Hernias and hydrocoeles are the commonest conditions seen by paediatric surgeons as they occur in about 3-5% of children. The cause for both these conditions is the failure of the processus vaginalis to close before or just after birth (see Figure 1).
- If the processus vaginalis is small, there is a passage between the abdominal peritoneum and the tunica vaginalis of the testis may allow fluid from the abdomen to trickle down and collect as a hydrocoele around the testis. This is called a HYDROCELE
- If the tract is larger, the bowel or momentum can also go into This is called an INGUINAL HERNIA
Hydrocoeles are harmless and majority spontaneously resolve by 2 years of age or require surgical closure if they persist beyond 3 years of age.
Figure 1: Hydrocele
Figure 2: Inguinal Hernia
Indirect inguinal hernias on the other hand, do not go away and can cause problems to the child especially for the under 1 year-old.
The risks are:
- Incarceration where the hernia is stuck causing bowel obstruction
- Strangulation of the hernia where the blood supply to the herniated bowel is cut off causing necrosis and perforation of the bowel
- The hernia may compress on the blood vessels to the testis at the inguinal ring and cause testicular atrophy (and loss of sperm production) in boys
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Hernias must be corrected as soon as possible, especially in the under 1 year-old. When the hernia is stuck (incarcerated) or strangulated, they will need urgent reduction or emergency surgery to prevent damage to the bowel or testis.
How to distinguish a hydrocele from an inguinal hernia
- Age of onset: hydroceles can be seen soon after birth as a non-tender scrotal swelling whereas hernias usually presents early in premature infants but usually within the first 2 years of life in term babies
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- Constancy: hydroceles are seen most of the time and often smaller in the mornings and gradually increase in size as the day passes. Hernias on the other hand, comes and goes and often appears when the child cries. It helps if the parent can take a photo to show the doctor
- Location: hydroceles are usually located are in the scrotum except for encysted hydroceles of the cord (see Figure 3 below) whereas hernias extend can from the inguinal area to anywhere down towards the scrotum
- Physical exam: one can get above a hydroceles whereas one cannot get above hernias
- Reducibility: Non-incarcerated hernias can often be reduced (made smaller in size) while hydroceles cannot
- Transilluminate: Hydrocoeles generally can transilluminate with a light while hernias look opaque
How the bowel gets stuck in the inguinal hernia
A painful non-reducible groin swelling associated with vomiting and constipation is an emergency and the child must to referred to a paediatric surgeon for reduction or surgery to prevent the bowel from getting strangulated.
Surgical Treatment of Hernias and Hydrocele
Treatment of inguinal hernias is surgery to prevent complications mentioned above. There is no role for any conservative treatment or bandages (Truss) to contain the hernia.
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Hernias can be repaired by an open procedure or using laparoscopic (keyhole) surgery. In up to 15% of children, a hernia can also be found on the opposite side. Laparoscopy allows for the contralateral side to be examined and repaired at the same time using the same incision.
Hydroceles that persist beyond 3 years of age also need surgery. There is no role of aspiration of the hydrocele as they often recur or can lead to an infection.
Dr. Nada Sudhakaran