology Ambiguous genitalia

Liver disease with ascites Abdominal wall defects Continuous ambulatory peritoneal dialysis Prematurity Low birth weight

Family history of hernia or hydrocele Hydrops Meconium peritonitis Cystic fibrosis

Connective tissue disease


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Reactive Hydrocele

A reactive hydrocele can result from the following factors:

Trauma Torsion

Infection (eg, epididymo-orchitis) Abdominal or retroperitoneal operations that impair

lymphatic drainage


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Physical signs

A bulge in the groin orscrotal enlargement is the classicpresentation of hernia or communicating hydrocele.

Pain is generally not a prominent feature but may occur if a

hydrocele expands quickly; tension in the wall may causemilder pain. Severe pain raises concern about a strangulatedhernia.

Very rarely, a hydrocele may become infected and cause pain.


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DD

Abdominal TraumaCryptorchidismTesticular TorsionVaricocele in Adolescents


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Diagnostics

Laboratory Studies Laboratory evaluation is generally not essential to the evaluation of

hydroceles and hernias. Leukocytosis may be a sign of a strangulated hernia. Leukocytosis with a higher percentage of neutrophils suggests an infectious

and/or inflammatory process (eg, epididymo-orchitis).Imaging StudiesUSabdominal plain films


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Treatment

SurgeryLaparoscopy


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Thankyou

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Hernias Paediatric Surgery by Adnan Akram