have a common etiology, and the
surgical correction of both
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pathologies is similar'.
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DEFINITIONS
Hernia : Protrusion of a part or whole
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of a viscus through a normal orabnormal opening in the wal of its
containing cavity.
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Hydrocele : Collection of fluid in the
tunica vaginalis sac.
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Must answer questions ?1. Is it Reducible or Cough Impulse?
2. Is the swelling Confined Scrotal?
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3. Can you identify the testes?
4. Can you get above the swelling?
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WHAT IS PROCESSUS VAGINALIS?
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Outpouching of peritoneum thatextends through the inguinal canal.
First seen during the 3rd month
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of intrauterine life.
It Follows the gubernaculum and
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testis through the inguinal canaland reaches the scrotum by the 7th
month of gestation.
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What normally happens to PV after testiculardescent?
The portion of PV surround
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the testis becomes tunicavaginalis.
PV Obliterate, eliminating the
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communication between
peritoneal cavity and scrotum.
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Up to 80%- 100% born witha patent PV
Closure- most likely to happen
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within the first 6 months of life
PPV: up to 20% in adulthood
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INGUINAL HERNIA
Most common surgical condition in
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childrenIncidence : 0.8-4.4%
Most commonly 1st year- peak in
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first 3 months of life.Almost always indirect hernias
(through deep inguinal ring).
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Not resolved spontaneously.
Risk of incarceration.
Should always be repaired.
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INGUINAL HERNIA
Up to 5% in Fullterm; 16-25% in Preterm
Up to 30% in wt <1000g and 60% in wt. < 750g
Up to 10:1:: M: F ratio
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60% right side; 30% left side; 10% bilateralIncrease incidence in:
Increased amounts of peritoneal fluid
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Ventriculoperitoneal shunts & Peritoneal
dialysis.
Increased intraabdominal pressure
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Repair of Gastroschisis or Omphalocele,
meconium ileus.
Associated urogenital conditions
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Undescended testis & Bladder exstrophy
Connective tissue disorders
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Ehler-Danlos, Marfan, Hunter Hurler syndromes.--- Content provided by FirstRanker.com ---
DIAGNOSIS`The diagnosis of inguinal hernia is clinical'
Classical presentation: Asymptomatic groin
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bulge which increases on crying & may disappearspontaneously if relaxed
Older children often complain of groin or
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inguinal "pain" during exertion.
If no mass can be identified, the older child -
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stand and do a Valsalva maneuver/coughimpulse.
An infant may be allowed to
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strain or cry to provoke an inguinal bulge toappear.
Silk glove sign: Index finger is lightly
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rubbed over the cord from side to side over
the pubic tubercle- cord structures are
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thickened (feels like two silk sheets rubbingagainst one another, reflecting the smooth
peritoneal sac edges).
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Sensitivity of 93% and specificity of 97%.
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Inguinal Ultrasonography:When examination is equivocal and for
preoperative evaluation of the
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contralateral groin in patients presenting
with unilateral hernias.
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- The upper limit of the normal diameter ofthe inguinal canal- 4 mm
- Diameter 4.9 mm ? 1.1 mm: patent
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processus vaginalis.
- Diameter 7.2 ? 2 mm : True hernia.
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Incarceration= contents of the sac cannoteasily reduced (3-16%; upto 30% in preterm
in 1st year of life.)
Strangulation= vascular compromise
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Contents may be small bowel, caecum, appendix,omentum, ovary and fallopian tube.
Management
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Will not resolve spontaneously, so surgical closure is always
indicated- herniotomy.
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Timing of surgery:- In infants younger than 1 year of age, the risk of
incarceration doubled with surgical wait times of more than
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30 days.- Most surgeons currently recommend repair of the hernia
soon after diagnosis.
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The fundamental principle guiding
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pediatric inguinal herniarepair is high ligation of the hernia
sac.
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Incarcerated Hernia
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An attempt at reduction should be made-using
analgesia and/or sedation.
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The hernia is palpated distal y while the clinician'sfingers are placed at the proximal neck of the
hernia.
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Compression on hernia slowly and consistently
until it is reduced.
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Risk of reincarceration 15% in 5 days.Subsequent surgical repair is attempted 24 to 72
hours later- al ow edema to resolve
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Contralateral Exploration
One of the most contentiously debated issues in pediatric hernia
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surgery.
While up to 60% to 80% < age 1 and 40% of older children(by 2
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yrs) with hernia will have a patent processus, half of these childrenwill develop a clinical hernia on the other side.
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~ Zavras, N., et al (2014) Current Trends in the Management of Inguinal
Hernia in Children. International Journal of Clinical Medicine, 5, 770-777.
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A recent review- overall risk to develop later an IH is 5.7%.Contralateral exploration has potential disadvantages- injury to
the contents of the spermatic cord, wound infection, increased
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cost, increased pain and prolongation of the operation.To resolve this debate, multiple strategies have been introduced
the more recent being ultrasound and laparoscopy.
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Laparoscopy repair
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Most pediatric surgeons consider itunnecessary.
Only recently it has become an
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alternative.
Gaining popularity with more and
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more studies validating its feasibility,safety, and efficacy.
Pros: Contralateral side seen.
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Cons: More time,transabdominal.
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Insufficient evidence
to support one
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approach overanother.
The peritoneal
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incision intentionally
created at the
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internal inguinalring, seems to result
in a more durable
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repair.
POSTOPERATIVE COMPLICATIONS
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1. Scrotal Swel ing2. Iatrogenic Undescended Testicle
3. Recurrence: 0-0.8%; Large hernia (0.8-4%), Preterm (15%) and
incarcerated hernia (20%).
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4. Injury To The Vas Deferens: 0.13-1.6%
5. Testicular Atrophy: 1% ; incarcerated hernia 2.6-5%
6. Intestinal Injury: 1.4%
7. Chronic Pain
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Congenital Hydrocele
When the processus vaginalis remains patent, allowing fluid from
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the peritoneum to accumulate in the scrotum.
70% Scrotal
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25% Cord5% commune
60% right
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30% left
10% bilateral.
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Primary Hydrocele - Types1. Congenital hydrocele
2. Funicular hydrocele
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3. Infantile hydrocele
4. Encysted hydrocele of the cord
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5. Vaginal hydrocele- commonest6. Bilocular hydrocele/-en-bisac
7. Hydrocele of the hernial sac
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Primary Hydrocele - Clinical features
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? Moderate to big size swelling
? Cough impulse negative ; Get above the swelling positive
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? Not reducible; Consistency- tensely cystic? Transillumination positive
? Testis not felt separately
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? Transillumination negative in Hematocele, Pyocele, Chylocele and
thick sac
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TREATMENTMost surgeons advocate
observation of hydroceles in
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infants <24 months.
Others continue observation as
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the majority PPV will close withinthe first 24?36 months of life.
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Inguinal herniotomy