Inguinal Hernia And Hydrocele In Children

Ida Ayu Wayan Mahayani, Made Darmajaya Departement of

Surgery Medical Faculty of UdayanaUniversity Sanglah
Hospital Denpasar

ABSTRACT
Inguial hernia and hydrocele is a fairly common disease in children. The study showed that
the incidence in the United States reached 10-20 of 100 live births, with more locations
hernia on the right side and 10% bilaterally. Hydrocele is a colection of fluid in the procesus
vaginalis, and it can cause swelling in the groin or scrotum. Inguinal hernias ocur when
abdominal organs protrude into the inguinal canal or scrotum. In healthy babies, balls
surounded by a closed room, the tunica vaginalis of the scrotum. In postnatal life, this is a
potential space that should not be related to the peritoneum.
Keywords: Inguinal hernia, Hydrocele.

INTRODUCTION
Highest risk associated with a hernia is when the intestine is trapped in the sac.
1
This
condition is referred to as incarceration. If allowed to incarceration, the colon will be
edema. Increased pressure can damage the venous flow, and lead to more severe edema,
where it can damage the arterial flow to the intestines and can be up to the scrotum. When
perfusion of the intestine is affected, Strangulated hernias occur. Strangulated hernias can
cause intestinal perfusion, peritonitis, sepsis, and death.
1
Because of this, incarcerated or
strangulated hernia included in the medical emergency. If the strangulated bowel surgery at
an early stage, the viability can be maintained, and bowel resection can be avoided.
2
In women, the ovaries or fallopian tubes can be entered into the hernia sac and become
incarcerated or Strangulated. Incarcerated ovaries is a problem because it can lead to
emergencies in ovarian infection and pain. However, the ovaries which incarcerated does
not carry the risk of perfusion and sepsis as the intestinal perfusion.
2
Studies show that in the United States the incidence reaches 10-20 of 100 live births, with
the location of the hernia more on the right side and 10% bilateral. Hernia 6 times more
often found in men than women. Incarcerated intestine is more common in women than
men. In women, the ovaries or fallopian tubes Incarcerated more common in the
intestines.
3
In addition, the overall incidence of bowel strangulation more often in women
than men. The lower the PPV incident with the aging age. In 80-94% of newborn infants
have PPV. A hernia occurs 20 times more frequently in infants weighing under 150 grams
than the general population. In addition, the overall incidence of bowel strangulation more
often in women than men.
2

ETIOLOGY
Most hernia and hydrocele in children is caused by failure of closure of the processus
vaginalis. The cause of failure closure of the processus vaginalis is still unknown. Various
conditions that increase intra-abdominal pressure may inhibit or prevent this closure.
4
Reactive hydrocele is caused by trauma, torsion, or infection of the testicles or scrotum.
3

Abdominal or retroperitoneal surgery which disrupt the lymphatic flow can also cause
reactive hydrocele. Reactive hydrocele causes inflammation and fluid collection in the
testis.
4

Inguinal hernias are classified into three, namely indirect inguinal hernia, inguinal hernia
complete, and inguinal hernia direct. Indirect inguinal hernia entry through the ring and is
caused by the failure of the processus vaginalis to close. Indirect hernia is a hernia which
occurs most often in children. The hernia may extend down the inguinal canal to the labia or
scrotum.
4
Complete inguinal hernia is indirect hernia extending into the scrotum. Anatomic
abnormalities similar to abnormalities in the hydrocele communicant, although the PPV
more patents on hernia. Direct inguinal hernia protruding through the inguinal canal and
base are from the medial inferior epigastric vein. In children, these hernias are rare and
usually observed only after other inguinal surgery.
4

Hydrocele is classified into five communicant hydrocele, hydrocele non communicant,
reactive hydrocele, hydrocele on the cord, hydrocele in the canal of Nuck, and hydrocele
abdominoskrotal.
4
Communicant hydrocele involves PPV that extends into the scrotum. In
this case PPV continuous with the tunica vaginalis surrounding the testis. Anatomic
abnormalities identical to abnormalities in the indirect hernia. However, a defect in
hydrocele smaller so that only the accumulation of fluid. Contains non communicant
hydrocele fluid trapped in the scrotal tunica vaginalis.
4
Processus vaginalisnya closed so that
fluid can not connect to the abdominal space. Hydrocele is more common in infants, and the
fluid will usually reabsorbed before the age of 1 year. Reactive hydrocele is a hydrocele non
communicant growing of inflammatory conditions in the scrotum. The cord hydrocele
occurs when the processus vaginalis closes above the testicles, but still there is a small
relationship with the peritoneum. In this hydrocele, there is a region such as the inguinal
canal sac filled with fluid. This fluid does not get into the scrotum. Hydrocele in the canal of
Nuck occurs in women when fluid accumulates in the processus vaginalis in the inguinal
channel.
5
Abdominoscrotal hydrocele occurs due to the small opening of the processus
vaginalis. Liquid into the hydrocele and trapped. Hydrocele will continue to grow and a sat
will extend upwards towards the abdomen.
5


PATHOPHYSIOLOGY
When fetal development, the testicles are located in the peritoneal space. When passing
through the inguinal canal testicle down into the scrotum and, he was followed by the
extension of the peritoneal sac which as we know as the processus vaginalis.
5
After the
testes down, the processus vaginalis to close in healthy infants and become fibrous cord
without a lumen. With this, the connection will be disconnected abdomen and scrotum.
Without this relationship abdominal organs or peritoneal fluid will not be through the
scrotum or inguinal canal. If the processus vaginalis is not closed, it is called a patent
procesus vaginalis (PPV).
6

If PPV small diameter and just enough liquid to pass by then this condition is called as a
hernia. Many theories that explain the failure closure procesus vaginalis.
6
The discovery of
the smooth muscle of the PPV network and not on the normal peritoneum is one of them.
The number of smooth muscle that is possibly related to the degree of patency. For
example, more commonly found in the smooth muscle hernia sac rather than PPV of
hydrocele. Research is still ongoing to find the role of smooth muscle in the pathogenesis of
this condition.
6


CLINICAL EXAMINATION
Bulge in the groin or scrotum enlargement is a classic sign of a hernia or hydrocele
communicant.
6
Pain is generally not a sign of conspicuous exception infected hydrocele or
strangulated hernia. Often times, parents reported bumps that sometimes appear and
sometimes not. Bulge could disappear at night or when the patient is supine.
4
History of
vomiting, colicky abdominal pain, or obstipation indicate a bowel obstruction which may be
related to or Strangulated hernia incarcerated.
5

Hernia and hydrocele can be diagnosed by physical examination. Check the child in the
supine and standing position. If the bulge clearly visible when standing, lay the child in the
supine position. The resolution indicates the bulge in the supine position hernia or
hydrocele with PPV.
4
If the bulge is not obvious, give a clue to an increase in intra-
abdominal. Example, let the children blow balloons or suppress stomach. The raising of the
child's hand on his head to make children struggling, and may be seen shadows or marks
that were not previously visible bulge. Sightings scrotum which showed the presence of fluid
in the tunica vaginalis, hydrocele signaling, but these tests are not completely reliable
because the intestines may also look sightings. Bowel sounds in the scrotum, is a strong
marker of the presence of a hernia.
6
Bulge below the inguinal ligament leading to the
presence of lymphadenopathy. Examiner should try to find a silk glove sign.
6
Touched gently
with a finger on the tuberculum pubis may be able to feel the presence of PPV. Cord
thickening of hernia or hydrocele sac in the spermatic cord provides sensation to the finger
like 2 fingers that use silk gloves touching. PPV is difficult to detect by physical examination,
if the PPV is not yet a hernia or hydrocele.
6

To help diagnose a hernia can be used as well as laboratory investigations and imaging.
3

Evaluation of the lab in general not very essential for the evaluation of hydrocele and
hernia. With finding leukocytosis may be a sign of a hernia which strangulated. Ultrasound is
used to check for the presence of PPV. However, ultrasonography is still need further study
because of the lack of clear data for the percentage of accuracy of diagnosis. Abdominal X-
ray may be used to distinguish obtruction the intestines hernia incarcerated or
Strangulated.
6


MANAGEMENT
There is no effective medical therapy for hernia or hydrocele communicant. Aspiration and
injection of scleroting agents have been recommended for the treatment of hydrocele non
communicant in adults but this therapy is contraindicated in children.
7
Because most of the
hernia and hydrocele in children associated with PPV, scleroting agent can damage the
intra-abdominal contents and no real impact on the improvement of the basic pathological.
Anti-inflammatory agents can be used in a reactive hydrocele condition.
7

Hernia and hydrocele was the same, but different natural journey. there is a high risk of
incarcerated hernia in premature infants.
8
As many as 60% of hernias in premature infants
be incarcerated role in 6 months after birth.
7
For that reason, the improvement of the
methods of operation can be accepted by the public as an effective method of treatment for
inguinal hernia in children and adults.
7
Unlike hernias in infants, many newborns with hydrocele can heal by itself because
spontaneous closure of the PPV shortly after birth. Residue on non communicant hydrocele
is not increased or decreased in volume, and there is no sign of silk glove.
8
Fluid in hydrocele
usually absorbed back into the body before the baby is 1 year old. Because of these facts,
observations are often required for hydrocele in infants.
8
Hydrocele should be treated, if not disappear after the age of 2 years, causing discomfort,
increase in size or be clearly visible increase or reduction in volume, if not visible, and
infected.
8

Hernia or hydrocele is not always prominent. A bulge in the crotch of the children must be
supervised by a parent or primary medical personnel. Often, this bulge is not visible when
the consultation, but the thickened cord structures ipsilateral to the side with a history of
protrusions (silk glove sign) can be suspected as a PPV. The situation is already a sufficient
indication for exploration hernia. A current photo bulge appears in the area can help clarify
the diagnosis.
8

Specific conditions have to do surgery if the hernia incarcerated hernia is not reducible, or
there are signs of strangulated hernia, in term infants with no history incarcerated, the baby
is not enough months in the NICU weighing 180 -200gr, and in premature infants with age
less than 60 weeks post-conceptus.
8

When there is a hernia, some urologists and surgeons to explore the contralateral groin. It is
done to detect PPV shadows that can cause a hernia on the opposite (contralateral
metachronous hernia).
8
Goldstein test can determine when to contralateral exploration. In
this test, the abdomen is inflated with air through the bag open hernia during surgery. The
presence of crepitus in the opposite groin indicates a positive test result, indicating the
presence of a contralateral PPV and an approval for the execution of contralateral
exploration. Alternatively, it can be used to detect shadow laparoscopic contralateral PPV.
8
Laparoscopy has a growing role in the hydrocele and hernia surgery. As per the above
statement, laparoscopic exploration can be done through a separate incision in the
umbilicus or through the hernia pouch after opening. This can be done by inspection of the
contralateral inguinal ring, and advanced procedures can be performed as needed.
7

Laparoscopic hernia repair in children is not common as it is commonly done in adults.
Babarapa medical centers in Europe using techniques which are not in exsisi hernia pouch,
sewn only at the end of his neck. The use of mesh is not commonly performed in children
are not like adults. The result is quite satisfactory, although the recurrence rate is higher
than open repair. Recent studies of rich et al from Germany (2006) reported that the results
more satisfying than laparoscopic reduction and repair of incarcerated hernias in children.
They reported no complications and recurrence, but further research needs to be done.
Recovery from hernia or hydrocele surgery is generally not complicated. To control pain, the
baby used ibuprofen 10 mg / kg every 6 hours and acetaminophen 15 mg / kg every 6 hours,
avoid narcotics because of the risk of apnea.
6
For older children given acetaminophen with
codeine (1 mg / kg codeine) every 4-6 hours. For 2 weeks after surgery, the straddle position
should be avoided to prevent shifting of the mobile testes out of the scrotum and cause
secondary cryptorchidism. In children during walking, the activity should be limited as much
as possible during 1 month. In children in the school, stretching and active sports activities
should be limited for 4-6 weeks.
6
Because most of the hernia and hydrocele surgery
performed by outpatient basis, patients can return to school as soon as it has been felt quite
comfortable (usually 1-3 days after surgery).
8



COMPLICATIONS
The complication rate of hernia surgery is 1-8%. Infertility can happen if there is a bilateral
injury to the vas deferens or injury to the vase of solitary testicle. The existence of such
structures in a vase pathology specimens need not mean an indication of the vase as 6% of
the specimens containing residual Mllerian tract which has a histologic appearance similar
to the vase. Testicular atrophy may occur due to injury during surgery on testicular blood
vessels. Incarcerated hernia can disrupt blood flow to the testicle. Figures testicular atrophy
after hernia repair of incarcerated can reach 19%. As with other operations, hematoma may
occur. Hematoma is usually not necessary unless the hematoma explored keeps getting
bigger. As with other operations, infection can also occur. Hypesteshia and neuropathic pain
can result from trapped nerve or injury. Secondary cryptorchidism may occur due to
excessive scar formation and increase with the growth of the testes.
8

PROGNOSIS
With open surgery, ipsilateral recurrence rate is less than 1%. Ipsilateral recurrence rates
with laparoscopic inguinal hernia repair is 3-4%. Recurrences are usually associated with
comorbid conditions.
8


SUMMARY
Inguinal hernia and hydrocele is a disease that is often found in children. Hernia and
hydrocele was the same, but different natural journey. there is a high risk of incarcerated
hernia in premature infants. Hydrocele is a fluid collection in the processus vaginalis, which
can cause swelling in the inguinal region or scrotum. Inguinal hernias occur when abdominal
organs protrude into the inguinal canal or scrotum. Hernia and hydrocele can be diagnosed
by a physical examination that is the classic sign of a bulge in the groin or scrotal
enlargement. Laparoscopic surgery became effective therapeutic modality in children with
inguinal hernia and hydrocele.






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