Inguinal Hernia in Children

In children, hernias, or a hernia, occur mostly at the umbilical ring and in the groin area, with inguinal hernias being the most common. The following developmental processes in the human embryo should make it understandable why inguinal hernias in particular are relatively common.

Causes of inguinal hernia in children and babies

There are basically two ways to treat inguinal hernia: conservative and surgical. The neural tube, the annex for the central nervous system, forms by invagination from the neural groove. Subsequently, primordial segments develop on both sides of the neural tube and protrude into the primary abdominal cavity. From these primordial segments, the primordial kidney and kidney anlagen develop, with the primordial kidney becoming the gonadal anlagen. The further development and positional change of the gonadal anlage depends on the sex of the germling. While in female germlings the ovary only approaches the anterior abdominal wall, the positional changes in male embryos are much greater. The male gonads migrate to the scrotum, i.e. to a part located outside the abdominal cavity, taking along peritoneal sheets. This process can be explained by the thermal conditions necessary for the formation of spermatozoa, which are about 36 degrees Celsius. However, since the temperature inside the abdominal cavity, the so-called core temperature, is around 37.5 degrees Celsius, the lower thermal conditions in the scrotum, due to the external temperature, are more favorable for the development of the spermatozoa. During their transfer to the scrotum, the gonads take with them a process of the peritoneum that envelops them along with blood vessels and the spermatic cord. Normally, at the time of embryo maturity, the wall sections of the peritoneal process stick together again, that is, the peritoneal process (now called the testicular sheath) separates completely, from the abdominal cavity. Only the inguinal canal remains open, because the blood vessels that nourish the gonads and the spermatic cord must continue to have a portal of passage, which, however, is usually covered by strong muscle bundles. However, if this peritoneal process does not close, there is an open connection between the abdominal cavity and the testicular sheath, which can become a hernial sac if intestinal loops and other parts of the abdominal cavity contents slip in. These anatomical and developmental conditions also explain why inguinal hernia is found in about 90 percent of all cases in boys. Parts of the intestines can slip into the hernia sac if the child presses the abdominal wall hard for various reasons, for example, when trying to empty hard stool from the bowel regularly. Then a protrusion in the groin can be seen externally. In most cases, the contents of the hernia sac are loops of bowel, but less frequently they are mesh parts that normally cover the loops of bowel.

Frequency and characteristics

A right-sided inguinal hernia (60%) is more common than a left-sided (25%) or a double-sided (15%) hernia because complete displacement of the right gonad into the scrotum occurs at a later time than on the left side, leaving the right peritoneal process open longer. Besides these congenital inguinal hernias, we also know the so-called acquired inguinal hernias. They occur directly through a place of the abdominal wall where the abdominal wall is not completely overlapped by the muscle bundles going in different directions. Thus, they do not need to follow the inguinal canal in the process. However, such inguinal hernias are rarely found in children.

Symptoms and signs

Congenital hernias usually do not become visible until several weeks to months after birth. Weak and premature babies tend to have them far more often than other children. The often severe compressive cough that occurs with whooping cough or other severe inflammatory diseases always stresses the abdominal walls, increasing the pressure within the abdominal cavity and thus favoring the occurrence of a hernia, especially in infancy and early childhood. It will be understandable that muscle training of the abdominal walls, started in early infancy with light gymnastic exercises and occasional abdominal positioning, then continued throughout kindergarten and school years, contributes to the prophylaxis (prevention) of such hernias. The hernia tumor may appear as a small protrusion in the groin, often only the size of a hazelnut.If it persists for a long time and bulges more frequently, considerable sizes are reached. It then often descends into the scrotum, which can sometimes become the size of a fist, greatly affecting the children’s well-being. They are then often restless and cry a lot, have low appetite, vomit easily and gain little weight for these reasons. If the child lies quietly or is placed in a warm bath, the hernial tumor often retracts into the abdominal cavity on its own. If this does not happen, the hernia sac contents must be carefully pushed back by hand. Such a hernia becomes problematic (for parents and child, not for the surgeon) only when the contents of the hernia sac become trapped in the hernial orifice, which can have many causes, but two conditions stand out in particular. Let us assume that there is a loop of small intestine in the hernia sac. In such a case, the intestinal contents pass through the inflow leg into the intestinal part stored in the hernia sac and then further into the outflow leg. Thus, the intestinal content (which always contains bacteria and in which chemical processes take place) has to pass twice through the intestinal section constricted in the hernial orifice. A spasmodic contraction of the abdominal wall muscles would narrow the hernial orifice. Congestion of the intestinal contents within the hernial sac and damage to the intestinal wall by chemical and bacterial processes would result.

Symptoms and signs of inguinal hernia

Besides this first condition, there is a second one for hernia sac contents entrapment, as already mentioned:

Namely, when bacteria and toxins pass through the intestinal wall, they cause inflammation of the peritoneum in this section, which causes suppuration, pain of the intestinal muscles, and adhesions. The other dangerous side of the incarceration is that the intestinal loops inside the hernial sac are accompanied by vessels (arteries and veins). Constriction of the hernial orifice also always leads to impaired circulatory conditions, insofar as the thin-walled veins are first constricted, thereby impeding blood outflow. If the arterial inflow into the intestinal loop of the hernia sac remains, blood stasis occurs, blood leaks from the vessels into the tissue crevices, which in turn favors inflammatory processes. The first signs of entrapment are restlessness and expressions of pain by the child. It suddenly starts crying, apparently without reason, and cannot be calmed down. Often, the children vomit. Since there is still stool below the strangulated intestinal segment, normal bowel movements may be feigned by its discharge. Afterwards, however, the contents of the intestine accumulate above the strangulation. Stool and flatulence no longer pass. Children vomit, and vomiting of feces in particular is a serious sign of illness. Food intake is also refused, and the abdomen slowly distends. The skin over the externally visible hernial mass reddens, and the mass hurts as soon as pressure is applied to it. Even at the first signs of an incarcerated hernia, it is advisable to see a doctor. Although many childhood incarcerations resolve spontaneously, which not infrequently occurs during transport to the hospital, for example, immediate removal of the incarceration must still be sought.

Treatment and surgery

For the treatment of inguinal hernia, in principle, two ways can be considered: conservative and surgical. It depends on the age and general condition of the patient in the first place, which treatment the doctor will perform. Non-incarcerated inguinal hernia in early infancy was treated until some time ago with a hernia band, which was supposed to prevent the hernial mass from escaping by exerting pressure on the inguinal canal. It was thought that this would promote closure of the open peritoneal process. Today, however, it is known that a hernia does not heal spontaneously after the first few months of life, either with or without a hernia band. In addition, prolonged wearing of the hernia band is always unfavorable, because the skin around the band and underneath becomes easily inflamed in the infant. Also, the underlying muscles gradually weaken and regress, and there is never a guarantee that the peritoneal process has closed. Therefore, if the child can be expected to undergo the operation, it should not be delayed too long. The operation procedure is easy to understand.The surgeon reduces the contents of the hernia sac into the abdominal cavity, first sutures the peritoneum and then the other layers of the abdominal wall together over the former hernial orifice. Finally, he cuts away superfluous parts of the skin that have been severely overstretched by the hernia and places a skin suture. Today, the procedure can be performed without significant risk and relatively quickly. Infants or toddlers and babies can be operated on as early as three months of age. Only in exceptional cases, for example in the case of an incarceration, an even earlier time must be chosen. Postponing the operation until the child is one or two years old does not pose a risk to the child, although it does mean that the hernia can become trapped at any time, endangering the child’s life. If healing proceeds without complications, children can be discharged from the hospital just a few days after the operation. To facilitate the final healing, it is still necessary to avoid flatulence and excessive abdominal pressing efforts for a while. For this reason, the doctor exempts school-age children from school sports for about three months after a leisten hernia operation. To spoil the child for the sake of the healed surgical scar and to exempt it from physical activities in the household is fundamentally wrong. Prolonged immobilization only weakens, so those who take it easy can easily have a fracture recurrence.