Hernia

Myth: "If it's not strangulated, it's elective"

Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because:

The risk of incarceration and strangulation is high
There is a 30% risk of testicular infarction due to pressure on the gonadal vessels
It is not worth messing around and "trying to navigate the system"

Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis).

Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well. 15% are bilateral.

Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney. They hate it and will cry. For older children, have them laugh, cough, or blow through a syringe.

The "silk glove sign" is not reliable, but if found is highly suggestive of an inguinal hernia. Roll the cord structures across the pubic tubercle. If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis.

Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved. Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation.

Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention. Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age.

Girls may have an ovary incarcerated in hernial sac.

Open repair or laparoscopic techniques are used. The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens.

A metachronous hernia develops later on the other side. Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored)

My take: regardless of presentation, needs admission

Selected References

Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877

Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006.

Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468.

Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254

Focus On: Inguinal Hernias in Children

Pediatric Emergency Playbook