Inguinal Hernia in Children

A hernia occurs when a part of the intestine pushes through a weakness in the belly (abdominal) muscles. A soft bulge shows up under the skin where the hernia is. A hernia in the groin area is
called an inguinal hernia.

A hernia can develop in the first few months after a baby is born. It happens because of a weakness in the abdomen muscles. Straining and crying don’t cause hernias. But the increased pressure
in the belly can make a hernia more easily seen.

As a male baby grows during pregnancy, the testicles develop in the abdomen. Then they move down into the scrotum through the inguinal canal. Shortly after the baby is born, the inguinal canal
closes. This stops the testicles from moving back into the abdomen. If this area does not fully close, a part of the intestine can move into the canal through the weakened area of the lower belly wall.
This causes a hernia.

In some cases, the part of intestine that pushes through a hernia may become stuck. It is no longer reducible. This means it can’t be gently pushed back into the belly. When this happens, that
part of the intestine may not get enough blood. A good blood supply is needed for the intestine to be healthy and to work the right way.

Although girls don’t have testicles, they do have an inguinal canal. So they can also have hernias in the groin.

How is an inguinal hernia treated in a child?
Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Your child will need surgery for an inguinal hernia. The surgery will happen fairly soon after the hernia is found. That’s because the intestine can become stuck in the inguinal canal. When this
happens, the blood supply to the intestine can be cut off. The intestine can then become damaged. Surgery is usually done before this damage can occur.

During surgery for a hernia, your child will be given medicine to put him or her to sleep (anesthesia).The surgeon makes a small cut (incision) in the area of the hernia. The surgeon puts the loop
of intestine back into the abdominal area. He or she stitches the muscles together. Sometimes, a piece of meshed material is used to help strengthen the area where the muscles are fixed.

What is an inguinal hernia?
A hernia is when there is a hole or weakness in the muscle layer of the abdominal wall. This means that organs or tissues inside the abdominal cavity can poke through the hole and cause the skin to
bulge. An inguinal hernia is a hernia that occurs in the groin region. In children these are almost all congenital hernias, meaning that the defect was present from the time the patient was born.

Although the defect was always there, it may not become apparent until something bulges through the hole. Sometimes parents worry that their child lifted something too heavy or strained too hard,
causing a hernia to develop, but in almost all cases this is not true. The hernia defect or hole was likely always there since birth. It was only the straining that pushed something through the hole to
make it become noticeable.

Why do we fix inguinal hernias?
Before answering that question, it is important to understand how we classify hernias. Hernias fall into three categories.

Reducible hernias: These are hernias in which the bulging intestine can be pushed back in. Most hernias are reducible. One can often feel or hear a “squish” as the hernia is reduced (pushed back in).
This feeling and sound is the actual intestine being pushed back through the hole in the muscle layer. Many hernias that are pushed back in pop right back out when one lets go. This is especially true
if the child is crying. Although the hernia won’t stay “in” or the bulge will not disappear, this is still considered a reducible hernia because it is possible to compress it. Reducible hernias generally don’t
cause a patient much pain, but these types of hernias can be mildly uncomfortable at times.

Incarcerated hernias: These are hernias that cannot be pushed back in; the intestine or tissue that came out of the hole in the muscle layer is now stuck. Incarcerated hernias are worrisome since it
places the child at-risk for having a strangulated hernia (see below). A child with an incarcerated hernia may complain of pain in the area. The bulge may be tender to the touch and there may be areas
of swelling or redness around the bulge. The child may also experience vomiting or pain in the abdomen (tummy). If the child has an incarcerated hernia, he or she needs to see a doctor right away.
Sometimes a doctor can push the hernia back in and relieve the incarceration; otherwise the child may need an operation right away.

Strangulated hernias: If a hernia becomes incarcerated it is possible that its blood supply can be choked off, becoming a strangulated hernia. A strangulated hernia is an emergency and requires an
immediate operation to help save whatever tissue or organ is being choked off in the hernia. Patients may become very ill as a result of the strangulated hernia.

Since inguinal hernias will not close on their own, generally all should be repaired. Of course, some children have health conditions that make surgery very risky, but for everyone else hernia repair is
recommended. The main reason that hernias are fixed is to prevent the problems that can arise from incarceration or strangulation of the hernia.

How are inguinal hernias repaired?
During the initial meeting with the surgeon, he or she will review the child’s health, confirm the presence of a hernia, and determine if any additional testing is necessary prior to the repair.
The surgeon will review the risks, benefits, alternatives, outcomes and complications of the various treatment options with the patient and family. If the patient requires surgery, a surgery can be
scheduled at this appointment.

In children, these operations are performed under general anesthesia and are generally done as an outpatient procedure, meaning the patient comes in and goes home on the same day.

There are three different approaches to pediatric hernias:
Open repair: This involves making an incision just below the belt line and dissecting down to the hole in the muscle layer. This hernia is closed with stitches. The deeper tissues and skin are then
sewn together with dissolvable sutures that are hidden under the skin so that there are no stitches to be removed. In teenagers, it is sometimes necessary to use a patch to help repair the hernia.

Open repair with laparoscopic exploration: This is the same as the open repair except that before closing the hernia hole, a small camera (about 3 mm in diameter) is passed into the abdomen to
examine the opposite groin from the inside. The surgeon will recommend this laparoscopic exploration in certain circumstances to rule out a potential hernia on the opposite side. If a hernia is
detected, a matching incision is made on the opposite side to allow repair of the second hernia.

Laparoscopic repair: In this approach the hernia is closed using laparoscopic techniques. A 3-mm or 5-mm camera is inserted through the belly button and additional instruments are introduced through
needle holes to perform the hernia closure. There a number of different laparoscopic hernia repair techniques in children (such as eversion technique, intracorporeal suturing technique, and single stitch
technique) that a surgeon can use depending upon the particular patient.