Development: The testis in a male child develops in the Abdomen (tummy). Few months before birth, it descends (comes down) into the scrotum on its corresponding side through a tunnel (processus vaginalis). After the testicles are in place the tunnel is supposed to close up and disappear. If this persists after birth (patent processus vaginalis – ppv – fig 2), then it may lead to a hernia/ hydrocele. Thus a hernia or a hydrocele in a child is fundamentally different in its cause from that of an adult and therefore the treatment also varies from that of an adult.

Girls may also have the tunnel and when it does not close, they too may develop a hernia.-Fig 3.

In the case of a hydrocoele, the ppv contains only some fluid because the communication is usually very narrow. It presents itself as a swelling of the scrotum which is painless. There maybe a variation in the size of the hydrocele from tine to time as the fluid may empty intermittently into the abdomen especially at night.

When the ppv contains other organs as its contents, the condition is called a hernia (inguinal hernia). In most cases, the hernia contains a loop of intestine – Fig 1, but in some cases it may also contain other organs like the ovary in a female child.

Inguinal Hernias occur in up to 4% of children but are as common as 30% in premature infants. Although the ppv exists since birth, most cases of hernia are noticed within the first year of life, especially once the child becomes upright and walking. It presents as an intermittent swelling of the groin on the affected side which is painless unless complicated. Hernias are nine times more common in boys. In a small proportion of patients, hernias may occur on both sides. The commonest complication of a hernia is irreducibility which may lead to strangulation of the contents within the hernia. This can pose an emergency situation whereby the hernia has either to be reduced as early as possible or operated. In late cases the contents of the sac- usually a portion of the intestine may become gangrenous and lead to a potential risk to life especially in a small child. In any patient with a painless intermittent swelling of the groin if the swelling becomes suddenly irreducible, red or painful it requires urgent medical attention and the patient should be seen by a pediatric surgeon as soon as possible.

Surgery for a hernia

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The propensity of irreducibility of a hernia is highest in the premature and the smaller children. In view of the potentially serious comlications possible in case the hernia does get strangulated, children (newborns and prematures too) are advised to get their hernia repaired at the earliest once they are fit for the anesthesia.

Anesthesia:

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Surgery for hernia is usually done under general anesthesia but in selected cases, it may also be possible to do the same under sedation with regional anesthesia. The procedure is a short procedure and the risk of anesthesia is usually quite small unless the patient has some pre-existing disease.

Procedure:

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The standard surgery for hernia( herniotomy) is performed through a small incision in the ipsilateral groin. In most cases the patient does not require to stay for more than 1 day in the hospital and post- discharge most children are reasonably comfortable with all their routine activities.

In recent years, surgery for hernia is also being done by the laparoscopic approach (MAS). Besides the general advantages of minimal access surgery, this approach offers the surgeon an opportunity to inspect the other side and in case there is a chance of developing a contra-lateral hernia, the same can be identified and operated laparoscopically at the same time without any additional incision. This could avoid a future hospitalisation since 10-15% of children are known to get a hernia on the other side in future.

Discharge Instructions After Surgery

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1. Your child may need some medicines the first few days after surgery.
2. It is advisable to avoid clothes which are too tight over the groin area.
3. Children will limit their activity if they are uncomfortable. Your child may resume activity whenever he feels ready. Children may miss 5 -7 days of school. Whereas there is no reason to routinely recommend restriction of activities in a child operated for a hernia, you need to ensure that there is no direct injury to the site of the incision for atleast 3 weeks after the surgery.
4. Bathing: Depending on the type of dressing used, your surgeon will advise regarding when the child can be bathed.
5. Diet: Your child may eat what he wants. Encourage your child to have a balanced and nutritious diet especially for 2-3 weeks after surgery.

Glossary

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1. Testis: it is the male organ of reproduction which produces the male hormone which enters the blood and gives the effect of manhood on various organs. It also produces the sperms which are delivered into the urethra at the time of ejaculation.
2. Scrotum: it is the sac of skin and surrounding tissue where the testis normally lies.