ORIGINAL ARTICLE

Knowledge, Attitude and Practice of General surgeons regarding

Paediatric inguinal hernia and hydrocele
ASIF IQBAL, ASAD SHARIF, ABEER ASIF, SOMIA ILYAS, TAHIR ANWER, NAEEM LIAQAT, SAJID HAMEED
DAR

ABSTRACT
Background: Inguinal herniotomy in children is a commonly preformed elective procedure. Early
herniotomy saves a significant number of patients from complications which may occur due to
obstruction or strangulation of intestine. Even in developing areas of the world, morbidity and mortality
related to complications are high in children especially in neonates.
Aim: To assess the knowledge, attitude and practices of general surgeons (GS) regarding pediatric
inguinal hernia & hydrocele
Methods: This study was conducted at services hospital Lahore over a period of two months from
October 2016 to November 2016 at different teaching hospitals in Lahore and sheikhupura. A
questionnaire was offered to GS which was divided into two parts: i. basic demographic data, ii: (a)
knowledge (b) attitude and practice. Data was analyzed using SPSS version 20.
Results: A total of 196 GS filled the proforma. The mean age of respondents was found to be
36.08±9.36 years. Among them, 172 respondents (87.8%) were male while 24 (12.2%) were females.
Among responders 53 %of the GS were right about the timing of intervention in hernia while 47%
suggest to with for 2 or 5 years.
Conclusion: On the bases of study we conclude herniotomy, although as simple procedure, its proper
management is still unknown to GS, particularly the young surgeons. We need to train young GS
regarding the proper management of hernia & hydrocele in pediatric population.
Keywords: Herniotomy; complications; morbidity; neonates.

INTRODUCTION
knowledge, attitude and practices of general
Inguinal hernia and hydrocele in pediatric age group surgeons towards pediatrics inguinal hernia and
are most frequently seen conditions. Recommended hydrocele.
1
procedure in both surgical conditions is herniotomy .
In case of inguinal hernia, early herniotomy saves a
MATERIAL & METHODS
significant number of patients from complications
2
which may occur due to obstruction or strangulation . This cross-sectional study was conducted at Services
Even in developing areas of the world morbidity and Hospital. Lahore over a period of 2 months, from
mortality related to complications are high in children October, 2016 to November, 2016. All available
especially in neonates. In developing countries like consultant GS and residents working at teaching
us, the risk of incarceration and complications is hospitals of Lahore and sheikhupura were asked to
3
much higher . Delayed treatment is to due poverty be included in the study. After approval from ethical
and lack of awareness among parents and lack review board, the questionnaire was offered to GS
proper knowledge of general practitioners and even which was divided into two parts: i. first portion
general surgeons about the timings of surgery for contains the basic demographic data (age, gender,
inguinal hernia in neonates and children. In routine year of graduation, year of post graduation, total
practice diagnosis of both inguinal hernia and experience after graduation, present working post
hydrocele is made on the history, parent’s and exposure to department of paediatric surgery.
4
observation, and clinical examination . Some of the Part ii: again included of two parts (a) knowledge (b)
investigation are also tried previously to confirm the attitude and practice. First part included basic
diagnosis like x- ray with contrast. Inguinal ultrasound questions regarding hernia and hydrocele
2 nd
is useful tool in asymptomatic cases . This cross management while 2 part included the simple
sectional study was planned to assess the questions and information about their personal
----------------------------------------------------------------------- experience and level of difficulty according to age.
Department of Paediatric Surgery, Services Institute of Medical All the data was analyzed using SPSS version 20.
Sciences, Lahore
Correspondence to Dr. Asif Iqbal Email: [email protected]
The quantitave variables like age were as presented
Cell: 0331-4838518 mean±SD. Qualitative variables like gender and other

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 Asif Iqbal, Asad Sharif, Abeer Asif et al

demographic variables were presented as frequency children below the age of one year is much higher
9
and percentages. P-value ≤ 0.05 was considered as when compared with older children . However the
significant procedure can be delayed if there are any ongoing
respiratory tract infections, ear infections or evidence
2
RESULTS of dermatological lesions in the area of operation . In
our study half of GS (53%) were right about the
A total of 196 GS filled the proforma. The mean age timing of intervention in hernia while 47% suggest to
of respondents was found to be 36.08±9.36 years. with for 2 or 5 years.
Among them, 172 respondents (87.8%) were male Bilateral hernia surgery is preferred approach
while 24(12.2%) were females. Most of them had among pediatric surgeons in healthy patients. This
experience less than 10 years and 111 participants approach reduces the risk of contralateral hernia
(56.5%) had worked at paediatric surgery complications. In this modern era of laparoscopy
department. All the details about biodata are given in bilateral herniotomy is the procedure of choice
2, 10
. It
table 1. is only contraindicated when there is obstruction/
We had 6 questions related to knowledge and 4 strangulation for which emergency surgery is
questions regarding attitude and practice of GS required. Most of responder agreed upon bilateral
towards patients with inguinal hernia. All the herniotomy in a single setting while 41% disagreed
questions and their answers are summarized in table and 10% of them not sure what to do.
2. Also we had stratified the correct answers of All pediatric surgical centers including ours,
respondents regarding age for inguinal herniotomy reduces the hernia under sedation and keep admitted
for inguinal hernia and age for surgery for hydrocele the patient for couple of days for elective surgery.
and are summarized in table 3 and table 4. The thought behind this delay is gave time for
settlement of edema. In the presence of edema the
DISCUSSION risk of complication can be higher. If the manual
Pediatric inguinal herniotomy is one of the most reduction did not work or signs of strangulation
commonly performed procedures. Historically appear emergency surgery is recommended.
considered as an “intern case”; at occasions it can be Responder above 50% of our study was advised
very challenging even for an expert pediatric emergency surgery. Thirty eight percent agreed with
surgeon. In experienced hands, repair can often be pediatric surgeon and 29% think if manual reduction
performed rapidly and with a low complication rate .
4 fails than emergency surgery.
In our study we assessed the knowledge, If no visible swelling is present, then the older
attitude and skills of GS about pediatric inguinal child should be allowed to stand, while infant is
hernia & hydrocele. Most of the participants were restrained so that he strains or cries to enable the
male 87% which may be attributed to less prevalence examiner to determine the presence of an inguinal
of female general surgeons in Pakistan. Major group swelling. Despite increasing intra-abdominal
of responders were having experience less than 10 pressure, a swelling cannot be demonstrated. In this
years & above 60% worked in pediatric surgery situation the cord is palpated to determine its
11
department. thickening . On the affected side the cord structures
Six basic questions were asked from GS. Most feel thicker when compared with the unaffected side.
imported question was age of surgical intervention in If the parents sure about the swelling while no
hernia& hydrocele. sign are present some surgeons prefer to do the
Herniotomy is recommended for inguinal hernia herniotomy. Ultrasonography is gaining popularity
5
soon after diagnosis . Early herniotomy saves a now a days in these small set of patient where no
significant number of patients from complications visible swelling seen. According to Erez et al.
which may occur due to obstruction or strangulation reported that diameter of inguinal canal above
2,13
6
of hernia . In order to prevent incarceration and 7.2±2mm is an indication of true hernia . In our
strangulation, hernia surgery is indicated immediately study 58% thing re-vist or re examination 25% wants
7
after diagnosis . Half of the patients with complicated to rely on parents while 16% recommend
2
hernia present before six months of age .According ultrasonography of the inguinal canal for diagnosis.
to a recent study, 79% of premature infants with Among pediatric surgeon hydrocele needs
inguinal hernia in neonatal intensive care units had observation till 12 to 24 months of life. If it remains
8
repair done just before discharge . Safety of modern unresolved by 2 years of life, surgical correction is
anesthesia has made this a practical approach. recommended is performed electively. Early surgery
Another study conducted by Özdemir & Arıkan is indicated when there associated hernia or any
14
reported that risk of incarceration and strangulation in underlying testicular pathology . Fifty four percent of
the general surgeons were right in our study while

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Knowledge, Attitude and Practice of gen. surgeons regarding paediatric inguinal hernia and hydrocele

other responded 23% and 22% as soon as possible 2. Glick PL, Boulanger SC. Inguinal hernias and
or at the age of 5 years respectively. hydroceles. Pediatric surgery. 2012; 2:986–987.
Standard procedure for hydrocele treatment in 3. Livingston MH, DCruz J, Pemberton J, Ozgediz D,
children is herniotomy. Aspiration or drainage is Poenaru D. Mortality of pediatric surgical conditions in
low and middle income countries in Africa. Journal of
contraindicated in children. In this study 79.6% pediatric surgery. 2015 May 31;50(5):760-4.
general surgeon gave the right answer, while 22.4 4. Palmer LS. Hernias and hydroceles. Pediatrics in
goes with aspiration or drainage of hydrocele. Review/American Academy of Pediatrics. 2013
Regarding attitude & practice of general Oct;34(10):457-64.
surgeons 4 questions were asked, in which referral of 5. Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF,
patients to paediatric surgery, age at which general Caty MG, Glick PL. Variability of inguinal hernia
surgeon feel uncomfortable and protocol to calculate surgical technique: a survey of North American
the dosage in pediatrics were assessed. pediatric surgeons. Journal of pediatric surgery. 2002
Since the surgery start, GS doing the surgeries May 31;37(5):745-51.
6. Head E, Madurska M. Abdominal wall hernias.
upon paediatric patients and Children called as InnovAiT. 2014 Nov;7(11):668-74.
young adults. As the time passed they came to know 7. Hebra, A., Glenn, J.B. Inguinal Hernia and
about unique feature of anatomy and physiology of Hydrocoele, in: Fundamentals of Pediatric Surgery.
children makes them thick about proper training or Springer New York. 2011. 663–672.
15
referral to trained people . In country like Pakistan 8. Crankson SJ, Al Tawil K, Al Namshan M, Al Jadaan S,
was pediatric surgery is a growing specialty and Baylon BJ, Gieballa M, Ahmed IH. Management of
general surgery departments should help to improve. inguinal hernia in premature infants: 10-year
GS who refer the patients to department of paediatric experience. Journal of Indian Association of Pediatric
surgery under the age of 1 month were 26%. And Surgeons. 2015 Jan;20(1):21.
9. Özdemir T, Arıkan A. Postoperative apnea after
less than 12 years 32.7% while other were refer inguinal hernia repair in formerly premature infants:
between ages of 6 months to 5 years. impacts of gestational age, postconceptional age and
Most of the GS feel uncomfortable under the comorbidities. Pediatric surgery international. 2013
age 1year. Some of them under 1 month while all the Aug 1;29(8):801-4.
GS were feel comfortable in doing herniotomy above 10. Lee DG, Lee YS, Park KH, Baek M. Risk factors for
the age of 5 years in this study contralateral patent processus vaginalis determined by
Among medical errors most common is transinguinal laparoscopic examination. Experimental
16 and therapeutic medicine. 2015 Feb 1;9(2):421-4.
medication error . Muhammad AA., reported that
medication error is 3 time more come in children 11. Kapur P, Caty MG, Glick PL. Pediatric hernias and
hydroceles. Pediatric Clinics of North America. 1998
when compared with adults. They also found 34% Aug 1;45(4):773-89.
17
medication error in study for prescribed antibiotic . In 12. Tekgül S, Riedmiller H, Gerharz E, Hoebeke P,
our study 60% of GS knew the exact dose of fluids Kocvara R, Nijman R, Radmayr C, Stein R. Guidelines
and antibiotics according to weight, 21 % consult on. Update. 2009 Mar.
pharma guide. Ten percent GS call to a pediatrician 13. Shalaby A, Curry J. Inguinal Hernias in Children.
for dose adjustment and rest of them reduces dose to InManagement of Abdominal Hernias 2013 (pp. 185-
half of the adult dose. 199). Springer London.
14. Peng Y, Li C, Lin W, Xu L. Application of a
laparoscopic, single-port, double-needle technique for
CONCLUSION pediatric hydroceles with multiple peritoneal folds: a
On the basis of the study we conclude that trial from a single-center 5-year experience. Urology.
herniotomy, although as simple procedure, its proper 2015 Jun 30;85(6):1466-70.
15. Akhtar J. Paediatric Surgery in Pakistan: Specialty
management is still unknown to GS, particularly the Come of Age. JLUMHS. 2008 Sep:146.
young surgeons. We need to train young GS 16. Cheragi MA, Manoocheri H, Mohammadnejad E,
regarding the proper management of hernia & Ehsani SR. Types and causes of medication errors
hydrocele in pediatric population. from nurse’s viewpoint. Iranian journal of nursing and
midwifery research. 2014 Jun 1;18(3).
REFERENCE 17. Aseeri MA. The impact of a pediatric antibiotic
standard dosing table on dosing errors. The Journal of
1. Magazines T, Savers S. IPEG Guidelines for Inguinal Pediatric Pharmacology and Therapeutics. 2013
Hernia and Hydrocele. Sep;18(3):220-6.

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Table 1: Demographic details of participants

N (%)
Age (in years) 36.08±9.36 yrs
Gender
Male 172 (87.8%)
Female 24 (12.2%)
Post-graduation experience
<10 years 122 (62.6%)
10-20 years 54 (27.6%)
>20 years 20 (10.2%)
Current level
Trainee 105 (53.6%)
Senior registrar 49 (25%)
Consultant 42 (21.4%)
Have you worked in Paediatric Surgery department?
Yes 111 (56.6%)
No 85 (43.4%)

Table 2: Questions to be asked for participants in this study

Questions: n (%)
1. 1 When inguinal hernia surgery is required in pediatric patient?
a. As soon as possible, when medically fit 104(53.1%)
b. Up to age of 2 years 72(36.7%)
c. Up to age of 5 years 20(10.2%)
2. 2 Do you prefer bilateral herniotomy in a single sitting?
a. Yes 103(52.6%)
b. No 81(41.3%)
c. Not sure 12(10.2%)
3. What is the treatment of irreducible inguinal hernia in children?
a. Emergency surgery 100(51%)
b. Manual reduction then elective surgery 38(19.4%)
c. If manual reduction fails then emergency surgery 58(29.6%)
4. If hernial swelling is not visible but parents are sure about it what is your opinion?
a. Re-visit 90(45.9%)
b. Re-examine 24(12.2%)
c. Rely on parents 50(25.5%)
d. Ultrasound 32(16.3%)
5. When hydroceles require surgery in pediatric patients
a. As soon as possible, when medically fit 44(22.4%)
b. Around the age of 2 years 106(54.1%)
c. Around the age of 5 years 46(23.5%)
6. What is the treatment of hydrocele in children?
a. Herniotomy 156(79.6%)
b. Aspiration 20(10.2%)
c. Drainage 20(10.2%)
ATTITUDE AND PRACTICE:
7. Below which age you usually refer the patients with inguinal hernia/hydrocele to
pediatric surgery department?
a. Under 1month of age 26(13.3%)
b. Under 6month of age 41(20.9%)
c. Under 1years of age 33(16.8%)
d. Under 5 years of age 32(16.3%)
e. Under 12years of age 64(32.7%)
8. Do you perform inguinal herniotomy?
a. Yes 160(81.6%)
b. No 32(16.3%)
c. No reply 4(2.0%)
9. In which age group you feel uncomfortable while performing inguinal herniotomy in
children? 55(28.1%)
a. Under 1month of age 41(20.9%)
b. Under 6month of age 68(34.7%)
c. Under 1years of age 32(16.3%)
d. Under 5 years of age
10. How do you write down dose of I.V fluids and I.V antibiotics in children?
a. I know exact dose according to weight 118(60.2%)
b. I always consult a pharma guide 42(21.4%)
c. I send a call to pediatrics department for dose adjustment 20(10.2%)
d. I reduce the dose to half of adult dose 16(8.2%)

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Knowledge, Attitude and Practice of gen. surgeons regarding paediatric inguinal hernia and hydrocele

Table 3: stratification of correct answer regarding age for inguinal herniotomy

Age for inguinal herniotomy P-Value
Right Answer Wrong Answer
Experience
<10 years 57 52
10-20 Years 30 24 0.79
>20 Years 12 8
Level
Trainee 49 56 0.000
Senior Registrar 21 28
Consultant 34 8
Experience in Paediatric Surgery
Yes 67 44 0.019
No 37 48
Do you perform inguinal herniotomy?
Yes 96 64 0.000
No 8 28

Table 4: Stratification of correct answer regarding age for inguinal herniotomy for hydrocoele
Age for surgery for hydrocoele in children P-Value
Right Answer Wrong Answer
Experience
<10 years 49 60
10-20 Years 32 22 0.008
>20 Years 16 4
Level
Trainee 49 56
Senior Registrar 28 21 0.334
Consultant 29 22
Experience in Paediatric Surgery
Yes 65 46 0.150
No 41 44
Do you perform inguinal herniotomy? 0.844
Yes 86 74
No 20 16

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