Inguinal Hernias in Children: A Comprehensive Review of Current Landscape

Abstract

Inguinal hernias are a common surgical condition in children, presenting as a protrusion of abdominal contents through a defect in the abdominal wall in the groin region. This review comprehensively examines the epidemiology, pathophysiology, clinical presentation, diagnosis, management, and complications of inguinal hernias in children. We discuss the current landscape of surgical techniques, including open and laparoscopic approaches, and explore emerging trends in hernia repair. Furthermore, we delve into the importance of risk stratification, the role of minimally invasive techniques, and the management of complications. This review aims to provide a comprehensive overview of inguinal hernias in children, highlighting the importance of timely diagnosis and appropriate surgical management to optimize patient outcomes.

Introduction

Inguinal hernias are a common surgical condition in children, particularly in infants and young children. They occur when a portion of the intestine or other abdominal contents protrudes through a weakness in the abdominal wall in the groin region. While typically not life-threatening, inguinal hernias can cause significant discomfort and, in some cases, lead to serious complications. This review provides a comprehensive overview of the current landscape of inguinal hernias in children, encompassing epidemiology, pathophysiology, diagnosis, management, and emerging trends.

Epidemiology

• Incidence:

  • Inguinal hernias are one of the most common surgical conditions in infancy and childhood.

  • The incidence varies depending on factors such as age, sex, and prematurity.

  • Boys are significantly more affected than girls, with an estimated male-to-female ratio of approximately 4:1.

  • Premature infants have a significantly higher incidence of inguinal hernias compared to term infants.

• Risk Factors:

  • Prematurity: Premature infants have weakened abdominal musculature and are at increased risk of inguinal hernia development.

  • Family history: A family history of inguinal hernias increases the risk in offspring.

  • Connective tissue disorders: Conditions such as Ehlers-Danlos syndrome can predispose individuals to hernia formation.

Pathophysiology

• Embryological origin:

  • During fetal development, the testes in males descend from the abdomen into the scrotum through the inguinal canal.

  • In females, the ovaries descend through the inguinal canal during fetal development.

  • In both sexes, this canal normally closes after the descent of the gonads.

  • Failure of complete closure of the processus vaginalis, the embryonic pathway through which the gonads descend, results in an indirect inguinal hernia.

• Indirect inguinal hernia:

  • The most common type of inguinal hernia in children.

  • Occurs when a portion of the intestine or other abdominal contents herniates through the internal inguinal ring and into the inguinal canal.

• Direct inguinal hernia:

  • Less common in children compared to indirect hernias.

  • Occurs due to a weakness in the transversalis fascia, resulting in a direct protrusion of abdominal contents through the posterior wall of the inguinal canal.

Clinical Presentation

• Symptoms:

  • Asymptomatic cases: Many inguinal hernias are asymptomatic and may be discovered incidentally during routine physical examinations.

  • Symptomatic cases:

    • Visible bulge: A visible bulge in the groin or scrotum, often more prominent during crying, coughing, or straining.

    • Pain or discomfort: May experience intermittent or constant pain or discomfort in the groin area.

    • Incarceration: The hernia contents become trapped within the inguinal canal, leading to severe pain, tenderness, and potentially bowel obstruction.

    • Strangulation: A life-threatening complication where the blood supply to the incarcerated hernia is compromised, leading to tissue ischemia and necrosis.

• Physical Examination:

  • Careful physical examination by a pediatrician is crucial for diagnosis.

  • The physician will gently palpate the groin area to assess for the presence of a bulge.

  • The reducibility of the hernia (ability to gently push the bulge back into the abdomen) is also assessed.

Diagnosis

• Clinical examination: Remains the cornerstone of diagnosis.

• Ultrasound:

  • May be helpful in confirming the diagnosis and assessing the size and extent of the hernia.

  • Can also help differentiate between an inguinal hernia and other groin masses.

Management

• Surgical repair:

  • The standard of care for inguinal hernias in children.

  • Aims to prevent complications such as incarceration and strangulation.

  • Typically performed as a day surgery under general anesthesia.

• Surgical techniques:

  • Open repair:

    • Traditional approach involving a small incision in the groin.

    • The hernial sac is identified and ligated, and the defect in the abdominal wall is repaired.

  • Laparoscopic repair:

    • Minimally invasive approach using small incisions and specialized instruments.

    • Offers potential advantages such as reduced postoperative pain, shorter hospital stay, and improved cosmesis.

  • Choice of surgical technique:

    • Depends on factors such as surgeon expertise, patient age, and the complexity of the hernia.

Complications

• Incarceration: The most serious complication, where the hernia contents become trapped within the inguinal canal.

• Strangulation: Loss of blood supply to the incarcerated hernia, leading to tissue ischemia and necrosis.

• Recurrence:

  • Relatively uncommon after successful hernia repair.

  • Risk factors for recurrence include:

    • Prematurity

    • Difficult surgical repair

    • Recurrent hernias on the contralateral side

Postoperative Care

• Pain management:

  • Adequate pain control is essential for postoperative comfort.

• Wound care:

  • Monitor the incision site for signs of infection.

• Activity restrictions:

  • Mild activity restrictions may be recommended for a short period after surgery.

Emerging Trends

• Minimally invasive techniques:

  • Laparoscopic and robotic-assisted techniques are increasingly being used for inguinal hernia repair in children, offering potential benefits such as reduced postoperative pain and improved cosmesis.

• Day surgery:

  • Most inguinal hernia repairs in children can be performed as day surgery, allowing for early discharge and reduced hospital stay.

• Role of robotics:

  • Robotic-assisted surgery may offer enhanced precision and visualization, particularly in complex cases.

Conclusion

Inguinal hernias are a common surgical condition in children, requiring timely diagnosis and appropriate management.

• Early detection and surgical repair are crucial to prevent complications such as incarceration and strangulation.

• Advances in surgical techniques, including minimally invasive approaches, have improved the safety and efficacy of hernia repair in children.

• Continued research is needed to optimize surgical techniques, minimize complications, and improve long-term outcomes for children with inguinal hernias.