Pediatric Inguinal Hernia
Raphael C. Sun
Graeme J. Pitcher
Inguinal hernias in infants and young children represent pure indirect hernias. Correction involves high ligation of the sac. The floor of the inguinal canal is left along and does not require repair.
SCORE™, the Surgical Council on Resident Education, classified inguinal herniorrhaphy in children as an “ESSENTIAL COMMON” procedure.
STEPS IN PROCEDURE
Skin crease incision centered over the mid-inguinal point (halfway between anterior superior iliac spine and pubic tubercle)
Divide Scarpa fascia
Incise aponeurosis of external oblique
Identify and preserve ilioinguinal nerve
Identify sac by separating cremaster fibers from sac
Identify cord and cord structures and dissect the sac away
In females, divide and ligate round ligament and sac simultaneously
In males, once sac separated from cord structures, transect sac and suture ligate
Pull scrotal contents into scrotum
Close external oblique, Scarpa fascia and skin in layers with absorbable sutures
HALLMARK ANATOMIC COMPLICATIONS
Injury to spermatic cord
LIST OF STRUCTURES
External oblique muscle and aponeurosis
Inguinal canal
Processus vaginalis
External (superficial) inguinal ring
Superficial (Scarpa) fascia
Spermatic cord (male)
Round ligament and ovary (female)
Background
Inguinal hernia in pediatric patients commonly require surgical repair. These are indirect hernias, and they develop from a processus vaginalis that remains patent after birth.
Inguinal hernias are more common in males than females. They are also more common in preterm than in full-term infants. Inguinal hernias occur more on the right (60%) compared to the left (25% to 30%), and 10% to 15% are bilateral.
Incision (Fig. 118.1)
Technical Points
The traditional adult hernia repair involves an incision from the anterior superior iliac spine (ASIS) to the pubic tubercle. However, for pediatric patients a curvilinear incision in the skin crease over the mid-inguinal point provides proper exposure to the structures of the inguinal canal and is better cosmetically (Fig. 118.1).
Deepen the incision down to the external oblique aponeurosis. This may be done with the use of electrocautery, blunt, or sharp dissection. The method is optional. The key is to locate the relatively avascular tissue plane superficial to the external oblique aponeurosis.
