Pediatric Inguinal Hernia and Hydrocele

History
Inguinal hernia remains one of the most common surgical disorders in children.
Literature for inguinal hernia has spanned more than 20 centuries and with new
techniques there have been new insights into management as well. Inguinal hernia is a
perfect example of a disorder where seemingly a lot has changed whereas in effect
nothing much has changed. As medical students it is often the first surgical disorder to
be demonstrated in ward rounds and which we learn to examine and diagnose.
Galen in 176 A.D was the first one to describe the pathogenesis of indirect inguinal
hernia when he described the processus vaginalis as The duct descending to the
testicle is a small offshoot of the great peritoneal sac in the lower abdomen (processus
vaginalis peritonei) [1, Singer, 1956]. First documented surgical therapy for inguinal
hernia was in 5th century A.D. by Susruta from India- also referred to as Father of Indian
Surgery [2]. An accurate description of inguinal canal anatomy preceded the first
successful repair in early 19th century. Contributions received from Camper, Cooper,
Hesselbach and Scarpa laid the foundations for Bassini and Halsted to propose sound
anatomical repairs [3-8]. Further results were enhanced by promulgation of antiseptic
techniques by Lister which allowed surgeons to proceed with surgery without worries of
wound infection, which was then the bane of all surgical procedures [9].
Ferguson proposed hernia repair by just exposure, dissection, simple high ligation and
removal of the hernia sac, and this was applied successfully to the pediatric population
by Potts et al [10,11]. While in adult hernia repairs, the underlying principle involved
reconstruction of weakened muscles and aponeurosis in multiple anatomical layers, for
pediatric hernia simple dissection and high ligation of processus at internal ring was
found to be sufficient to provide a long lasting cure to repair indirect inguinal hernia. The
Ferguson principle sans the excision of hernia sac still is the basis of all pediatric hernia
repairs even in the 21st century. With advances in operating room asepsis, better suture
materials and pediatric anesthesia almost all the indirect hernia repairs have become
day surgery procedures.
Pathogenesis
Inguinal hernia and various types of hydrocele in children result from a patent processus
vaginalis which has failed to obliterate after the descent of testis through it (Figure 1).

A: Schematic representation of normal anatomy of spermatic cord and inguinal canal.

B: Collection of fluid around

testis in tunical vaginalis constitutes scrotal hydrocele

C: Communicating hydrocele exists

when the processus vaginalis is patent through inguinal

D: Herniation of bowel loops into scrotum in an

3
4

inguinal hernia.
(Illustrations by Dr Paul Gleich, M.D.)
In contrast to acquired weakness leading to hernias in adults, indirect inguinal hernias in

5
6

children result from an arrest of embryologic development and this also explains the
increased incidence in premature infants. The formation of inguinal hernias in children is
directly linked to descent of the developing gonads. In the developing fetus, the
processus vaginalis is first seen as an outpouching of the peritoneal cavity in the third
month of gestation. Testes develop in the embryologic retroperitoneum near the kidney
and come to lie at the level of the internal ring in the seventh month. The processus
vaginalis extends across the inguinal canal into the scrotum and provides the necessary
pathway for the testis to make its way into scrotum. Once this pathway is laid, a well
orchestrated sequence of events allows the testis to descend to the scrotum [12].
Shortly after descent of testis, sometime in the first few months of life, most of the
processus gradually obliterates except the terminal portion around testis which persists
as the tunica vaginalis. The tunica normally contains a small amount of fluid and invests
the testis on almost all sides in the scrotum forming an important covering and a
protective layer for the testis. Hydrocele and hernia occurs as a variation of this theme
itself whereby a part of processus vaginalis remains behind. The calibre of the patent
processus determines whether a hernia or a hydrocele will manifest. A small calibre
channel allows only peritoneal fluid to seep through leading to a communicating
hydrocele, while a larger defect allows intra-abdominal viscera to migrate manifesting as
an inguinal hernia. The precise timing of spontaneous closure of the processus is not
known in the normal population as most of the studies concerning the rates of patencies
at various ages in childhood have been done at the time of contralateral open or
laparoscopic visualisation during routine hernia repair. According to variable data, 40%
of the patent processus vaginalis close during first few months of life and an additional
20% close by 2 years of age [13, 14]. As the left testis descends before the right, the
right processus closes later explaining the higher incidence of hernias and patent
processus on the right side. A patent processus has been recognised more and more
often with evolution of laparoscopic techniques for pediatric hernia repairs and has been
theorised to be a potential area for development for hernia [14]. The presence of a
patent processus vaginalis is a necessary but not sufficient variable in developing a
congenital indirect inguinal hernia. Put in another way, all congenital indirect inguinal
hernias are preceded by a patent processus vaginalis, but not all patent processus
vaginalis go on to become inguinal hernias. In recent studies on adults with indirect
hernias, the contralateral processus has been found to be patent in 12-14%, and further,
in those with patent rings only 12-14% have been shown to develop contralateral hernias
[15, 16]. Because the overall incidence of indirect inguinal hernias in the population is
approximately 1% to 2% and the incidence of a patent processus vaginalis is
approximately 12% to 14%, clinically appreciable inguinal hernias should develop in
approximately 8% to 12% of patients with a patent processus vaginalis [17]. These data
imply that all open internal rings and patent processuses do not lead to clinical hernia.
There may be other factors which may influence the development of clinically evident
herniaHERNIASEpidemiology
Incidence, Age, Sex, Side, Family History
Inguinal hernia is one of the common disorders in childhood and has been documented
to occur in 0.8-4.4% of the children; the incidence is higher in neonates and infants
[18,19]. The incidence of pediatric inguinal hernia is highest during the first year of life
and then gradually decreases thereafter. One-third of children undergoing surgery for
hernia are less than 6 months of age [15]. Premature infants have an even higher risk of
developing inguinal hernia with reports of incidence of upto 25% [20-22].
Incidence of hernia is 6 times more in boys than girls, and the sex ratio has been
reported to be variously from 3:1 to 10:1 [23]. This is possibly related to descent of testis
through the inguinal canals in males.

8
9

10
11

Hernias are more common on right side with 60% occurring on the right side, 30% on left
side and 10% are bilateral. This distribution does not change with sex as even in girls a
right side predominance is seen [23].
Increased incidence of inguinal hernia has been documented in the second twin once
the first one has been diagnosed to have a hernia. Sisters of an affected girl have the
highest relative risk of 17% while for other siblings, the risk is 4-5% [24]. Also, there may
be a history of inguinal hernia in another member of the family in 11.5% of the cases
[18,24,25].
Risk Factors for hernia:
Table 1: Table 1: Risk factors for increased incidence of hernia in children
Undescended testis
Urogenital
Exstrophy of bladder
Increased peritoneal fluid

Ascites
Presence of Ventriculoperitoneal shunt
Peritoneal dialysis

Increased intra-abdominal
pressure

Repair of gastroschisis/ exomphalos

Severe ascites- liver failure, chylous etc
Meconium peritonitis

55
56
57
58

59

Chronic respiratory disease

Cystic fibrosis

Connective tissue disorders

Ehlers-Danlos syndrome
Hunter- Hurler syndrome
Marfan syndrome
Mucopolysaccharidosis

Miscellaneous

Developmental dysplasia of hip

Clinical Features
Symptoms
Inguinal hernia is suspected when a child is noticed to have a swelling in inguinal area or
scrotal area (Figure 2). Classically, the hernia swelling is intermittent in nature,
appearing only when intra-abdominal pressure rises, forcing intra-abdominal contents
down the inguinal canal. Commonly this occurs when the child is coughing, playing or
crying. At this stage the hernia is reducible and there are no other symptoms.
Occasionally, in a large hernia, there may be some dragging sensation or mild heaviness
in the scrotal or inguinal area. Significant pain signifies onset of complications such as
incarceration or strangulation.Examination
Examination for hernia requires patience and involvement to keep the small child
engaged. It is a good practice to establish a rapport and not to hurry for the examination.
Hands should be warm and the ambient temperature in the room should not be too low
so as to prevent shivering and discomfort. Clinically, in a child with an evident hernia a
smooth soft mass would be seen emerging from external ring which lies cephalad and

60

61

62

63

64

lateral to pubic tubercle. This mass would be seen to enlarge when the child strains,
cries or coughs. In case of an uncooperative child or preverbal age, straining can
induced, by one of the many techniques to elicit hernia. The most common method is to
try to straighten the legs as this causes the baby to strain and may result in hernia
becoming evident.
Many a times a hernia is suspected on basis of history but cannot be demonstrated on
examination in the outpatient setting. If the history is classical and referring pediatrician/
physician has seen the swelling and confirmed it to be a hernia, then surgery can be
recommended. In case of any doubt, it may be wise to call for a second visit or ask the
pediatrician/ physician to confirm whenever possible. Another diagnostic aid is the so
called Silk Glove Sign. Silk glove sign refers to thickening and silkiness of the
spermatic cord which can be palpated as the cord crosses the pubic tubercle [26]. This
indicates presence of hernia sac around the cord and is a reliable sign especially in a
unilateral hernia where the difference between the two sides may be easy to appreciate.
A recent study has documented 91% sensitivity and more than 97% specificity for silk
glove sign to predict presence of hernia [27].
On relaxing, the hernia swelling may disappear or become less prominent or it can be
gently reduced by superolateral pressure towards the internal ring. Sometimes a
retractile testis may lie near the external ring or even in the inguinal canal giving rise to a
bulge in the inguinal region which can be mistaken for a hernia. Therefore, one must
ascertain the position of testis before beginning examination for hernia. If the testis is
retractile, then it should be brought into scrotum and then only hernia examination
should be begun. Secondly, hernias are a part and parcel of the spectrum of
undescended testis and if the testis is undescended, then orchiopexy will be required
concomitantly.
Another tool to increase the diagnostic accuracy is use of office ultrasound in doubtful
cases [28-31]. Ultrasound has been shown to differentiate between patent processus
and a hernia reliably in some recent studies. Based on pre-operative and operative
findings in more than 600 children with inguinal hernias who underwent pre-operative
ultrasound, Erez et al reported that a hypoechoic structure in the inguinal canal
measuring more than 6 mm indicates a hernia while between 4-5 mm indicates a patent
processus vaginalis [29].
A recent study has explored the use of a suggestive history and digital photographs
taken at home if the hernia is not clinically demonstrable in clinic [32]. Parents were
asked to send in digital photographs if the history was suggestive of an inguinal hernia
and children were operated if the photograph was unequivocal. All the children thus
operated were confirmed to have an inguinal hernia intra-operatively. Though the study
was a small one (23 patients), further consideration in the context of todays digital world
is reasonable. Inguinal Hernia in Girls
Inguinal hernia predominantly occurs in males, as girls comprise less than 10% of all
reported cases [33]. Clinically, the child would be brought with a history of inguinal
swelling appearing on coughing or crying (Figure 3). Whenever a hernia is suspected in
a girl, it is important to be aware of a potential disorder of sexual differentiation. Upto 12% of all female children with hernia would be found to have Androgen insensitivity
syndrome [34-36]. In such a circumstance, a testis may be palpable in the inguinal
region. In a girl with inguinal hernia, investigations should be done to rule out Androgen
Insensitivity syndrome if there is any suspicion. Though the incidence is very low, it may
have important medicolegal consequences if CAIS is discovered during surgery and has
not been mentioned pre-operatively [34]. But given the low incidence, it is important to
proceed with investigations thoroughly. The various investigations include ultrasound
and karyotype. Routine screening with karyotype, though most specific may not be

65

66

67

feasible for economic and technical reasons except when the hernia sac contains
palpable gonads. In girls with only a hernia without a palpable gonad, ultrasound
examination from a trained radiologist may be an adequate screening tool. Unequivocal
visualisation of ovaries with follicles conclusively rules out Androgen insensitivity
syndrome. Only in cases where ovaries are not visualised, karyotype may be required.
Another adjunctive tool can be measurement of vaginal length in girls with hernias as
children with androgen insensitivity syndrome have a shorter vaginal length [35, 36].
Commonly, the contents of the hernia sac are omentum and/ or small bowel. In girls,
ovaries have a propensity to herniate into the sac and undergo incarceration (Figures 4,
5). If torsion sets in, this may lead to rapid infarction. Once diagnosed to have an ovary
in the sac, surgery should be performed as early as possible to prevent such an
eventuality [33, 37, 38]. Sliding hernias are also known to occur in children where part of
the bladder wall or fallopian tubes/ uterus have been found in the hernia defect [33, 37,
38]. SURGICAL PROCEDUREThough Ferguson and Czerny were the first ones to
describe high ligation of the sac in pediatric patients, the classic contemporary
description of the repair of indirect inguinal hernias in children was provided by Potts
[10,11]]. High ligation of the sac is a technique which is practiced globally by all pediatric
surgeons and urologists. With time, only minor changes have occurred, but the basic
technique is directly descended from the procedure taught by Ladd and Gross, the
founders of North American pediatric surgery [39].
With the advent of Laparoscopic techniques, multiple series have validated the feasibility
and safety of laparoscopic approach for pediatric hernia repair, though the actual benefit
over conventional open approach still remains debatable except in certain special
circumstances.Conventional Open approach
Surgery for hydrocele and hernia in children is classically performed via inguinal or groin
crease incision. Inguinal herniotomy is a simple and precise surgery which can be
performed expeditiously provided anatomical orientation is good and a layer by layer
exposure of the structures is completed. Herniotomy can be performed under caudal
epidural analgesia along with sedation or under inhalational anesthesia with a laryngeal
mask airway. The child is placed in a supine position on the table and parts are prepped
with an iodophor solution from epigastrium to midthigh level. The surgeon stands on the
side of hydrocele/ hernia. Lower inguinal skin crease incision is marked centred over the
pulsations of the femoral artery, over the expected internal ring (Figure 6). An incision is
made through the dermis until the fatty layer of the superficial fascia is encountered. In
this plane there is a constant vein which needs to be coagulated as this vessel may be a
source of minor bleeding if not recognised early on. Then membranous layer of the
superficial fascia (Scarpas fascia) is divided with cutting diathermy and this exposes the
external oblique fascia. A small nick is given in the fascia and this fascia is divided with a
fine scissors along the length of the incision. The edges of the inferior leaf may be held
with fine haemostats and everted; this maneuver opens up the inguinal canal. Genital
branch of the genitofemoral nerve is recognised coursing along the inferior leaf and this
is gently retracted and protected. Caudal and medial traction is exerted with small
fingertip retractors to expose the course of the spermatic cord. Cremaster fascia is
gently separated to reveal the glistening white processus or hernia sac and this is held
with a hemostat. In case of any difficulty in recognising the cord, a gentle to and fro pull
on the testis will help in delineating the sac better. The sac once held, is lifted out of the
incision and this should be easy to lift out. If this step is difficult, reassess the anatomy
as it may be some other tissue or some more separation from the surrounding tissues
may be required. Sac is splayed on the index finger of the left hand and tissues are
teased off gradually layer by layer with an atraumatic forceps (Figures 7, 8) This way the
spermatic cord with vessels and vas deferens are separated from the sac. It is vital not

68

69
70

to handle vas during this maneuver as it can be injured very easily (vide infra). Once the
sac is totally dissected clear of the cord, two hemostats are applied and the sac is
divided in between (Figure 9). It is a good idea to confirm once again before applying the
hemostats that no spermatic cord structure is caught in the sac tissue. After division of
the sac, a gentle traction is kept on the proximal sac by the surgeon and the spermatic
chord is gently held with the help of a gauze piece by the assistant. This allows splaying
of the tissues between the sac and chord so that they can be bluntly pushed away with
an atraumatic forceps. This dissection is continued till internal ring area is reached. This
endpoint is recognised by visualisation of the extraperitoneal fat or the inferior epigastric
vessels. An inspection and palpation is done to confirm that the sac is empty; in case of
any doubt the sac can be opened by removing the hemostat and looking inside (Figure
10). This maneuver should be routinely done for all females undergoing hernia repair to
rule out prolapsed ovary/ fallopian tube and also to confirm the presence of round
ligament (Figure 11). Any contents are replaced inside the peritoneal cavity and the sac
may be longitudinally twisted for 2-3 turns (Figure 12). This allows narrowing of the neck
and also provides a slightly tougher tissue for placing a transfixation suture. Caution
must be exercised as the twist of the sac could evert a spermatic cord structure
inadvertently. A transfixation suture is passed with a delayed absorbable suture such as
polyglactin or Poliglecaprone to secure the neck of the sac at level of internal ring. Sac is
sectioned about 0.5 cm distal to the transfixation suture; at this juncture if the dissection
has been adequate, the tied sac would be seen to retract into the depth. Now the
attention is paid to the distal sac which has been held with the hemostat. The distal sac
is laid open with a bipolar diathermy for a short distance to decrease the incidence of
post-operative hydrocele. Hemostasis is ensured and the cord and testis are reposited
back to the scrotum by a gentle pull on the scrotal tissues. This is again an important
step, otherwise the testis can get trapped in the healing process and result in an
iatrogenic ascended testis.
Tissues are re-approximated in layers with absorbable sutures and skin is closed in a
subcuticular fashion or a tissue adhesive can be used for approximation. Tissue
adhesives remain popular, but two studies showing that tissue adhesives have no
improved outcome, take more time to use and may have slightly more complication rate
bear mention [40, 41]. Typically a single poliglecaprone suture on a cutting needle is
sufficient for the whole surgery. A small gauze dressing or skin strips are placed at the
end of the procedure.Special circumstances
Hernias in Premature infants
The preterm babies pose a unique combination of operative and perioperative risks,
which influence the basic algorithm for management. Inguinal hernias are more common
in premature infants, are more frequently bilateral and are prone to undergo
incarceration [19-22]. The recent literature suggests that the risk of incarceration may
not be as great as previously thought. In one prospective study of 51 premature infants
who were observed to watch the natural history of their patent processus vaginalis and
hernias, only 1 (2%) experienced an incarceration [42]. The hernia sac in premature
infants is more fragile than in older infants and children, and, not surprisingly, the
recurrence rate and complication rate after repair are slightly higher [43]. In addition,
premature infants have an added risk of postoperative apnea and bradycardia [44-47].
This risk decreases as the infant matures. Postoperative apnea in premature infants
after inguinal hernia repair using current anesthetic techniques is much less common
than previously reported. Risk factors appear to include infants with prior history of
apneas, lower gestational age, lower birth weight, lower weight at time of surgery, and a
complicated neonatal course such as intraventricular hemorrhage, patent ductus
arteriosus, bronchopulmonary dysplasia, and requirement for mechanical ventilation and

71

72
73

74
75
76
77

78
79

80

supplemental oxygen after birth. Selective use of postoperative ICU monitoring for highrisk patients could result in significant resource and cost savings to the health care
system [48]. Using regional anesthesia to limit or eliminate the need for general
anesthesia is also a helpful advance.
Balancing the increased risk of incarceration against the risk of perioperative
complications in premature infants has led to two distinct schools of thoughts: to repair
the hernia before the infant is discharged from the hospital or wait until they reach
enough maturity to decrease the risk of postoperative apnea [44-47]. Premature infants
who have symptomatic hernias, who have hernias that are difficult to reduce or who
have families without the means to quickly follow-up with the surgeon should undergo
repair before discharge. Otherwise, there are no good data to suggest that early repair
versus waiting is superior, and both options should be discussed with the family [17].
Infants
In infants, the inguinal canal length is very short and the internal ring and external ring
just lie over each other. As a result, infant herniotomy can be performed through the
external ring without actually opening the inguinal canal. A small incision just above and
slightly lateral to pubic tubercle may suffice to expose the sac as it exits the external
ring. From there on the procedure is essentially the same as for older kids.
Large internal ring
In children with a large sac and a wide open internal ring, sutures can be placed laterally
on the edges of the internal ring to make it smaller after a high ligation of the sac has
been done [49].
Herniotomy for girls
As discussed previously, it is important to open the sac and confirm the presence of
round ligament and also rule out fallopian tube, uterus, ovary which may frequently
prolapse into the sac in female children [33,37,38]. If there is no content, then the sac
can be just ligated as usual. If there is a fallopian tube inside then it should be gently
reposited back into the abdomen and sac ligated distal the tube. The sac can be inverted
back into the abdomen and internal ring closed.
Incarcerated hernia
Classically, the child would present with painful and persistent inguinal swelling (Figure
13). There may be redness and tenderness on examination. Abdominal distension and
signs of intestinal obstruction may set in if diagnosis is not made early. Unless there is
clear peritonitis or bowel compromise, attempt should be made to manually reduce the
incarcerated hernias by using a technique called taxis. In this technique, with the infant
relaxed (using sedation if necessary), gentle inferolateral pressure is applied to the
incarcerated hernia with some pressure from above to straighten the canal.
Approximately 80% of incarcerated inguinal hernias can be reduced using this technique
[50]. Because of the high rate of early recurrent incarceration, it is recommended to
admit these children and then do the surgery 24 to 48 hours later after the edema has
subsided. Any child with an incarcerated hernia that cannot be reduced must undergo
immediate operative repair. It is important not to reduce the hernia under anesthesia
before the incision in order to inspect the incarcerated bowel for evidence of
strangulation. In girls, an incarcerated ovary may be present in the hernia sac. If
reduction is unsuccessful, there is a risk of vascular compromise from ovarian torsion
occurring in as many as 33% of cases. Immediate repair can prevent this complication
and is recommended by multiple authorities [38,50, 51]. Lately, laparoscopic approach to
incarcerated hernia has been recommended by various authors and is discussed later
(vide infra). COMPLICATIONS OF HERNIOTOMY
The classical open approach with high ligation of hernia sac has stood the test of time
and is associated with a complication rate of less than 2% [52].

1
81

1
82
1
83

1
84

1
85
1
86
1
87

Bleeding
Bleeding due to severing of small veins in superficial fascia may be a minor trouble and
is generally easy to control. Bleeding may also occur secondary to injury to one of the
fragile veins in the pampiniform plexus and can be easily controlled by pressure or
bipolar diathermy. Bleeding from the edges of distal sac may lead to post-operative
haematocele; thus it is important to achieve hemostasis by coagulating the edges of
distal sac with bipolar cautery. Only after an adequate hemostasis should the testis be
replaced back into the scrotum.
Wound infection
Occurs in less than 2 % of the cases and can be prevented by meticulous asepsis and
hemostasis in operation room [52].
Injury to Ilioinguinal nerve
Injury to Ilioinguinal nerve is a rare occurrence. This slender nerve runs through the
inguinal canal and upon opening the leaf of external oblique aponeurosis just runs over
the spermatic cord. Careful eversion of the edge along with the nerve will prevent
damage.
Injury to vas deferens
Prepubertal vas deferens is a very delicate structure and is susceptible to injury during
pediatric hernia repairs as it runs along the hernia sac often invested in soft tissue of the
wall of the sac [52-59]. Fortunately, incidence is less than 2% [52, 53]. Vasal injury
during pediatric hernia repairs though rare, has been documented to be the most
common etiology for obstructive azoospermia later on in adulthood and also the most
difficult to repair [56]. Open exploration is associated with an increased risk of infertility;
as many as 40% of infertile males who had bilateral hernia repairs as children have
bilateral obstruction of the vas deferens [58]. Two types of injuries may occur- ischemic
injury or sectioning of the vas. Ischemic injury results in a long segment of vas becoming
fibrosed and is difficult to recognise during surgery itself. Classically, patients present
with obstructive azoospermia later on in life and may need repair. Second type of vasal
injury - sectioning of the vas is very uncommon in experienced hands, though the risk is
higher in giant hernias of infants. If such an injury is recognised, it should be
documented and surgical repair tried after mid-puberty as pre-pubertal narrow vasal
diameter does not permit successful repair till tanner stage 3 has passed [56]. Overall,
vasal injuries during hernia repairs are associated with longer vasal defects, impaired
blood supply and longer obstructive intervals frequently resulting in secondary
epididymal obstruction [50]. Vas deferens injury can also result in sperm-agglutinating
antibodies which influence fertility [53]. Even minor inadvertent pinching of the vas or
stretching of the cord can result in injury, which also increases the risk of infertility [54,
55, 61]. This inadvertent injury may be more likely when there is no true hernia sac
present because the vas is more exposed making a case against routine contralateral
exploration in a unilateral hernia.
Testicular atrophy
Vascular compromise of testis leading to atrophy occurs in less than 0-3% - 2% of all
hernia repairs [52]. This mostly occurs due to injury/ spasm of testicular vessels.
Iatrogenic ascended testis
After mobilisation of the testis and division of the processus vaginalis, there is a raw area
created which may entrap the testis. To prevent this from happening it is vital to pull the
testis down and reposition it into the scrotum.
Post operative Hydrocele
Post-operative hydrocele is a common occurrence and represents the continuing
secretion of fluid by the left over distal sac. Most of the times it is a minor collection and
gets resorbed spontaneously over a period of 2-3 weeks. In large hernias, the incidence

1
88

1
89

90

91

92

may be higher. Therefore, during herniotomy, it is important to lay the distal sac widely
open [62]. This maneuver widens the neck and thus provides more surface area for the
fluid to get resorbed and prevent hydrocele. Hemostasis should be achieved adequately
with preferably bipolar current after the sac edges have been laid open.
Recurrence
Factors that may contribute to recurrence in open inguinal hernia repair in children
include failure to ligate the sac high enough, inadvertent tearing of the sac (and its
extension into the peritoneal cavity), an excessively dilated internal ring, injury to the
floor of the canal (with subsequent development of a direct inguinal hernia), and the
presence of co-morbid conditions (eg, collagen disorders, malnutrition, or pulmonary
disease). The recurrence rate has been documented to be around 1-3% [52, 63, 64].
Metachronous contralateral hernia
In 1950s reports appeared about a high rate of contralateral hernias in children
presenting with unilateral hernias and Rothenberg recommended prophylactic
contralateral exploration in all children [65]. These reports became the basis for the
recommendation that all children undergo a contralateral exploration when a unilateral
hernia was diagnosed. It has become clear now that these hernias were often the
patent processus vaginalis and that, had they been left alone, a majority of them may not
have become clinically significant hernias. The debate about contralateral exploration
involves a choice between treating only obvious hernias (and dealing with a
metachronous hernia later) versus preventing metachronous hernias by closing any
patent processus vaginalis that is found. Ein etal in one of the largest series of pediatric
hernias reported only a 5% metachronous hernia rate in a follow-up as long as 35 years.
Among the risk factors for developing metachronous contralateral hernias, age less than
18 months, initial left side and large hernia seem to be significant [66-68]. Still the risk is
not high enough (less than 5% in most series) to mandate a routine contralateral
exploration. After weighing the risks such as real possibility of vasal injury or testicular
atrophy in the light of low risk of contralateral hernia, most surgeons now believe that
routine open contralateral exploration is not indicated [66-70]. Even in preterm babies if
there is a unilateral clinically evident hernia at presentation, contralateral exploration is
no longer recommended. A close clinical follow-up is advisable though [71].
Laparoscopic Approach to Pediatric hernias
Although the classic open inguinal hernia repair remains the gold standard for most
pediatric surgeons, laparoscopic repair is increasingly being performed in many centers
across the world. Initial use of laparoscopy in pediatric inguinal hernia was for diagnostic
purposes; primarily to determine contralateral patent processus vaginalis (CPPV) [7282]. The diagnostic efficacy of laparoscopy has been enhanced further by the use of an
ever-expanding range of probes, endoscopic retractors, needles, and other endoscopic
instruments to explore the patency in doubtful cases. Of these, the transinguinal
approach with a 120 degree scope has been the most favored as a diagnostic tool [82].
With a sensitivity of 99.4% and specificity of 99.5%, laparoscopy has proved to be the
gold standard for the detection of CPPV [78-82]. After the initial enthusiasm in detecting
CPPV and repair thereof, recently many reports have challenged its validity as CPPV
may not manifest into a clinical hernia later [70]. In other words, diagnosing a patent
processus and treating it, is not analogous to treating a hernia.
Therapeutic use of Laparoscopy in pediatric inguinal hernia was first reported by ElGohary in 1997 when he performed laparoscopic repair in girls by successfully everting
the sac into the peritoneal cavity and then using an endoloop [83]. The first successful
laparoscopic repair in boys was reported in 1999 by Montupet [84].
In essence, laparoscopic hernia repair in children is an extension of conventional
herniotomy involving fundamentally a high ligation of the indirect hernia sac. The

93
94

95
96

97

98
99

reported advantages of the laparoscopic approach include the ease of examining the
contralateral internal ring, the avoidance of access damage to the vas and vessels
during mobilization of the cord, decreased operative time, and an ability to identify
unsuspected direct or femoral hernias [85-91]. In a prospective, randomized, single-blind
study of 97 patients, the laparoscopic approach was associated with decreased pain,
parental perception of faster recovery, and parental perception of better wound cosmesis
[89].
Broadly, laparoscopic hernia repairs in children can be classified into two approaches purely intracorporeal ligation and a laparoscopic-assisted extracorporeal ligation.
Laparoscopic Intracorporeal repair
The first large series of intracorporeal repair was reported by Schier, with primary
closure of the peritoneum lateral to the cord with interrupted sutures [85]. This technique
was then modified by Schier to use a Z-suture closure rather than interrupted sutures
[86]. In girls, in whom injury to the vas deferens and vessels is not an issue,
laparoscopic inversion and ligation [83] or excision and closure of the sac can be used
[92]. Other modifications include an N-suture instead of a purse-string suture [90] and
the flip-flap hernioplasty, in which two folds of peritoneum are used to cover the
inguinal ring similar to the vest over pants repair [94, 95]. This technique theoretically
has an advantage of allowing the scrotum to drain through the slit that is created,
preventing postoperative hydroceles; however, there is only short follow-up, and there
are no reports of the incidence of recurrence for this procedure.
Laparoscopic-assisted extracorporeal repair
In laparoscopic-assisted extracorporeal closures, a small stab wound is made over the
inguinal ring, and a suture is passed through the abdominal wall behind the peritoneum.
It is then directed around the internal ring, avoiding the vas deferens and vessels, and
passed out the same stab wound. It is tied extracorporeally under laparoscopic
visualization [88, 96-105]. Over the last few years, the technique has evolved from use
of two ports to a single port laparoscopic repair with an extracorporeal component. In a
two port technique, the variations on the extracorporeal technique have included using
an endoneedle [96,100], Reverdin needle [101], using a Lapher closure, which
consists of a wire on the end of a 19-gauge needle that allows the purse-string suture to
be passed [99] and using an Obwegeser maxillary awl to pass the suture [88]. These
instruments are introduced percutaneously (in the inguinal region) under laparoscopic
guidance and manipulated around the medial or lateral hemi-circumference of the
internal ring extraperitoneally, in sequence, to place a purse-string around the internal
ring. A grasper, placed through a separate port, is used to manipulate the thread in and
out of the hollow of these needles to form a mattress suture. The two ends of the thread
then are pulled from the operating port, after which the knot is tied extracorporeally and
pushed inside with or without a knot pusher. This technique reduces the need for the
second working port and thus only two ports are required- a camera port for visualisation
and a working port for guiding the needle.
In a single port extraperitoneal technique, the technique is similar to that described
earlier, rendering working ports, endoscopic instruments, and most important, the need
for intracorporeal knotting unnecessary. The internal ring is looped under endoscopic
control using a 1-0 or 2-0 absorbable suture swaged on a large needle (3640 mm,
curved round body) introduced percutaneously using a strong conventional needle
holder [102-105]. The technique has not been standardized yet and there is a high risk
of collateral damage and also recurrence if done in inexperienced hands [103,105].
Laparoscopy in incarcerated hernias:
Schier in 2006 reported that creation of pneumoperitoneum itself dilates the ring
sufficiently aiding in reduction of the incarcerated contents [106]. In addition, external

100
101

102
103

104

compression, forbidden in conventional surgery, is found to be safe and useful because

the contents can be observed from inside. Even gentle traction with endoscopic
instruments is safe under vision and can facilitate reduction of hernia contents
immensely. Further viability of the incarcerated intestine can be assessed and if contents
prove unviable, as a result of strangulation, they can be excised without adding to the
morbidity. In addition, intracorporeal repair is performed in non-edematous tissue at the
internal ring [106,107].
Rarer forms of hernia (Direct/ femoral or combinations thereof)
Laparoscopy has a unique advantage of diagnosing rare hernia forms such as direct or
femoral hernia forms. Also, combinations of these such as pantaloon hernia and all three
hernias (indirect, direct and femoral hernia) have been reported to occur in the same
pediatric patient [87, 108,]. With a magnified view from inside, the defect can be clearly
visualised and the appropriate repair performed. Repair for a direct or a femoral hernia is
different technically from an indirect inguinal hernia [87, 108]. Direct and femoral hernias
are discussed in more detail below.
Laparoscopy in recurrent inguinal hernia
For recurrent hernias after previous open herniotomy, re-operation with the open method
needs to go through the old operation site which in boys almost always has the vas
deferens and testicular vessels embedded in dense fibrous tissue. The operation is
always tedious and possesses the danger of damaging these important structures. In
such a scenario, the laparoscopic approach allows an approach from the virgin area and
helps avoid the previous operation site. So in effect, technically it may as simple as a
fresh laparoscopic hernia repair and can be done quite expeditiously.
Also, laparoscopy accurately identifies the nature of the defect in children with recurrent
groin hernias, detecting unsuspected contralateral indirect, direct, or femoral hernias in a
large number of those undergoing laparoscopy [109-111].Complications of
laparoscopic hernia repair
Complications secondary to laparoscopic approach: Laparoscopy, in general, carries its
own set of complications such as air embolism, hypothermia, decreased venous return,
hypercapnia, acidosis, needle/ trocar injury, and gut/vessel injury. These become less in
experienced hands. Pressure should be kept below 10 cm H2O, especially in infants, to
avoid respiratory embarrassment or hypercapnia. End tidal carbon dioxide monitoring
and core body temperature should be monitored rigorously in all babies.
Vascular injuries: In addition, laparoscopic surgery for inguinal hernia has specific
complications of injury to the iliac vessels in the triangle of doom, the inferior epigastric
vessels, and the gonadal vessels for a small number of patients, as well as trivial
bleeding from small peritoneal vessels [103,105,112,113]. Although small in number, the
vascular complications have the potential to assume sinister proportions, especially
when needle puncture goes unnoticed and the suture is tightened inadvertently,
converting a puncture into a vessel wall tear [105].
Post-operative hydrocele: In a laparoscopic herniotomy, the distal portion of the sac is
left intact without even being split, it has the potential to form a postoperative hydrocele.
And though hydrocele after open surgery is a known complication, especially in
neonates and infants, this complication is found to be surprisingly less common in
laparoscopic surgery.
Recurrence: The reported recurrence rate in various series of laparoscopic hernia
repairs is 0% 5%, which is comparable with that for open repair [84-86, 89-91]. In
addition to the patient volume and level of the surgeons experience, as with open
repairs, several other factors may contribute to recurrence in laparoscopic surgery
[110,111]. Partial omission of the ring circumference [102-105], strength and
appropriateness of the knot, inclusion of tissues other than peritoneum in the ligature

105
106

1
2
3
4
107
108
109

110

111

with a propensity for subsequent loosening [105], use of absorbable sutures [102,104],
and failure to detect a rarer and direct hernia are some factors suspected as causes for
recurrence [87,108,114]. Schier et al reported a large series of hernia repairs, and
recurrences occurred in 3% [114]. They observed that boys had more recurrences than
girls and recurrence rate was lower with experienced surgeons. During re-laparoscopy
they found that most recurrences occur medially. Thus, the stitches at the medial aspect
of the hernia, close to the vas, seem to be the most crucial ones [114]. This can be
explained by extreme caution and margin which a surgeon intends to exercise while
passing the needle close to vas or epigastric vessels at the medial side of the internal
ring. It seems that even leaving a small medial gap is enough to invite subsequent
widening and hernia recurrence. It has quite rightly been stated that these cases should
be more correctly called incomplete closures rather than true recurrences. In girls the
surgeon will have no concerns in placing stitches medially. Therefore, probably, girls
have fewer recurrences [114].
Others: The other known complications with open surgery such as iatrogenic ascent,
tethering of the testis, inguinodynia, and wound infections are rare with the laparoscopic
approach. Data regarding testicular atrophy and injuries to the vas is yet not available as
long term results have not been studied. Though, it has been proposed that these may
be observed much less frequently in MAS, supposedly due to less and more precise
dissection enabled by magnification [91].
Personal View
In our experience, children who undergo open herniotomy for a unilateral hernia have a
very rapid recovery, are discharged within a few hours and are ambulatory shortly
thereafter. Post-operative pain is not much of a concern and acetaminophen is adequate
and no antibiotics are required. A minimally invasive unilateral hernia repair by
laparoscopic approach seems more invasive in terms of anesthesia and makes a purely
extraperitoneal procedure an intraperitoneal one. Laparoscopy does have a definite
advantage in selected circumstances such as:
Contralateral exploration in children less than two years of age
Recurrent hernia
As an adjunct to laparoscopic orchidopexy or other concomitant procedure
Females, where a disorder of sexual differentiation is to be ruled out
Direct Inguinal hernia
Although congenital direct inguinal hernias are rare in children, they do occur. In two of
the largest series of inguinal hernias operated by open technique, the incidence of direct
hernia has been less than 1% [52,115]. In the latter series, a third of these had
undergone a previous hernia repair on the same side "for presumed indirect hernia". In
another series of 1600 inguinal hernia operations, 14 children had direct hernias (0.9%),
and half of these were recurrences [116]. Schier also highlighted the similar fact that due
to rarity of these hernias, they are often missed and end up having recurrence [108,114].
Intra-corporal view during a laparoscopy may help in a reaching a correct diagnosis and
avoid diagnostic pitfalls and subsequent recurrence. Classically an indirect hernia
defect will be located lateral to the epigastric vessels, direct hernias defect opens
medially to the epigastric vessels and femoral hernias are those which opened medially
to the femoral vessels and below the inguinal ligament [87].
The principles of repair and the techniques include closing the defect in an anatomical
fashion without prosthetic materials. Pediatric tissues have greater elasticity, and primary
repair is usually much more straightforward than in the adult population [17, 108]. Also,
laparoscopic repair with strengthening by the median umbilical ligament has been
reported to be more successful [108].

112

113

114

115

116
117
118
1
2
3
119
120
121

122

Further, sometimes indirect and direct sacs may coexist, the so called hernia-enpantaloon or pantaloon hernia [52,87,108]. Laparoscopy provides a better elucidation for
these rarer hernias and also if the hernia has recurred after a previous open surgery
[87]. Femoral Hernia
Femoral hernias in children are rare, difficult to diagnose, and require a different
treatment approach than the standard indirect inguinal hernia repair. The incidence is
less than 1% of all hernias as reported in various series [87, 117-124]. These hernias are
exceedingly rare in infants, usually presenting in older children [117, 123]. They often
present as recurrent hernias after inguinal hernia repair, most likely because the surgeon
was misled by the findings of a processus vaginalis at the initial surgery and missed the
actual hernia defect [87, 117-119].
As discussed previously (vide supra), laparoscopy may help in correct diagnosis in most
instances, but a surgeon needs to be aware that these hernias may not be that rare as
previously thought and that they may also very rarely exist in combination with other
direct or indirect hernias [87].
Femoral hernia can be repaired by open technique such as the classic McVay repair
[117-119] or by one of the various laparoscopic techniques recently described. These
include laparoscopic mesh plug or patch repair [120,121], use of the umbilical ligament
as a plug for laparoscopic repair [122] and laparoscopic assisted inversion of the sac
and endoloop closure [124]. Schier recommends a proper dissection of the peritoneum,
exposing the underlying defect and anatomy thoroughly and then closing the defect with
multiple interrupted sutures to avoid recurrences [87].
HYDROCELE
Hydrocele is a collection of serous fluid in the tunica vaginalis and may extend up into a
patent processus vaginalis.
Hydroceles may be classified as:
Scrotal
Inguinoscrotal
Encysted hydrocele of cord
Symptoms:
Hydroceles are clinically evident anomalies whereby the child is noted to have
enlargement of the scrotum. Hydrocele is very common in newborn babies occurring in
upto 10% of the male babies.
Examination: Enlargement of the scrotum is observed on inspection and there may be a
loss of scrotal rugae with larger hydroceles. Most of the hydroceles are confined to the
scrotum but in the inguinoscrotal hydrocele the swelling may be observed going upto the
inguinal region. There is no change in size with the straining, crying or coughing, except
in a communicating hydrocele.
On palpation, the testis can be felt separately in most of the cases except in a very large,
tense hydrocele. In a hydrocele which is limited to the scrotal region the spermatic cord
would feel normal at the root of the scrotum while in the inguinoscrotal hydrocele the
swelling can be palpated proceeding right into the inguinal canal. The swelling may be
felt to be fluctuant, though in a tense hydrocele the fluctuation may be difficult to elicit.
Mostly, hydroceles are non-reducible in nature even if there is a patent communication
with the peritoneal cavity as the communication is usually small; and works as a ball
valve mechanism. Some of the hydroceles may have a fluctuation in size and may be
reducible clinically. In these cases the differentiation between a hydrocele and a hernia
becomes less important as these are treated the same way as a hernia.Transillumination remains the most important test to diagnose a hydrocele and differentiate it
from a hernia. It is a remarkably simple & rapid test and many a mistakes can be
avoided by taking two minutes to perform this test in the out-patient department. A small

123

124

125

126

127
128

pencil torch with a pointed beam is required for this examination and this should form
essential equipment in the office of all physicians dealing with small children. Hydroceles
in children are always brilliantly transilluminant while hernias do not allow much light
transmission; this difference allows a quick and consistent method to distinguish a hernia
from a hydrocele. Encysted hydrocele of the cord is a special type of hydrocele whereby
a localized fluid collection occurs along the spermatic cord anywhere from internal ring to
the testicular upper pole. Such encysted hydroceles are often tense swellings and due to
their predominance in the inguinal region, they may not be amenable for eliciting
transillumination. The key test is to palpate the swelling while keeping the testis in a
slight traction. Then the movement of the swelling is assessed with respect to the cord
structures. In an encysted hydrocele the movement of the swelling becomes restricted
and often it can be felt to slide down with the cord when the cord is pulled caudad.
Investigations: In most cases, a good and thorough clinical examination suffices and no
further investigations are required. When in doubt especially, in an encysted hydrocele of
cord, an ultrasound examination may be required to rule out other differentials such as
inguinal lymph node enlargement. Similarly, if transillumination and physical exam fail to
identify the testis, an ultrasound may be considered to rule out the rare case of a
reactive hydrocele in response to an instrascrotal process such as inflammation, torsion
of the appendix testis and neoplasm.Management
A newborn or infantile asymptomatic (so-called pure) scrotal hydrocele (no evidence of
associated hernia or communication) has a high chance of spontaneous resolution when
the patient reaches 1 to 2 years of age [52,125-128]. Thus a watchful expectancy should
be offered to such boys with a 3-6 monthly review unless the hydrocele is very large and
tense or increases rapidly. On the other hand, a majority of surgeons recommend
surgery for a communicating hydrocele, though from 1996 to 2003 the number of
surgeons electing to wait for surgery increased [64, 128]. A recent report has challenged
this knee jerk operative view by suggesting that even for communicating hydroceles in
infancy, spontaneous resolution rate may be more than 60% [129]. Out of 110 infants
with a communicating hydrocele at presentation, only 40% required surgery and only 6
progressed to a clinical hernia. On a short term follow-up, in boys in whom a clinical
resolution was observed, 2 were found to have a hernia later on in follow-up. No
episodes of incarceration were observed, possibly due to small PPV in such cases. A
recent study with limited follow-up, it will be important to observe long term assessments
to determine if any further hernias develop. If indeed this is a long term resolution, then it
deserves to be incorporated into the management protocol and offered to the patients.
Ein in a largest single series of hernias so far suggested that boys with the later onset of
a scrotal hydrocele should be considered to have an accompanying hernia and offered
surgery upfront [52]. Christensen et al though showed that even in late onset hydrocele,
if the clinical history and examination are suggestive of a non-communicating hydrocele,
there is still a reasonable (75%) chance of spontaneous resolution. A watchful
expectancy of 6-9 months was recommended [130].
There is some debate in the literature about management of encysted hydroceles of the
cord.A majority of physicians recommend surgery for a cord hydrocele considering it to
be consistent with an indirect inguinal hernia even if the cord hydrocele disappeared
before operation [52, 64,128,129]. In our personal experience, cord hydroceles in infants
have a high rate of spontaneous resolution though it may not be as high as scrotal
hydroceles. If a hernia component is definitively ruled out, waiting until 18 months of age
even for encysted hydroceles of the spermatic cord is reasonable.
Surgical Approach to hydroceles
In pediatric hydroceles, in most of the cases, a patent processus vaginalis would be
found and would required to be ligated during surgery. So, a standard surgical approach

129

130

131

132

133

as for hernia is used for hydroceles in children (vide supra).

Upto 10% the processus may found to be obliterated during exploration. In such cases
dissection to look for a PPV through an inguinal incision potentially increases the risk of
cord injury with a subsequent increased risk of testicular atrophy or reduced fertility [130,
131]. Unfortunately, there are no definite guidelines or means to identify this non-patency
pre-operatively.
One aid to identify a PPV during surgery is intraoperative injection of a methylene blue
solution into a hydrocele sac. A PPV is identified as a blue line. Anatomy of a PPV was
better delineated in encysted hydrocele or a in a recurrent case facilitating dissection
and thus minimising the risk of cord damage [130].
Scrotal approach for a non-communicating hydrocele was first reported by Belman [132].
Infants with large abdominoscrotal hydrocele have an obliterated processus and have
been seen to do well after a purely scrotal approach. Inguinal incision in such babies is
associated with a higher risk of damage to cord structures and a higher incidence of a
persistent scrotal component [133,134].
Age may also be considered while deciding for the surgical access. Wilson et al reported
that as the age advances the incidence of a patent processus decreases justifying a
pure scrotal approach in boys more than 12 years of age [135]. Again in this report and
accompanying discussion it was stressed that a good clinical history and examination to
confirm a non-communicating hydrocele is a must before proceeding with a scrotal
approach. Also, once the hydrocele sac is opened, it may be wise to do a retrograde
probing to confirm the absence of PPV.Conclusion
The pedaitric hernia and hydrocele comprise a spectrum of scrotal disorders that are
commonly encountered in routine pediatric practice. A clinical history of the temporal
and quantitative nature of the swelling is as important as the findings on physical exam
in differentiating a potential surgical case from one that may be observed. A clear
understanding of the inguinal anatomy, adequate magnification and experience will
ensure success in the repair of these processes.Legends to Figures:
Clinical photograph of a 5 year old boy showing an obvious Left Inguino-scrotal swelling.

Clinical photograph of a 6 year old girl with Right inguinal hernia. Note the bulge
cephalo-lateral to pubic tubercle

Clinical photograph of a 1 year old girl with obvious inguinal hernia and a palpable hard
nodule in the hernia swelling.

Ultrasound picture of child in Figure 4 showing an ovary with follicles herniating into the
sac.

Standard incision for herniotomy is placed in lower skin crease.

The sac and the cord structures are displayed over the index finger of left hand and then
spermatic cord is gently teased off.

The sac has been separated from the cord structures which have dropped down.

Division of the sac allows the proximal dissection to be completed towards internal ring.

Opened up sac in a girl with right inguinal hernia shows round ligament.

Sometimes, the fallopian tube may prolapsed into the neck of the sac in girls. Sac should
always be opened and contents examined and replaced back before closing the sac at
internal ring.

Sac is twisted before placing the transfixation suture. Visualisation of pre-peritoneal fat,
as in this picture, signifies adequate proximal dissection.

Clinical photograph of a 3 year old child with obstructed left inguinal hernia. Note
appearance of erythema.

Laparoscopic view of left indirect inguinal hernia showing a widely open internal ring
(Courtesy- Dr Felix Schier, Germany)

Schematic picture showing setup of operation theatre for Pediatric Laparoscopic inguinal
hernia repair and the steps involved. Note care is taken to avoid gonadal vessels and

vas during passage of suture (Courtesy Dr Felix Shier, Germany)

Laparoscopic view of an incarcerated hernia which has been partly reduced under
anesthesia. (Courtesy- Dr Felix Schier, Germany)

Laparoscopic view of a direct inguinal hernia- note the defect medial to the inferior

epigastric vessels (Courtesy- Dr Felix Schier, Germany)

Pantaloon hernia with direct and an indirect defect as seen on Laparoscopy (CourtesyDr Felix Schier, Germany)

Direct, indirect and femoral hernias all co-occurring in one patient. (Courtesy- Dr Felix
Schier, Germany)