Childhood Hernias

And that’s pretty common. While the most common image that comes to mind when we say the word hernia is that of an elderly gentleman, hernia surgery is the most common operation performed by pediatric surgeons. In some studies, up to 4.4% of children have inguinal hernias ( groin hernias). Up to 75% of premature infants weighing less than 1500g could have an umbilical hernia. At present, this article deals only with inguinal hernia.

Both boys and girls can have inguinal hernias. The formation of the hernia is related to the normal course of development of the child while still in the womb. Early in pregnancy, the human gonads ( testes in boys and ovaries in girls) are located high up in the abdomen, in about the same place as the kidneys. As development progresses, these gonads descend. The ovaries remain in the lower part of the abdomen called the pelvis while the testes exit the abdomen and enter the scrotum, taking with it its blood vessels and the vas deferens. The ring through which these structures exit the abdomen usually closes once the testis is through. When this ring remains open, it predisposes to the formation of a hernia. In girls, a structure called the round ligament exits the abdomen into the groin in similar fashion. Thus, by a similar mechanism, a hernia can form in girls.

When the testis or the round ligament pass through the abdomen, they carry with them a sheath of the inner lining of the abdomen. Normally, this sheath becomes obliterated. If this sheath persists, it is called a patent processus vaginalis. When abdominal contents such as fluid, fat or intestine enter the patent processus vaginalis, it manifests as a hernia.

Remember that hernias in children and young adults are primarily because of a patent processus vaginalis. This is unlike the elderly population where the prime cause of hernia is muscle weakness.

In children, most hernias present in the first year of life. The highest occurrence is seen in premature babies: 16 to 25% of them will have a hernia. About 11.5% of children with hernias have had another family member with a childhood hernia.

You would typically see a bulge in your child’s groin. Classically, the bulge isn’t continuously present- it may go away completely when your child is sleeping, but become very large and prominent when the child cries or strains. Very often, parents tell me that they notice a groin swelling in the evening, but they can’t see it when the child wakes up in the morning.

A hernia is usually painless. Although it appears when the child is crying, the crying is usually because of some other reason ( hunger or a wet diaper).

Well, all hernias need to be fixed, without exception; but as long as the bulge goes away when the child is calm, you’re fine. When the bulge won’t go away anymore, the hernia becomes “irreducible”, and this is an emergency. We doctors don’t recommend that you wait till it’s an emergency- once diagnosed, a hernia should be fixed as soon as reasonably possible.

Yes. Surgery is the only treatment for an inguinal hernia. And as I said before, it should be performed as soon as reasonably possible. The reason why a hernia needs to be treated without undue delay is that a part of the child’s intestine can enter the hernia and get stuck there. Once that happens, the blood supply to the intestine can get cut off leading to a situation that is potentially life threatening. On the other hand, surgery for a simple hernia is quite a straightforward affair. Depending on the age of your child, the surgery can be done on a day care basis.

In recent times, paediatric hernia surgery has been done laparoscopically. While there are definite benefits to this approach in adults, the advantages of laparoscopy in childhood hernia are still a matter of debate. Each surgeon would have his or her own reasons for recommending one approach over the other.

Well, we talked about hernias developing due to muscle weakness in the elderly. So the possibility of your child developing a hernia in adulthood remains. Other than that, it would be surprising if the hernia came back.

Recurrence of the hernia remains rare. The recurrence rate for hernias that were uncomplicated at the time of operation is 0 to 0.8%. The risk of recurrence is higher if the hernia was irreducible- as high as 20% in some studies. Recurrence is also more frequent in premature babies. Most recurrences occur within the first year of surgery, and the treatment would be another operation.

There is also a chance of your child developing a hernia on the opposite side. This occurrence is in no way related to the surgery your child already had. It simply means that your child had a patent processus vaginalis all the time- it only manifested itself later. Upto 10% of patients present with a hernia on both sides, and the surgeon repairs them in a single operation. 12% of patients who present with a hernia on one side have a patent processus vaginalis on the other side, but not all of them will manifest a hernia. Therefore, routine exploration of the opposite groin is not done, except under specific circumstances.

Your doctor will talk to you about caring for the surgical wound. In uncomplicated cases,children are usually up and about the day after surgery. Mild pain killers may be needed for the first couple of days, but they pain rarely persists longer. Be sure to contact your surgeon if your child should have any of the following:

• excessive pain
• Redness of the wound
• Fever
• Discharge from the wound

For school going children, a break of a week or two is usually advised. While your child can perform all his routine activities- walking, running, climbing stairs- it is advisable to wait a few weeks before resuming sports. After that period, your child can be encouraged to participate in anything that he or she likes, and be allowed to grow up like everyone else.