Adopt a wait-and-see attitude for patent processus vaginalis in neonates

PURPOSE

The purpose of this paper is to describe the ultrasonographic findings of the patent processus vaginalis (PPV) in neonates.

METHODS

The patency of the processus vaginalis was examined by ultrasonography in 117 neonates. The ultrasonographic findings, with increment and decrement of the intraabdominal pressure, were categorized into 6 types as follows: type I, the intraabdominal organ is observed; type II, cystic PPV; type III, the PPV is widened with abdominal pressure increment, the length is > or =20 mm; type IV, the PPV contains moving fluid without PPV widening; type V, the PPV is widened with abdominal pressure increment, the length is less than 20 mm; type VI, others. The authors we regarded types I to IV as PPV with inguinal hernia.

RESULTS

Twenty-two of 40 neonates with a birth weight under 2,500 g had PPV, including 8 with type I. Twenty of 37 premature neonates 22 to 37 gestational weeks had PPV, including 8 with type I. Eighty-one percent (13 of 16) of PPV in low-birth-weight neonates and 91% (10 of 11) in premature neonates closed spontaneously. The median ages at the time of spontaneous regression of PPV were 242 days in low birth weight neonates and 262 days in premature neonates.

CONCLUSIONS

Most premature or low-birth-weight neonates with PPV regress spontaneously. The inguinal hernia in neonates (especially in premature or low-birth-weight neonates) should be observed until at least 9 months of age without attempting hernia repair.

Duplication of the Testis with Contralateral Anorchism

We describe the case of a newborn infant with duplication of the testis and absence of the contralateral testis. The patient also had bilateral indirect inguinal hernias and an ipsilateral undescended testicle.

The etiology of indirect inguinal hernias: congenital and/or acquired?

The development of indirect inguinal hernias in infants is caused by a patent processus vaginalis (PPV). Consequently, this type of hernia is cured by simple herniotomy. In adults, however, herniotomy alone is accompanied by a high recurrence rate. This indicates that additional factors play a part in the development of indirect inguinal hernias in adults. The aim of this study was to determine the etiology of the development of an indirect hernia in adult life. Also, the prevalence of a PPV without clinical evidence of a hernia was determined and related to age. From November 1998 until February 2002, 599 patients from four different teaching hospitals, who underwent abdominal laparoscopy for various pathologies, were included. During laparoscopy, the deep inguinal ring was bilaterally inspected. Patients undergoing laparoscopy for inguinal hernia repair were excluded. Mean age was 45 years (range 8-89 years). Thirty-two percent (189/599) were male. Twelve percent (71/599) had PPV, all without clinical symptoms. Fifty-five percent (39/71) with PPV were male (P<0.0001). Fifty-nine percent (42/71) with PPV were right-sided, 29% (21/71) with PPV were left sided, and 12% (8/71) were bilateral (P=0.01). The prevalence of PPV in patients under 20 years was 22%. Of those between 20 and 30 years of age, 6% had PPV. Of those between 30 and 50 years, 24 patients (11%) had PPV. Of patients over 50 years, 33 (14%) had PPV. No significant differences between ages were observed. It is concluded that asymptomatic patent processus vaginalis frequently exists in adult life. The prevalence of PPV does not increase significantly with age. Assuming that indirect hernias start with asymptomatic peritoneal protrusion that can be observed laparoscopically, the incidence of PPV, like the incidence of adult indirect hernias, should increase in case of acquired etiology. Such an increase of incidence with age was not confirmed by our results. It is concluded that the etiology of indirect inguinal hernia in adults, as in infants, is congenital.

A prospective study of neonatal inguinal herniotomy: the problem of the postoperative hydrocele

Previous studies have reported an increased incidence of complications following neonatal inguinal herniotomy (IH) in boys. The incidence and natural history of postoperative hydrocele in such cases has not been described. A prospective follow-up study of a consecutive series of male infants weighing less than 3 kg at the time of IH was undertaken. Regular follow-up examinations were scheduled for at least 1 year. Thirty-eight boys weighing less than 3 kg underwent IH during an 18-month period. One subsequently died from complications of prematurity. Complete follow-up data were available for 29/37 (78%) patients, yielding a total of 46 IHs. There were 2 recurrent hernias (4%), 2 unequivocally atrophic testes (4%), and 1 iatrogenic testicular ascent (2%). Five ipsilateral hydroceles complicated the postoperative course of 4 boys (14% of patients, 11% of herniotomies). Two of these were explored, but in neither case was a recurrent/residual patent processus vaginalis found. One hydrocele was aspirated without recurrence, and the remaining 2 resolved spontaneously. The complication rate in small infants undergoing neonatal IH is significantly higher than in older boys. The presence of a hydrocele after neonatal IH may simply reflect the accumulation of fluid in the distal hernia sac and, provided there is no evidence of a recurrent inguinal hernia, an expectant approach is recommended.

Congenital "transhaesio intestini tenuis supragastrica" in a 14-year-old girl - a rare case of internal hernia

Intestinal obstruction caused by internal hernia is a rare condition. A 14-year-old girl who suffered from acute abdominal pain two days after appendectomy is presented. Abdominal sonography and plain abdominal x-ray showed dilated small bowel loops and air-fluid levels indicating mechanical intestinal obstruction. Exploratory laparotomy revealed small intestine loops herniated through the lesser omentum. The anatomical aspects are reviewed and discussed.

Apnoea in a former preterm infant after caudal bupivacaine with clonidine for inguinal herniorrhaphy

Awake regional anaesthesia for inguinal hernia repair in former preterm infants is suggested to avoid life-threatening respiratory complications known to occur after general anaesthesia. Caudal anaesthesia is becoming a more popular technique for this purpose. To prolong duration of anaesthesia and to reduce postoperative need for analgesics in these infants, caudal clonidine has been considered useful. We report a former preterm infant, who had two awake caudal anaesthetics for herniotomy within 3 weeks. The first was uneventful with bupivacaine 0.25% at 35 weeks postconceptional age. At 38 weeks, the baby suffered form intra- and postoperative apnoeas after inadvertent administration of bupivacaine 0.125% plus clonidine.

Sliding appendiceal inguinal hernia with a congenital fibrovascular band connecting the appendix vermiformis to the right testis

It is not uncommon to find the appendix vermiformis within a hernia sac; however, sliding appendiceal inguinal hernia is rare. A 9-month-old boy with an incarcerated right scrotal hernia is presented in this case report. Although the hernia was reduced through a conservative approach, appendix vermiformis remained in the hernia sac because of its attachment to the upper pole of the right testis. Exploratory surgery during the inguinal hernia repair revealed a connecting band that extended from the appendix vermiformis into the scrotum and attached to the right testicle. Histologic examination showed that the band was congenital. After reduction of an incarcerated hernia, the persistence of a thickened or a cord-like structure is a warning for the presence of a sliding hernia. We suggest that this uncommon developmental anomaly is likely to cause the processus vaginalis to remain patent, thus facilitating hernia formation.

Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia

We prospectively studied the post-operative recovery profile of 28 ex-premature infants undergoing inguinal herniotomy. All infants had a post-conceptual age of less than 46 weeks at the time of surgery and were randomized to receive either sevoflurane (group 1, 14 patients) or spinal anaesthesia (group 2, 14 patients). All patients received supplemental caudal analgesia before skin incision. Cardiorespiratory function was continuously recorded in all patients before and after surgery. A blinded observer analysed each paired recording for predefined episodes of apnoea, hypoxaemia or bradycardia and the reports were used to compare the two groups. Spinal anaesthesia was attempted unsuccessfully in four patients in group 2. Five patients in group 1 demonstrated an 'excess' number of episodes (median 4, range 3-12) of clinically silent post-operative cardiorespiratory complications. ('Excess' in our study was defined as a 3-fold or greater increase in the number of post-operative episodes of bradycardia or apnoea relative to pre-operative occurrence). Three of these patients had pre-existing abnormal respiratory function and accounted for 80% of the episodes (26/32) of post-operative bradycardia and all five episodes of post-operative apnoea identified. All episodes of bradycardia and apnoea were temporally unrelated. None of the remaining patients in group 2 demonstrated an unacceptable number of post-operative cardiorespiratory complications. Our limited study suggests that general anaesthesia with an inhalational agent such as sevoflurane may induce or unmask abnormalities of cardiopulmonary function in predisposed infants. Spinal anaesthesia may be preferable but it is potentially stressful for the infant and associated with a clinically significant failure rate.

Myofibroblasts defined by electron microscopy suggest the dedifferentiation of smooth muscle within the sac walls associated with congenital inguinal hernia

OBJECTIVE

To ascertain the presence of myofibroblasts in sacs associated with inguinal hernia in children, through an ultrastructural evaluation using electron microscopy.

MATERIALS AND METHODS

Sacs were obtained from 10 boys and 10 girls (of similar age, approximately 45 months) with inguinal hernia and processed for electron microscopy. Thin sections were examined specifically for the presence of myofibroblasts.

RESULTS

The ultrastructural evaluation showed myofibroblasts with classical electron microscopic features within all of the sacs, regardless of the gender of origin.

CONCLUSION

The persistence of smooth muscle hinders the obliteration of the processus vaginalis; myofibroblasts are found in association with smooth muscle and thus such cells within the sac walls seem to originate from the smooth muscle, reflecting the dedifferentiation of smooth muscle. This dedifferentiated state may represent attempted apoptosis, which usually causes the disappearance of the smooth muscle and obliteration of the processus vaginalis after the descent of the testis into the scrotum.

Embryotoxicity and teratogenicity studies of an ayurvedic contraceptive--pippaliyadi vati

An ayurvedic contraceptive--pippaliyadi vati, containing equal parts of powdered seeds or fruit berries of Embelia ribes, fruit of Piper longum and borax powder was fed orally to two groups of pregnant rats: 2.5 times to one and five times to the other; the recommended dose for humans. The foetuses of mothers fed with pippaliyadi had low birth weights and were smaller in length. The mothers gained less weight during gestation. Developmental defects of soft tissues and skeletons were analyzed. There were instances of herniation of the intestines into the umbilical cord in foetuses of mothers who were administered pippaliyadi. The control and the gum acacia groups did not show such herniation.

Evaluation of caudal anaesthesia performed in conscious ex-premature infants for inguinal herniotomies

Ex-premature infants, before 45 weeks postconceptional age, are at high-risk of apnoea after surgery. General anaesthesia increases the risk of apnoea. We evaluated the tolerance and the efficiency of caudal anaesthesia performed in 25 consecutive conscious ex-premature infants for inguinal herniotomies. N2O/O2 and EMLA cream are used to facilitate caudal puncture. Anaesthesia procedure, patient comfort and complications following the 24 postoperative hours were studied. We report good anaesthesia conditions without compromising the baby's comfort and few perioperative complications. Only two infants with a prior history of apnoea or bronchopulmonary dysplasia had apnoea during and after surgery. A total spinal anaesthesia was the major complication in one infant and prolonged surgery requiring general anaesthesia was the main limitation of this technique in another child. The principal advantage of the procedure is to facilitate and simplify the postoperative management of the babies. The anaesthetic technique does not alter surgical conditions. Caudal epidural anaesthesia performed in awake high-risk preterm infants is beneficial for these infants but requires experienced operators.

Individual and associated effects of length of inguinal canal and caliber of the sac on clinical outcome in children

PURPOSE

The caliber of processus vaginalis is accepted to define the clinical outcome to be an inguinal hernia or hydrocele not based on any evaluation. The caliber of sacs and length of inguinal canals of boys and girls were evaluated to define the relation of sex, age, and the diagnosis with caliber of the sac and the length of inguinal canal.

METHODS

A total of 217 inguinal canals in 24 girls and 112 boys with inguinal hernia, 30 boys with hydrocele or hydrocele of the cord, and 31 boys with undescended testis have been evaluated. Twenty patients had bilateral involvement. The length of inguinal canal, and the circumference of the sac were measured. A formula was developed to predict the length of inguinal canal according to the age and sex. The circumferences of the sacs, length of inguinal canals, and the ratios of the circumference to the length were compared according to the clinical pictures.

RESULTS

The regression model of the relationship between the age and the length of the inguinal canal is an equation of third degree (inguinal canal in millimeters) = 0.0000119 x age 3 (months) - 0.00292 x age 2 (months) + 0.3168 x age (months) + 19.979 (r2 = 0.47). Inguinal canal is longer in boys (25.133 and 27.996 mm; P = .018), and length does not differ among diagnoses but differs according to age showing a linear growth after 24 months. Although the circumference as a sole parameter could classify only 55.3% of boys correctly, the ratio of length of inguinal canal to circumference of the sac has been the significant parameter in classifying boys into 1 of 3 groups including inguinal hernia, undescended testis, and hydrocele with a 70.2% success rate.

CONCLUSIONS

Inguinal canal that shows a linear growth after 24 months of age is longer in boys. Caliber is not the unique factor that determines the clinical outcome. Although the ratio of length of inguinal canal to the circumference of the sac defines the clinical picture best, even this parameter cannot classify the cases correctly. Therefore, some factors in addition to the caliber and length of inguinal canal might have roles in determining the clinical outcome.

Laparoscopic treatment of congenital inguinal hernia in children

PURPOSE

The authors report their experience in the laparoscopic treatment of congenital inguinal hernia in children.

METHODS

Between September 1994 and September 1995, 45 boys between 8 months and 13 years of age (mean, 4 years) were treated laparoscopically for hydroceles, spermatic cord cysts, or hernias. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and two cases (4.4%) presented the clinical data of a bilateral pathology. The approach used for small hernias was the placement of purse-string suture around the internal orifice of the inguinal canal (28 cases). As to hernias exceeding 4 to 5 mm in diameter, the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture (17 cases). There was never need to use a prosthesis.

RESULTS

Surgery lasted from 15 to 45 minutes with the duration decreasing with experience. There were no intra- or postsurgical complications. Two patients (4.4%) experienced a recurrent inguinal hernia, which was successfully operated on again with laparoscopy.

CONCLUSION

The early results of these authors suggest that laparoscopic surgery is a feasible and safe technique for the treatment of patent peritoneal vaginal canal (PVC) and inguinal hernia in children.

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh.

Risk of congenital inguinal hernia in siblings: a record linkage study

Using data from the Oxford Record Linkage Study (ORLS), we conducted a case-control study to estimate the sex-specific risks of inguinal hernia in siblings of children with this condition. There were 1921 male and 347 female cases born during 1970-86 who were operated on for inguinal hernia at ages 0-5 years during 1970-87, with 12,886 male and 2534 female control subjects. The relative risk of inguinal hernia was 5.8 [95% confidence interval 4.0-8.4] for brothers of male cases and 4.3 [2.1-8.7] for brothers of female cases (both relative to brothers of control subjects). The relative risk was 3.7 [1.8-7.9] for sisters of male cases and 17.8 [6.9-46.3] for sisters of female cases (both relative to sisters of control subjects). The pattern of sex-dependent risks, particularly the large risk for sisters of female cases, suggests a multifactorial threshold model for the disease. Girls have much lower rates of inguinal hernia than boys, and if these rates are low because of a low susceptibility to disease due to the absence of a sex-related risk factor, then those girls who develop disease might have a potentially large contribution to susceptibility from genetic or intrauterine risk factors unrelated to sex.

Neonatal scrotal faecal fistula

Incarceration of a congenital inguinal hernia, if untreated promptly, can result in dreaded complications like faecal fistula. We report one neonate who presented with a scrotal faecal fistula due to late presentation.

Advances in neonatal surgery

Neonatal surgery has reached a high degree of sophistication. We are now entering a new era of widespread screening of the unborn by means of ultrasound, with planned intrauterine, intrapartum, and immediate postpartum interventions. Many pediatric surgical centers are now focusing their investigative efforts on elucidating the cellular, molecular, and biochemical response to disease and therapeutic agents. The author presents the topic of neonatal surgery to some of the newer applications, techniques, and approaches.

[Inguinal herniotomy in prematurely born infants]

INTRODUCTION

Inguinal hernia is the most common surgical condition in childhood; more than half of the cases occur during infancy (1, 2). As the number of surviving premature infants continues to grow, the pediatric surgeon has become more involved in the management of these hernias (3, 4). Several issues are contentious, such as the optimal time for herniotomy after diagnosis (5), the role of contralateral exploration, and the proper management for incarcerated inguinal hernia (6). Based on our experience, we attempted to study the above points in the infant population and we also examined the role of ventilator therapy in the etiology of inguinal hernia.

MATERIAL AND METHODS

We performed a retrospective review of records of all infants under 6 months of age who underwent a repair of inguinal hernia at the Clinic for Pediatric Surgery in Novi Sad between January 1994 and December 1996. After surgery, all infants were included in a 6-week follow-up examination.

RESULTS

During this period, 144 infants under 6 months of age underwent inguinal hernia repair. There were 114 males and 30 females. Fourteen patients had bilateral hernias at the time of presentation. Incarceration occurred in 32 infants (22%), that is in 27 of the 99 full-term cases (27%) and in 5 of the 45 preterm cases (11%). Only in three cases (8%) did it occur while the infant was awaiting repair. Over 90% of the full-term infants had their hernias repaired within 3 weeks from diagnosis. After reduction of incarceration, our policy is to operate within 24 to 48 hours. Four testicles appeared to be ischemic; one of these was excised. Patchy bowel ischemia was present in six cases, and bowel resection was required in one. The ovary and tube were twisted and ischemic at the time of operation, requiring oophorectomy in two female infants. Forty-five infants were premature. The mean age at the time of diagnosis was 8 weeks; at the time of herniotomy, it was 13 weeks. In the 24- to 28-week group, 44 of hernias were bilateral, and 7 of the 9 infants had been ventilated for an average of 6 weeks. The mean interval between diagnosis and surgery was 8 weeks for this group.

DISCUSSION

The management of an apparently simple condition such as pediatric inguinal hernia can prove difficult. Deaths have occurred after complications or surgery for inguinal hernia, and most are probably avoidable (9). Morbidity is common and primarily related to incarceration or to damage to vas or testicular vessels during a difficult herniotomy. Because of our policy to operate within 3 weeks from diagnosis, only 8% of incarcerations occurred in infants known to have inguinal hernia. It is surprising that 35% to 41% of incarcerations repeatedly occur in already diagnosed cases (10, 11). Our policy of operating within 24 to 48 hours of manual reduction of incarceration would avoid the 40% reincarceration rate still being reported (6, 10). Our recurrence rate of 2% (3 cases) in comparison to that of other reports (5.4%) (12) we consider acceptable. Because only 5% of cases developed a contralateral hernia, the contralateral exploration is unnecessary. Testicular atrophy has been reported in 1%, even after routine herniotomy (13). There was a large number of premature infants (31%) in our series; the typical range is 9% to 21% (1, 4). The incidence of bilaterality (44%) in this group is very high. The explanation could be that hernias may be caused by ventilation-induced positive intraabdominal pressure, which keeps the processus vaginalis open. Contrary to contemporary belief (1), we found that incarceration is less common in preterm (11%) than in full-term infants (27%).

CONCLUSION

The waiting period for premature infants is not hazardous, and herniotomy can be safely performed once the baby is mature (gestational age of 38 to 40 weeks), weighing more than 2200 grams, and is ready for discharge from the neonatal unit.

Diagnostic laparoscopy for congenital inguinal hernia

Repair of indirect inguinal hernias is the most common general surgical procedure in infants and children. The question of whether or not to explore the contralateral side, however, has been the source of much debate among pediatric surgeons. With the advent of laparoscopy and the development of miniature telescopes, diagnostic laparoscopy has been advocated to decide in which child the contralateral side should be explored and a patent processus vaginalis ligated. This article describes the historical perspective in which this technique developed, the technique itself, and a report of the author's experience.

[An uncommon complication: cryptorchidism in an adult]

This unusual pathology has not been described in the medical literature of the last ten years. A 39-year-old patient, affected by unilateral cryptorchidism, on the right side, and congenital inguinal hernia, reached the operating theatre suffering from occlusive intestinal syndrome, due to a clogged hernial sac. This clog was caused by a retracting testicle which in turn stopped the ileal ansa from slipping back in to the peritoneum. Through this case we can underline the excursus of such pathology, which isn't very frequent in the adult but can, nevertheless create a fairly serious pathology, often leading to neoplan.