Inguinal region diseases in children

INGUINAL HERNI

Definition

hernia or hernia; It is called the protrusion of an organ or organs from a weak point that is not normally in the wall that surrounds it. Inguinal hernias in children are one of the most common surgical procedures in pediatric surgery. Inguinal hernia repair accounts for approximately 30-50% of operations performed in a year in all pediatric surgery clinics. While the incidence of inguinal hernia is 10%, it increases up to 30% in premature cases. It is seen on the right in 60% of the patients, on the left in 30%, and bilateral in 10%. Inguinal hernias constitute 85-90% of all hernias. Three different hernias are seen in the inguinal region (Kenneth & Welch, 1986; O’ Neill et al., 1998; John, 1998).

Indirect inguinal hernia:Almost all pediatric hernias are indirect hernias.

Direct inguinal hernia: They arise from the Hasselbach triangle. They do not follow the inguinal canal.

Femoral hernia:They arise from the canalis femoralis

history

The first written source about hernia is the Ebers Papyrus written by the Egyptians in 1550 BC. Information on treatment begins with Hippocrates. The anatomy of the inguinal canal was described in detail by Camper, Cooper Hesselbach and Scarpa in the early 19th century. Eduardo Bassini (1894) is the surgeon who opened the modern era in hernia surgery. In 1884, Banks recommended the complete removal of the hernial sac via the external ring. Fergusson in 1889

described a high level of suturing of the hernia sac (Kenneth J. Welch, 1986; O’ Neill et al., 1998; John, 1998).

Embryogenesis and Pathogenesis

Processus vaginalis: 6-7. It is a peritoneal protrusion sac brought by the testis under the guiding leadership of the gubernaculum in the fetal month. Continued patency of the processus vaginalis is the main cause of congenital hernia and hydrocele. Processus vaginalis occurs in the third month of pregnancy as the peritoneal cavity protrudes from the internal inguinal ring. After the 7th month of intrauterine life, the descent of the testis begins and after the testis descends into the scrotum, the open processus vaginalis begins to close from the level of the internal ring to the scrotum. Processus vaginalis often begins to close three weeks before birth on the left and one week after birth on the right (Ashcraft & Holder, 1993; Spitz et al., 1997; Başaklar, 1994).

Incidence

The incidence of indirect inguinal hernia is 1-4% in term babies and 30% in premature babies. 30-40% of children with indirect inguinal hernia are in the first 6 months and approximately half are under the age of 1 year. Hernia is 4-20 times more common in boys than girls. 60% of inguinal hernias are on the right, 30% are on the left, and 10-20% are bilateral. The reason why it is seen more on the right is that the right testis descends into the scrotum later than the left, and therefore the processus vaginalis on this side closes later. Family members of 5-20% of children with inguinal hernias have hernias (Spitz et al., 1997; Başaklar, 1994; Kelalis et al., 1985).

Associated problems

Undescended testis can be seen with bladder extrophy. Apart from this, conditions such as cystic fibrosis, omphalocele, gastroschisis, meconium ileus, where intra-abdominal pressure increases, ventriculoperitoneal shunts with increased intra-abdominal fluid, peritheonal dialysis, chylous acid, Ehler-Danlos syndrome, Marfan syndrome, Mucopolysaccharidoses are accompanied by connective tissue diseases such as inguinal hernias, 1994. ; Kelalis et al., 1985).

Clinical Findings

Inguinal hernias appear as a weeping swelling in the groin that descends into the scrotum. In the examination, the cord and its elements are compressed between the index finger and the pubic bone at the level of the outer ring, and the “silk sign” finding, which gives the feeling of thickening due to the sac and rubbing of the silk stockings, is sought. Testes should be checked in the scrotum before starting the hernia examination in boys. Hernias that go down into the scrotum are called scrotal hernias. The presence of an irreducible mass in the canal in girls may be a sign of sliding of the ovary into the sac (Kenneth & Welch, 1986; O’ Neill et al., 1998; John, 1998).

Differential diagnosis

Differential diagnosis should be made with inguinal lymphadenopathy, hydrocele, cord cyst, testicular torsion, undescended testis.

Treatment

Open Surgery

In inguinal hernia surgery, a transverse incision is made in the inguinal region. The inguinal canal is exposed by crossing the Camper and Skarpa fasciae. There are cord and vascular structures and the structure where the hernia sac is located. The sac is dissected from the cord and vascular structures. The hernia sac is tied high. This treatment is the standard treatment for inguinal hernia. Preoperative stomach should be fasted for 4-6 hours. In inguinal hernias reduced by self or sedation, at least 4-5 days or 1-2 weeks should pass for surgical repair of the hernia. During the operation, a.epigastrica superfisialis, a.iliaca circumflexia superfisialis and n. It is necessary to pay attention to the ilioinguinalis. The recommended time for surgery under ideal conditions is the age at the time of diagnosis (Spitz et al., 1997; Başaklar, 1994; Kelalis et al., 1985).

There is no age limit to wait for surgical treatment. It should be done in elective conditions as soon as possible when the diagnosis is made. A good history should be taken before surgery. The surgery is performed as a day surgery. The patient is discharged approximately 6 hours after the operation. In patients who are not operated on, the hernia carries a risk of strangulation in the inguinal canal. This possibility is higher in infants because the canal is narrower (Spitz et al., 1997; Başaklar, 1994; Kelalis et al., 1985).

Laparoscopic Surgery

Laparoscopic interventions in inguinal hernia repair are becoming increasingly common. The advantages it brings are closely related to the experience of the surgeon. There are several methods for this repair. One of them is minimally invasive methods with 3-port laparoscopy or needle method (Kelalis et al., 1985; Candan, 2001; Lee, 2018).

Advantage over Open Surgery ( Bittner, 2016; Pini et al., 2015; George et al., 2014)

  • Finding out if there is an inguinal hernia on the other side
  • Short operation time
  • Better cosmetic result than open surgery
  • It has advantages such as less post-operative pain.

HYDROCEL

Definition: It is an increase in fluid that occurs around one or both testicles, causing swelling in the scrotum or inguinal region, when the processus vaginalis, which should normally be closed after birth, remains open and allows only fluid passage. It usually disappears towards the end of the first year. It is a painless, well-defined, transilluminated (+) mass that may not shrink with palpation (George et al., 2014; Lin et al., 2018; Chan et al., 2005; Patkowski et al., 2006).

A hydrocele formed along the inguinal canal that has closed proximally and distally is called a “cord cyst”. If the hydrocele inlet part will allow very small fluid inlet and outlet, it is called a communicating hydrocele. In these patients, small swelling in the morning and growth in the evening is typical.

A distinction should be made between hydrocele and incarcerated inguinal hernia. Hydrocele is usually painless. Boundaries are clear. It is soft and mobile. It gives translumination.

An incarcerated hernia is painful. Boundaries are not clear. It is hard and immobile. It usually does not transluminate (Lin et al., 2018; Chan et al., 2005; Patkowski et al., 2006; Aydogdu et al., 2016).

Treatment

Hydrocele usually starts to shrink after the first 4 months and usually disappears after 1 year. Persistent or newly formed hydrocele after 1.5-2 years of age is permanent and should be treated surgically. The surgical procedure is the structure described above in inguinal hernia. The difference between hydrocele surgery and inguinal hernia is that the proximal processus vaginalis is thinner and narrower in hydrocele. The distal is fluid-filled. In the same way, the hydrocele sac is dissected from the cord and vascular structures and tied twice at high. The distal hydrocele sac is removed. The non-removable sac is cauterized (Chan et al., 2005; Patkowski et al., 2006; Aydogdu et al., 2016).

DIRECT INGUINAL HERNI

Direct inguinal hernias are rarely seen in children after surgical repair. A typical sac is not found. It arises from the fascia defect, medial to the inferior epigastric vessels, at a place called the Hasselbach Triangle.

Hasselbach’s triangle borders its lower edge ligamentum inguinale, its upper edge a.-v. epigastrica inferior, medial edge of m. it forms the lateral rectus abdominis (Kenneth & Welch, 1986; O’ Neill et al., 1998; John, 1998).

Treatment → Surgical repair of the transverse fascia is performed. Surgical repair should be done by McVay, Bassini, Ferguson, etc. methods.

FEMORAL HERNI

Femoral hernia occurs as a result of protrusion of intra-abdominal organs from the femoral canal. It is rare in children. The hernial sac arises from under the medial part of the ligamentum inguinale and from the outer side of the pubic tubercle. Patients present with recurrent swelling in the groin area. Early repair is recommended because of the high risk of incarceration. Various techniques have been described in the repair of femoral hernias. Surgery can be performed with techniques such as simple repair of the femoral ring, Mc Vay repair, Bassini repair, and Nyhus repair (1-5).

Complications of Hernia Surgery

CONCLUSION

In conclusion, diseases of the inguinal region are among the most common pathologies of the pediatric surgery department. Inguinal pathologies constitute half of many pediatric surgery clinics. The diagnosis is usually made by detailed anamnesis and physical examination. Surgical repair should be done as soon as possible. Otherwise, both the surgery becomes difficult and an urgent and difficult surgery may be encountered due to the risk of incarceration. That’s why all physicians should routinely examine the inguinal region. The existence of such pathologies should be questioned in detail.

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