One of the most frequently performed pediatric surgeries is inguinal hernia surgery. Normally, during the development of the baby in the womb, the testicle begins to develop in an area adjacent to the kidney and, under the influence of some factors, is located in the bag (scrotum) during the prenatal period. One of the factors affecting the descent of the testicle is a structure called processus vaginalis, which is an extension of the abdominal membrane and extends from the abdomen to the groin. This structure must close after the descent of the testicle. An inguinal hernia occurs when the structures in the abdomen (such as the intestines, omentum, ovaries and tubes in girls) enter the inguinal canal as a result of this abdominal membrane remaining open rather than closing. In girls, the ovary remains in the abdomen, but one of the ligaments that help keep the uterus stable in the abdomen passes through the inguinal canal and attaches to the labium. The extension of the abdominal membrane, which we call the processus vaginalis, is normally open at a rate of 10-20%. However, the incidence of inguinal hernia is around 1-2%. There is no rule that every open processus vaginalis will develop an inguinal hernia. One day, without any reason or for any reason (straining, coughing, crying, jumping from heights, etc.), the intra-abdominal organs enter the inguinal canal and form a hernia. It is more common in boys and on the right side. It can be seen on both sides at a rate of 10%.
This type of inguinal hernia seen in children is called indirect hernia. Direct hernia, which is seen in adults, is very rare in children.
What are the symptoms of inguinal hernia?
Inguinal hernia manifests itself with a painless swelling or bulge in the groin area. This swelling may be limited to the groin area, or it may extend to the scrotum in boys and the labium in girls. The cause of this swelling is the intra-abdominal organs entering the hernia sac, and this swelling becomes more obvious in cases where intra-abdominal pressure increases, such as crying or coughing. The swelling may disappear spontaneously as the intra-abdominal organs return to their normal position. It often disappears by pressing on it, just like it does. However, it becomes evident again in situations such as crying, straining and coughing. This situation may recur frequently.
How is Inguinal Hernia Diagnosed?
In inguinal hernias in babies and children, the first person to notice the condition is often the mother. A mother who sees a swelling in the groin area brings her child to the doctor with this finding at the first time she sees it or in case of recurrent swelling. During a doctor's examination, if the swelling in the groin disappears when you press it upwards and outwards with your hand, a hernia is diagnosed. However, sometimes the swelling may have disappeared when the baby or child is brought for examination. In this case, the pediatric surgeon diagnoses hernia with a careful examination. Once the diagnosis is made, there is no need for any further examination. However, if the diagnosis cannot be made or to distinguish inguinal hernia from hydrocele and other conditions that cause swelling in the groin, ultrasonographic examination may be required.
Which Diseases Are Included in the Differential Diagnosis of Inguinal Hernia?
It is necessary to distinguish inguinal hernia from conditions such as lymph node enlargements, abscess and dermoid cyst that cause swelling in the groin area. Particular attention should be paid to the fact that the testicle is in its normal position during examination. Sometimes a testicle that does not descend normally can be confused with an inguinal hernia.
What is a Strangulated Hernia?
In 10% of children with inguinal hernia, the organs that have entered the hernial sac get stuck here and the abdomen They can't go back into it. This situation is called hernia strangulation (incarceration). Hernia strangulation is a painful condition. The child is restless, cries, and may vomit in the coming hours. The groin area becomes tender, red, and may even bruise. In this case, your child needs to be examined urgently by a pediatric surgeon. The organ stuck in the groin is tried to be returned into the abdomen by the pediatric surgeon by pressing it properly by hand (hernia reduction). If the trapped organ cannot be reversed, blood circulation is disrupted and gangrene may occur (strangulation). In this case, urgent surgery is required. If the contents of the sac are reduced, surgery is performed after 48 hours. The reason for waiting for this period is the damage on the sac wall. It is for the purpose of solving the problem and making the surgery safer. The younger the child, the greater the risk of strangulation due to a hernia. The majority of strangulated hernias occur in children under the age of 1.
When and How is an Inguinal Hernia Treated?
When an inguinal hernia is diagnosed, as soon as possible. (not urgent)surgery should be planned. The surgery is performed on an outpatient basis without the child being hospitalized. If a hernia is detected in a newborn baby, the surgery is planned and performed at an appropriate time, if the baby's health conditions are suitable, without waiting. Surgery is planned when a hernia is diagnosed due to the possibility of serious complications such as incarceration or strangulation. It is not possible to correct the hernia by waiting or by applying a hernia ligation. The complication rate after emergency surgeries performed due to incarcerated hernia or strangulated hernia is much higher than hernia surgeries performed under normal conditions. For this reason, surgery should be planned as soon as the diagnosis is made, especially in small babies. The surgery is performed under general anesthesia through a small (1.52cm) incision in the groin area. The hernial sac (the open processus vaginalis) is ligated and cut. The skin is closed aesthetically with absorbable stitches. While the surgery area is closed, a local anesthetic is injected into that area to prevent the baby or child from feeling pain, and a pain-relieving suppository is inserted into the anus. In this way, the postoperative period is ensured to be painless. The child begins to be fed orally two hours after the surgery and is discharged from the hospital on the same day.
Post-Operative Period
After the surgery, almost every child stands up and returns to his/her daily life as soon as possible. To prevent pain, babies are given pain-relieving suppositories and older children are given pain-relieving syrup. On the third day after the surgery, you will be called for a check-up, the dressing will be removed and the surgical area will be checked. If there is no negative development, all kinds of activities are allowed, including bathing. If there is bleeding, abnormal swelling, redness and bruising in the surgery area; If conditions such as abdominal pain or swelling in the abdomen and inability to defecate develop, spend time with your child. It is appropriate to bring it to your doctor beforehand. Inguinal hernia surgeries are extremely safe and have a very low complication rate when performed by pediatric surgeons or pediatric urologists.
What is a water hernia (Hydrocele)?
A water hernia (hydrocele) develops as a result of the processus vaginalis, which should normally close after birth, not closing, but only being open enough for intra-abdominal fluid to pass through. If the hydrocele is limited to the testicle, it is defined as testicular hydrocele, and if it is limited as a cystic structure along the spermatic cord, it is defined as cord hydrocele or cord cyst. If the hydrocele is associated with the abdominal cavity, it is defined as a communicating hydrocele. In this case, the swelling increases when the child is awake and active; It decreases or disappears when the child sleeps and lies down calmly. Hydrocele is manifested by a painless, water-filled swelling in the inguinal area or scrotum. On examination, it is felt as a non-tender, water-filled cystic structure. Since spontaneous closure of the processus vaginalis may be delayed until the age of 2, surgical treatment of communicating hydrocele is waited until the age of 1.5-2. If it is a cord cyst or testicular hydrocele, surgery can be performed earlier depending on the size of the mass. Surgical treatment of hydrocele is similar to the treatment of indirect inguinal hernia.
Conclusion
Inguinal hernia in children is a serious condition that requires surgery as soon as it is diagnosed, which can cause severe complications such as incarceration and intestinal gangrene if left untreated. is a situation. The important thing is to perform the surgery safely before such complications develop.
We wish you and your children health and happiness,
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