Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Pediatric Surgery 2 Congenital Hydrocele And Hernia PPT-Powerpoint Presentations and lecture notes
CONGENITAL HYDROCELE AND
HERNIA
`Inguinal hernia and hydrocele
have a common etiology, and the
surgical correction of both
pathologies is similar'.
DEFINITIONS
Hernia : Protrusion of a part or whole
of a viscus through a normal or
abnormal opening in the wal of its
containing cavity.
Hydrocele : Collection of fluid in the
tunica vaginalis sac.
Must answer questions ?
1. Is it Reducible or Cough Impulse?
2. Is the swelling Confined Scrotal?
3. Can you identify the testes?
4. Can you get above the swelling?
WHAT IS PROCESSUS VAGINALIS?
Outpouching of peritoneum that
extends through the inguinal canal.
First seen during the 3rd month
of intrauterine life.
It Follows the gubernaculum and
testis through the inguinal canal
and reaches the scrotum by the 7th
month of gestation.
What normally happens to PV after testicular
descent?
The portion of PV surround
the testis becomes tunica
vaginalis.
PV Obliterate, eliminating the
communication between
peritoneal cavity and scrotum.
Up to 80%- 100% born with
a patent PV
Closure- most likely to happen
within the first 6 months of life
PPV: up to 20% in adulthood
INGUINAL HERNIA
Most common surgical condition in
children
Incidence : 0.8-4.4%
Most commonly 1st year- peak in
first 3 months of life.
Almost always indirect hernias
(through deep inguinal ring).
Not resolved spontaneously.
Risk of incarceration.
Should always be repaired.
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
60% right side; 30% left side; 10% bilateral
Increase incidence in:
Increased amounts of peritoneal fluid
Ventriculoperitoneal shunts & Peritoneal
dialysis.
Increased intraabdominal pressure
Repair of Gastroschisis or Omphalocele,
meconium ileus.
Associated urogenital conditions
Undescended testis & Bladder exstrophy
Connective tissue disorders
Ehler-Danlos, Marfan, Hunter Hurler syndromes.
DIAGNOSIS
`The diagnosis of inguinal hernia is clinical'
Classical presentation: Asymptomatic groin
bulge which increases on crying & may disappear
spontaneously if relaxed
Older children often complain of groin or
inguinal "pain" during exertion.
If no mass can be identified, the older child -
stand and do a Valsalva maneuver/cough
impulse.
An infant may be allowed to
strain or cry to provoke an inguinal bulge to
appear.
Silk glove sign: Index finger is lightly
rubbed over the cord from side to side over
the pubic tubercle- cord structures are
thickened (feels like two silk sheets rubbing
against one another, reflecting the smooth
peritoneal sac edges).
Sensitivity of 93% and specificity of 97%.
Parent's digital images.
Inguinal Ultrasonography:
When examination is equivocal and for
preoperative evaluation of the
contralateral groin in patients presenting
with unilateral hernias.
- The upper limit of the normal diameter of
the inguinal canal- 4 mm
- Diameter 4.9 mm ? 1.1 mm: patent
processus vaginalis.
- Diameter 7.2 ? 2 mm : True hernia.
Incarceration= contents of the sac cannot
easily reduced (3-16%; upto 30% in preterm
in 1st year of life.)
Strangulation= vascular compromise
Contents may be small bowel, caecum, appendix,
omentum, ovary and fallopian tube.
Management
Will not resolve spontaneously, so surgical closure is always
indicated- herniotomy.
Timing of surgery:
- In infants younger than 1 year of age, the risk of
incarceration doubled with surgical wait times of more than
30 days.
- Most surgeons currently recommend repair of the hernia
soon after diagnosis.
The fundamental principle guiding
pediatric inguinal hernia
repair is high ligation of the hernia
sac.
Incarcerated Hernia
An attempt at reduction should be made-using
analgesia and/or sedation.
The hernia is palpated distal y while the clinician's
fingers are placed at the proximal neck of the
hernia.
Compression on hernia slowly and consistently
until it is reduced.
Risk of reincarceration 15% in 5 days.
Subsequent surgical repair is attempted 24 to 72
hours later- al ow edema to resolve
Contralateral Exploration
One of the most contentiously debated issues in pediatric hernia
surgery.
While up to 60% to 80% < age 1 and 40% of older children(by 2
yrs) with hernia will have a patent processus, half of these children
will develop a clinical hernia on the other side.
~ Zavras, N., et al (2014) Current Trends in the Management of Inguinal
Hernia in Children. International Journal of Clinical Medicine, 5, 770-777.
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
cost, increased pain and prolongation of the operation.
To resolve this debate, multiple strategies have been introduced
the more recent being ultrasound and laparoscopy.
Laparoscopy repair
Most pediatric surgeons consider it
unnecessary.
Only recently it has become an
alternative.
Gaining popularity with more and
more studies validating its feasibility,
safety, and efficacy.
Pros: Contralateral side seen.
Cons: More time,
transabdominal.
Insufficient evidence
to support one
approach over
another.
The peritoneal
incision intentionally
created at the
internal inguinal
ring, seems to result
in a more durable
repair.
POSTOPERATIVE COMPLICATIONS
1. Scrotal Swel ing
2. Iatrogenic Undescended Testicle
3. Recurrence: 0-0.8%; Large hernia (0.8-4%), Preterm (15%) and
incarcerated hernia (20%).
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
Congenital Hydrocele
When the processus vaginalis remains patent, allowing fluid from
the peritoneum to accumulate in the scrotum.
70% Scrotal
25% Cord
5% commune
60% right
30% left
10% bilateral.
Primary Hydrocele - Types
1. Congenital hydrocele
2. Funicular hydrocele
3. Infantile hydrocele
4. Encysted hydrocele of the cord
5. Vaginal hydrocele- commonest
6. Bilocular hydrocele/-en-bisac
7. Hydrocele of the hernial sac
Primary Hydrocele - Clinical features
? Moderate to big size swelling
? Cough impulse negative ; Get above the swelling positive
? Not reducible; Consistency- tensely cystic
? Transillumination positive
? Testis not felt separately
? Transillumination negative in Hematocele, Pyocele, Chylocele and
thick sac
TREATMENT
Most surgeons advocate
observation of hydroceles in
infants <24 months.
Others continue observation as
the majority PPV will close within
the first 24?36 months of life.
Inguinal herniotomy
This post was last modified on 08 April 2022