Abstract

Congenital inguinal hernia is a very important subject for both general and pediatric
surgeons, and many issues related to the inguinal hernia in infants and children are
still confusing. Herein, the subject of congenital inguinal hernia, including the relevant
embryology, related anatomy, the symptoms and signs essential for diagnosis, and the
needed examination tests and investigations, is presented in a systematic manner. Also,
the updated treatment options were discussed including both open and laparoscopic
approaches with spotlight on the very recent single incision laparoscopic inguinal hernia
repair in children. Finally, at the end of the chapter, there are many valuable references
for more details.

Keywords: congenital inguinal hernia, inguinal canal, infants, children, laparoscopic hernia
repair

1. Introduction

Congenital inguinal hernia in infants and children is a common surgical problem. Numerous
issues, including the rational and timing of the repair, the need to explore the contralateral
-
nal hernias in both full-term and preterm infants are commonly repaired shortly after diag-

optimal timing for repair of inguinal hernias in infants. In this chapter, the reader will be able
to know and understand:

• the embryology and anatomy of pediatric inguinal hernia,

•
•

• the treatment options for pediatric inguinal hernia, and

• the common open and laparoscopic approaches to pediatric inguinal hernias.

2. Embryology

Inguinal hernia in children represents arrest of development rather than acquired weakness.
It is directly related to the descent of the developing gonads. The testes are preceded in their

seen around the 12th week of gestation, and it is usually closed between the 36th and 40th
weeks of gestation, except for the part that becomes the tunica vaginalis. In many newborns,

Approximately 40%
.
-

contents can be herniated via the inguinal canal. However, sometimes the entrance may be
adequately covered by the internal oblique and transverses abdominal muscles, preventing
-

tunica distally, a non-communicating hydrocele is the result [1, 2].

3. Anatomy

3.1. Open anatomy

The inguinal canal is an oblique inter-muscular passage that extends from the deep to super-

internal oblique and transverses abdominis muscles. The posterior wall of the canal consists of
the transversalis fascia along its whole length. The inferior border of the canal is formed by the

Figure 1
and it was very short with both external and internal inguinal rings overlapping. Therefore,
during open herniotomy before 1 year of age, there is no need to open the external oblique
muscle [3, 4].
Figure 1. The open anatomy inguinal canal.

3.2. Laparoscopic anatomy

is no longer viewed as a protrusion from the abdominal wall, but rather as an extrusion of
a viscous from the peritoneal cavity. So, the layers of the inguinal region and the abdominal
wall are viewed in a reversed order or practically it is seen from an opposite view point.
Therefore, during laparoscopic hernia repair, the following changes must be considered: the
inguinal anatomy is visualized from inside with an optimal panoramic view of the posterior
-
lyzed and expanded abdominal wall muscles. The pneumoperitoneum itself distorts normal
-

and the abdominal wall muscles when compared with its normal characteristics found during
Figure 2 5, 6].

mid-line is the median umbilical ligament, which represents the obliterated remnant of the
embryonic urachus and extends from the fundus of the bladder to the umbilicus. The medial
umbilical ligament consists of a peritoneal fold covering the obliterated distal portion of the
Figure 2. The laparoscopic view of inguinal anatomy.

umbilical artery. The lateral umbilical ligament consists of a fold of peritoneum around the
7, 8].
The pre-peritoneal space is important for the laparoscopic surgeon. It contains a variable
amount of connective tissue, the residual of the umbilical artery, and the inferior epigastric
vessels. The external iliac vessels and the inferior epigastric vessels lie free in this space and
have no intimate anatomic relationship with the fascia transversalis, a fact that is important
during laparoscopic hernia repair. The obturator artery originating from the inferior epigas-

to this artery during inguinal hernia repair may cause serious hemorrhage into the pre-peri-
toneal space. Finally, the laparoscopic pediatric surgeon must become familiar with the pre-
peritoneal space anatomy and its vascular contents, as vascular injury during laparoscopic
hernia repair is easy and usually leads to severe hematoma formation [9 11].
The vas deferens ascends from the side wall of the pelvis, curving upward around the obliter-
ated umbilical artery, below the level of the transverse vesical fold as it passes from medial
to lateral across the external iliac vessels. Then, it disappears from view as it meets with the
testicular vessels immediately lateral to the base of the epigastric artery. The round ligament
alone enters the deep inguinal ring. The artery to the vas or round ligament accompanies each

the vas forms just a ridge beneath the peritoneum, the round ligament tends to lie deeper at
an intra-peritoneal level. The testicular vessels usually not seen through the peritoneum dis-
appear from laparoscopic view as they meet with the vas on its lateral aspect, and they enter
Figure 3 12, 13].
Figure 3.

4. Clinical presentations

60% occurring on the right side, premature infants are at higher risk. The male-to-female ratio
is estimated to be 6:1. Inguinal bulge with straining or crying is the most common presenta-
tion described by the parents or observed during physical examination. Classically, the diag-
nosis is established by history taking and clinical examination.

4.1. History taking

region in boys or inguino-labial region in girls appears with crying or straining, and usually
it disappeared during night while the baby is sleeping. The swelling is usually not associated
with pain or discomfort. But, sometimes, the parents may perceive the bulge as being pain-
ful, which is not true as it in facts causes no discomfort to the baby except if complicated. The
presence of a painful bulge should alert the pediatric surgeon to the presence of an incarcer-

inguinal hernia depending on a classic history description by parents or a referring physician,

others still insist on seeing the hernia themselves and may return the child for a second exami-
14, 15].

4.2. Clinical examination

usually starts with inspection of the inguinoscrotal region to see the inguinal bulge, and if it
is not obvious by inspection, holding baby legs and arms gently against the examination table
will result in crying with increased intra-abdominal pressure and appearance of the inguinal
bulge. For older children, blowing bubbles, or having them blow up balloons or examina-
tion gloves will increase intra-abdominal pressure and inguinal bulge may appear. The “silk

cord structures across the pubic tubercle. The feeling of a sac moving on itself is considered

-
able approach is to consider the silk purse sign as supporting but not conclusive evidence to

retractile testicle, which can be associated with an inguinal hernia. In girls, feeling the ovary
in the hernia sac is not uncommon and may be mistaken for a lymph node [16, 17].

-
ity of the direct hernia in children and the fact that direct hernia in children will never reach
scrotum, the pediatric surgeon can easily diagnose that an inguinal hernia in a child is of the

inguinal hernia. It is located below the inguinal canal, through the femoral canal. The only

inguinal ligament are clearly visualized. The clinical presentations of femoral hernias in chil-
dren are essentially the same as indirect inguinal hernias. In a case of incarcerated inguinal

be fussy, unwilling to feed, and crying inconsolably. The overlying skin may be edematous,
erythematous, and discolored. On the other hand, the hernia may be huge enough to be easily
Figure 4 18, 19].

always straightforward. The well-known trans-illumination test is essential for distinguishing

the scrotal sac. However, in cases of incarcerated inguinal hernia, trans-illumination test may
-
Figure 4. Bilateral huge congenital inguinal hernia.

-
lar torsion. In most cases, inguinal ultrasound was used to increase the diagnostic accuracy
of inguinal hernia in children from 84% on physical examination alone to 97.9% and that

mm was a hernia [20, 21].

5. Treatment

Congenital inguinal hernia repair is one of the most common operations performed by pedi-
atric surgeons, and consultations for inguinal hernia are among the most frequent reasons
for pediatric surgical referral. In infants and young children, the risk of incarceration of the

on the inguinal bulge to prevent incarceration of the contents until the elective surgery is
performed. On the other hand, in neonates, the surgical treatment of hydrocele is delayed

closed or be in the process of closing. If the hydrocele persists after this observation period,
operative repair is usually indicated [22, 23].

5.1. Open repair

Open hernia repair in children is usually an outpatient procedure. Surgery should be post-

The basic principle of the repair includes high ligation and excision of the hernia sac with or
without narrowing of the internal inguinal ring. The classical open herniotomy is performed
as follows: a lower abdominal skin crease incision is made, and then both Scarp’s fascia and

be seen. The sac is then gently separated from the cord structures, dissected to the level of
the internal inguinal ring, ligated, and divided at this level. In patients with a wide internal

recurrence or hydrocele formation, suggesting that simply opening the anterior wall is suf-

increase the risk of injury to the cord structures and the testis and may cause hematoma. It is
important to ensure that the testis is in the scrotum at the end of the operation to avoid iatro-

in the scrotum, even if the infant is younger than 12 months old. This avoids the possible risk
of incarceration, strangulation, and testicular infarction [24, 25, 26].

The introduction of the telescope through the sac of the hernia to visualize the contralat-

27, 28].

5.2. Laparoscopic repair

Laparoscopic hernia repair recently challenged the conventional open herniotomy, with
reported results that comparable to open herniotomy with nearly similar recurrence rate and

in children is a high ligation of the hernia sac from inside either in continuity using complete
purse string suture or after complete dissection of the peritoneum around internal inguinal
-

guidance [29, 30].

5.2.1. Intra-corporeal techniques

ports for the repair, two intra-peritoneal working instruments to make a complete purse
-
tion of the umbilical camera port by the open Hasson’s technique. Then pneumoperitoneum

the pelvis and both internal inguinal rings were done. Then two 3-mm ports for the working
 -

a complete purse suture around the opened internal inguinal ring, with intra-corporeal knot
tying. The sutures include only the peritoneum with no underlying tissues. The contralateral

children, when compared to open herniotomy, which was performed through a small lower
-
nia repair technique and introduced a novel technique for laparoscopic hernia repair using

his novel technique is feasible, simple, secure, and more cosmetic. It permits extension of ben-

Figure 5 18, 31, 32].

5.2.2. Percutaneous extra-corporeal technique

This technique entails percutaneous insertion of complete purse string suture using non-

Figure 5.
extra-corporeally and burred subcutaneously. The suture crosses over the spermatic duct or
the gonadal vessels to avoid their injury. In girls, the round ligaments were not dissected, and

short operative time. It is suitable for laparoscopic surgeons that don’t have a good experience
in intra-corporeal laparoscopic suturing and tying techniques. However, the main concerns
about this technique are the presence of the suture subcutaneously which may cause stitch
granuloma or sinus formation. Also, the inclusion of the abdominal wall muscles with the
suture may cause later losing of the suture or the suture may cut through the muscle which
may increase the risk of hernia recurrence. The subcutaneous endoscopic assisted ligation

Ozgediz et al., and its main principles include passing a curved needle threaded with a 2/0
non-absorbable suture through the anterior abdominal wall under direct vision to surround

driver, and the heel of the needle is backed through the subcutaneous tissue to come out
through the original stab incision. The suture is then secured and ligated subcutaneously. The
needle may jump over the vas and vessels, and a peritoneal gap may be left untouched. This
skip area is the cause of recurrence of hernia. However, if the size of the defect is extraordi-
narily wide, an additional instrument to assist guidance of the needle or conversion to open
herniotomy is necessary. The steps of the technique are showed in Figure 6 -

separate the peritoneum over the vas and the vessels [33, 34].

5.2.3. Single incision laparoscopic hernia repair

many laparoscopic surgeons prefer to perform most laparoscopic operations through sev-
eral tiny incisions rather than one large incision, to improve the cosmetic outcome. At the

Figure 6. The steps of the subcutaneous endoscopic assisted ligation technique.

newly developed technique for minimizing the post-operative pain, reducing the invasive-
ness of traditional laparoscopy, and reducing hospital stay with nearly scar less surgery.
It is a new paradigm in minimally invasive surgery world. In our hospital, we perform

Figure 7

would be no reason to perform multiple incisions in laparoscopic hernia repair in children

in single umbilical wound which is already scar area in the body, the scar is hidden in the
fold of the umbilicus, and the puncture wounds from the epidural needle are practically

than open herniotomy [35 37].

Figure 7.
scar is practically unnoticeable.
6. Post-operative care

hernia repair. Small premature babies may need overnight observation and monitoring due

very common, and they represent normal post-operative changes rather than a complica-
-
sorbed spontaneously in 95% of the cases. Only major physical activity should be avoided

most children do well with acetaminophen alone, although the addition of non-steroidal anti-

of herniotomy include injury to the vas deferens, iatrogenic cryptorchidism, and testicular

Fallopian tubes in girls subjected to bilateral herniotomy during childhood. Factors that may
contribute to recurrence after congenital inguinal hernia repair include failure to ligate the sac
high enough, tear in the sac or missing the posterior wall of the sac, leaving wide internal ring,
38].

7. Summary

Inguinal hernia in children can be a simple problem or a major catastrophe. True direct hernia is

or round ligament and should therefore not require repair per se. In fact, narrowing of a normal
internal inguinal ring may cause entrapment of the cord structures. Instead, simple ligation and
division of the hernia sac should allow the hiatus to close down to a normal functional size.

The open herniotomy through a lower skin crease incision is still the gold standard for inguinal
hernia repair in children. It is very safe, well-tolerated, with low recurrence rate, leaving early
invisible scar. On the other hand, at the moment the great advancement in laparoscopic tech-
niques for inguinal hernia repair challenged this traditional operation, because of short opera-
tive time after learning curve, the untouched cord structure with increased fertility later on

in female children, with great parent’s satisfaction. I hope to someday be proven that lapa-
roscopic hernia repair in children will be a gold standard like laparoscopic cholecystectomy.

repair of inguinal hernia in children should be undertaken as soon as possible after diagnosis.
In case of incarcerated hernia if a trial of manual reduction is to be performed, the following
precautions must be considered, the use of sedation is mandatory even anesthetic consultation

hydrocele may be confused with an incarcerated hernia, and in such situation, urgent surgical
exploration is mandatory without losing time in doing diagnostic investigations.
Laparoscopic hernia repair needs a learning curve especially in doing intra-corporeal sutur-

extra-corporeal self-sliding knot becomes a suitable solution for replacing traditional intra-

junior pediatric surgeons not to be in hurry to perform laparoscopic repair of inguinal her-

for repair of inguinal hernia in children. However, laparoscopic dissection of the hernia sac
is mandatory in recurrent cases and in the presence of very wide internal ring which needs
repair of the muscular defect. Injection of saline will elevate the peritoneum over the vas and
vessels and make a plane for the needle to pass safely. The needle sign is very important dur-
ing laparoscopic repair of inguinal hernia in which the needle and the thread are clearly seen
under the peritoneum. Inclusion of tissue with the suture around internal inguinal ring will
cause later losing of the suture with increased recurrence rate.

Home message
• Congenital inguinal hernia is a common surgical problem in infants and children.
•
• Incarcerated hernia if not managed within a reasonable time will lead to bowel necrosis and testicular atrophy.
• History is very important aspect in diagnosis of inguinal hernia in children.
• Hernias in children are usually painless, except if complicated.

Author details

Address all correspondence to: [email protected]

References

[1] -
18:1738-1741
 [2]
18:192-194
[3]
22:1751-1762

[4]
54:1020-1029

[5]

198:13-16

[6]

[7]

[8] -
9:393-398

[9] -

16:211-217.

[10]
27:985-989

[11]
86:536-540

[12]
41:980-986

[13]
1:185-187

[14]
of inguinal hernia in children. A single-institute experience with 1257 repairs compared
23:1706-1712

[15]

37:865-868

[16] -
136:696-703