Inguinal Hernia And Hydrocele Flashcards
What is a hernia?
A hernia is the protrusion of viscera from its normal cavity through a defect in the cavity wall.
What is an inguinal hernia?
An inguinal hernia is the protrusion of abdominal contents into the inguinal canal via a patent processus vaginalis.
What is the processus vaginalis?
The processus vaginalis is an embryonic out-pouching of peritoneum within the inguinal canal along the path of testicular descent.
What percentage of males have a patent processus vaginalis at birth?
80%.
How does the incidence of patent processus vaginalis change with age?
It decreases to 40% at 2 years and 20% in adults.
What is the most common cause of groin hernias in children?
Persistence of a wide patent processus vaginalis (PPV), leading to an indirect inguinal hernia.
How common are femoral and direct inguinal hernias in children?
They are exceptionally rare.
What percentage of term infants have patent processus vaginalis (PPV) at birth?
About 95%.
What are the typical contents of an inguinal hernia sac?
Usually bowel, but may include the fallopian tube, ovary (in girls), or bladder (in sliding hernias).
What is a hydrocoele?
A fluid hernia where peritoneal fluid accumulates around the testis within the PPV, without bowel involvement.
What are the potential complications of an inguinal hernia in neonates?
Irreducibility, bowel ischaemia, necrosis, septicaemia, shock, and testicular infarction.
Why is the risk of hernia complications higher in smaller children?
The inguinal ring becomes tighter as the bowel swells, cutting off vascular return and increasing the risk of ischaemia.
What is a sliding hernia?
A hernia where the bladder forms part of the hernia sac.
What percentage of obstructed hernias result in testicular infarction?
Approximately 10%.
What is the incidence of inguinal hernias in premature and term infants?
30% in premature infants and 3-5% in term infants.
At what age do 50% of inguinal hernias present?
Less than 1 year of age, with the highest risk under 6 months
Why should surgical repair not be delayed in neonates and premature babies?
They have a higher risk of complications, and age/size are not valid reasons for delay.
What is the most common side for inguinal hernias in children?
The right side (64%).
What is the male-to-female ratio for inguinal hernias?
6:1.
What is the incidence of bilateral hernias in girls?
Up to 75%, and bilateral operations are usually recommended.
What is a common symptom of an inguinal hernia in children?
A mass in the inguinal area that increases with coughing or crying.
What might be the only clinical indication of a spontaneously reducing hernia in an asymptomatic baby?
A reliable history from the mother.
What symptoms may indicate a complicated inguinal hernia with bowel involvement?
Symptoms of bowel obstruction and septicaemia.
What are the clinical findings of an uncomplicated inguinal hernia?
Swelling in the inguinal area and scrotum, thickening of the spermatic cord, “silk sign,” palpation of bowel or bowel sounds, inability to get above the mass, and increased size with crying.
What is the “silk sign” and what does it indicate?
The “silk sign” feels like two pieces of silk being rubbed together and indicates fluid in the processus vaginalis sac.
How can an inguinal hernia be differentiated from a hydrocoele on physical examination?
An inguinal hernia cannot be palpated above the mass, while a hydrocoele can.
What are the signs of an irreducible inguinal hernia?
Swelling in the inguinal area and scrotum that cannot be reduced, abdominal distension, and signs of bowel obstruction.
What defines an irreducible inguinal hernia?
A hernia with contents persisting outside the abdominal cavity that cannot be manually pushed back into the abdominal cavity.
What are the signs of a strangulated inguinal hernia?
Pain, redness, tenderness, edema of overlying skin, and abdominal wall tenderness, along with signs of intestinal obstruction
What complications can arise from a strangulated inguinal hernia?
Ischaemia, necrosis of the contents, dehydration, and shock due to fluid loss from vomiting and third-space accumulation.
How can an incarcerated hernia containing an ovary or fallopian tube present?
It may strangulate but will not have signs of bowel obstruction.
What are the differential diagnoses for a groin swelling?
Differential giagnosis of a groin swelling
• Lymphadenitis (external iliac)/ abscess (from suppurating lymphadenitis)
• Undescended testis
• Hydrocoele/ fluid hernia
• Hydrocoele of the cord
• Buried penis
• Varicocoele
What are the differential diagnoses for scrotal swelling?
• Congenital causes: Inguinal hernia, hydrocele
• Infections: Epididymo-orchitis, viral orchitis
• Trauma: Testicular rupture, scrotal or para-testicular haematoma
• Torsion: Testicular or testicular appendage torsion
• Neoplasms: Germ cell tumour, paratesticular rhabdomyosarcoma
• Medical causes: Oedema and anasarca, idiopathic scrotal oedema, Henoch-Schönlein purpura
What are the congenital causes of scrotal swelling?
Inguinal hernia, hydrocele
What infections can cause scrotal swelling?
Epididymo-orchitis, viral orchitis
What trauma-related conditions can lead to scrotal swelling?
Testicular rupture, scrotal or para-testicular haematoma
What conditions related to torsion can cause scrotal swelling?
Testicular torsion, testicular appendage torsion
What neoplasms can present with scrotal swelling?
Germ cell tumour, paratesticular rhabdomyosarcoma
What medical conditions can cause scrotal swelling?
Oedema and anasarca, idiopathic scrotal oedema, Henoch-Schönlein purpura
What is the management for an uncomplicated inguinal hernia in small babies?
Urgent elective surgical repair on the next available list.
When is surgery for inguinal hernia postponed?
Surgery is postponed if there are associated problems (e.g. pneumonia). The medical condition is treated first, and herniotomy is performed once the child is better, usually before discharge
Can older children wait for surgery for an inguinal hernia?
Yes, older children can be placed on a waiting list if symptoms and signs of complications are explained.
What is the operation of choice for inguinal hernias in children?
Herniotomy
What are the risks of emergency operations for an irreducible hernia?
Higher incidence of wound infections, haematoma, recurrent hernias, and possible damage to the vas deferens or veins.
What is the initial management for an irreducible hernia?
Resuscitation, nasogastric tube drainage, and sedation.
Can the irreducible hernia reduce spontaneously?
Yes, the hernia may reduce spontaneously with gentle manipulation of the scrotum or scrotal neck.
When is surgery performed for an irreducible hernia?
Surgery is carried out as an emergency if conservative management is unsuccessful or 24-48 hours later if the reduction is successful and the swelling has subsided.
Why is a strangulated hernia with necrotic bowel considered a surgical emergency?
The mortality rate is high, and it requires immediate intervention.
What should not be attempted in a strangulated hernia with ischaemic sac contents?
No attempt should be made to reduce the ischaemic sac contents.
What is the initial management for a strangulated hernia?
Active resuscitation with intravenous fluids, broad-spectrum antibiotics, and correction of electrolyte deficits.
What is done surgically for a strangulated hernia with necrotic bowel?
Resection of ischaemic bowel and primary anastomosis, followed by a herniotomy.
What is required postoperatively for a strangulated hernia?
High care/ICU is generally required for monitoring and recovery.
What is the operation performed to repair an inguinal hernia in childhood?
A herniotomy, performed under general anaesthetic.
How is the hernia sac treated during a herniotomy?
The hernia sac is dissected from the spermatic cord, divided, ligated, and the contents are either returned to the abdomen or resected and anastomosed if necrotic.
What important structures are identified and preserved during a herniotomy?
The ilioinguinal and iliohypogastric nerves.
What is the role of laparoscopic surgery in inguinal hernia repair?
Laparoscopic surgery allows for the identification and closure of the patent processus vaginalis from the inside of the abdomen.
What are some surgical complications of inguinal hernia repair?
Injury to vas deferens & testicular vessels, bladder, wound infection, haematoma, recurrence.
What is a common anaesthetic complication in premature infants after inguinal hernia repair?
High risk of post-operative apnoea in premature infants <60 weeks corrected gestational age.
How is post-operative apnoea managed in premature infants after inguinal hernia repair?
Monitoring for 24-48 hours post-operatively and possibly administering caffeine to decrease the risk.
How common are direct inguinal hernias in children?
They are extremely rare and usually occur when there is underlying muscle weakness (e.g., prune belly syndrome).
How are femoral hernias in children managed?
They are managed similarly to how they are treated in adults.
In which gender are femoral hernias more common in children?
Femoral hernias are more common in girls.
What causes a hydrocoele in children?
A hydrocoele is caused by an open processus vaginalis, which allows fluid to pass into the scrotum but prevents bowel and omentum from doing so.
What happens if the processus vaginalis only partly closes?
If the processus vaginalis partly closes, some fluid may become encysted, creating a hydrocele of the cord.
What are the clinical signs of a hydrocoele in children?
Clinical signs include swelling in the scrotum that may increase and decrease in size, a cystic feel, and the ability to get above the fluid-filled scrotum.
How is hydrocoele typically differentiated from other scrotal swellings?
Hydrocoele is usually not reducible, and transillumination is more likely to show hydrocele.
What percentage of congenital hydrocoeles close on their own in the first two years of life?
50% of congenital hydrocoeles will close in the first two years of life.
When might surgery be indicated for a hydrocoele?
Surgery may be indicated if the diagnosis is uncertain or in the case of a secondary hydrocele, where testicular pathology must be considered.
What is the surgical procedure for a hydrocoele?
The operation for a hydrocoele is the same as for an inguinal herniotomy.
