Vaginal bleeding in an infant secondary to sliding inguinal hernia

BACKGROUND

Vaginal bleeding in infancy is rare and, to our knowledge, has not been reported in association with an inguinal hernia.

CASE

A premature infant with a known reducible inguinal hernia developed vaginal bleeding at 8 months. Work-up revealed no coagulopathy and no endocrine abnormality. Physical examination and ultrasound found no anatomic lesion responsible for her bleeding. At surgery, she was found to have an indirect hernia in which the uterus, fallopian tube, and ovary were sliding components. Her vaginal bleeding ceased after herniorrhaphy.

CONCLUSION

Vaginal bleeding in a child with an inguinal hernia may occur when the uterus is a sliding component of the hernia.

[Hernia in children]

Congenital hernia seems to be the right term to define "hernia in childhood". Especially in newborn and infant, it is possible to observe numerous different pathologies which have nothing in common apart their congenital origin. Some as inguinal or umbilical hernia are very commonly encountered and others us omphalocele, gastroschisis or diaphragmatic hernia are quite rare and involved in the field of prenatal diagnosis and neonatal surgery.

Transverse testicular ectopia: report of three cases

Two patients who presented with a history of right inguinal hernia and a third with an impalpable left testis were found to have transverse testicular ectopia. Both testes were fixed in their own scrotum, through a modified Ombredanne operation in two patients and a subdartos pouch in one.

The genitofemoral nerve may link testicular inguinoscrotal descent with congenital inguinal hernia

The genitofemoral nerve (GFN) hypothesis for inguinoscrotal testicular descent proposes that calcitonin gene-related peptide (CGRP), released from the genitofemoral nerve, controls the migration of the gubernaculum from the inguinal region to the scrotum between 26 and 40 weeks of gestation. The processus vaginalis provides a channel through which the testis descends from the abdomen to the scrotum. Following descent of the testis the processus vaginalis undergoes luminal obliteration and disappearance between the internal inguinal ring and the upper pole of the testis. The mechanism underlying closure of the processus is unknown and failure for it to occur normally results in congenital inguinal hernia, scrotal hydrocele and possibly even an 'ascending' testis. Recent work in our laboratory suggests that CGRP, released from the genitofemoral nerve, may cause fusion and disappearance of the processus vaginalis. We propose that abnormalities in the GFN link a spectrum of disorders encompassing congenital undescended testis, inguinal hernia, scrotal hydrocele and ascending testis.

The incidence of positive contralateral inguinal exploration among preschool children--a retrospective and prospective study

Retrospective and prospective studies were undertaken to evaluate the true incidence of bilateral inguinal involvement in preschool children in an established general pediatric population. Unbiased, anatomically based criteria were established for a "positive" exploration. It was found that bilateral inguinal involvement was highest during the first year of life (68%) and decreased through the advancing years, to just above 50% at 6 years of age. Because a widely patent processus vaginalis may be a precursor of indirect inguinal hernia, contralateral exploration may carry lifelong benefits in those who have the processus vaginalis ligated. Based on the authors' observations, contralateral exploration can be offered to all preschool children, and in selected cases (difficult preoperative preparation, anesthetic high risk, strong family history, etc), even beyond this age. Contralateral exploration is a safe, effective, and cost-wise practice when performed in an appropriate setting.

Hepatogonadal fusion

Fusion of the testis with adrenal remnants is a relatively common incidental finding during orchidopexy. Splenogonadal fusion has been described in several cases. Herein the authors report a case of hepatogonadal fusion. To their knowledge, this is the first such case in the literature. Ectopic liver tissue has been encountered in a variety of locations, but had not been found in a testicle. The trapping of hepatocyte-destined mesenchyma in different areas may explain the presence of heterotopic liver tissue in different organs. If these cell aggregates are trapped in the area of peritoneum where the testis is forming, heterotopic liver tissue can end up in the testis.

Unilateral inguinal hernia in girls: is routine contralateral exploration justified?

To determine the incidence of contralateral hernia development after unilateral inguinal hernia repair in girls, collected case series from two large hospitals were analyzed retrospectively. Among the 294 girls who had analyzed repair of a unilateral inguinal hernia (during a 15-year period), 245 could be traced; the mean follow-up period was 8.4 years. In 25 (10.2%) of the patients, contralateral hernia developed, mostly within one year (4 months to 6.5 years). The incidence of contralateral hernia development with respect to the original side of the inguinal hernia was significantly higher (19%) for the originally left-sided hernias than for the right-sided ones (6%) (P < .01). Although the incidence of contralateral hernia development for girls with a left inguinal hernia decreased as age increased, it was still 14.9% for the girls age 3 and up. Contralateral exploration should not be routine for girls who have a right-sided hernia, at any age. For left-sided hernias, it may be performed routinely for girls up to 2 years of age, and selectively for older patients.

A familial Xp+ chromosome, dup (Xq26.3-->qter)

A maternally transmitted Xp+ chromosome was associated with an abnormal phenotype, including developmental delay and short stature, in two male cousins and their 12 year old aunt. The respective mothers were not mentally impaired but had short stature. The G banding pattern identified the extra chromosome segment as a repeat of Xq26.3-->qter attached to an apparently intact Xp22.3 sub-band, so the Xp+ chromosome may be described as rea(X)(Xqter-->p22.3::Xq26.3-->Xqter). The rearranged chromosome was late replicating in 97 to 100% of the metaphases in the mothers but it was early replicating in 43% of the lymphocytes in the mentally defective female (n = 100 cells/subject). Fluorescence in situ hybridisation using X and Y chromosome paints, as well as cosmids A and 1A1 specific for loci within Xq28, confirmed both the identity of the extra segment and the entirety of the Xp pseudoautosomal region. Therefore, the phenotypic consequences in this family can be related to the Xq26.3-->qter functional disomy allowing for the effects of X inactivation in the female carriers.

Thermal burns with injury to the intestine in a congenital hernia sac

It is unusual to have a bowel injury in association with thermal injury. It is even rarer to encounter a patient with cerebral palsy and thermal injury to an intestinal loop in a congenital hernia sac. A case report of such a child is presented and the management is discussed.

Epidermolysis bullosa junctionalis associated with urinary bladder exstrophy: a case report

We report the second infant of nonconsanguineous parents with epidermolysis bullosa junctionalis associated with urinary bladder exstrophy, epispadias, anteriorized anus, and bilateral inguinal hernias. The family history also included the death of a maternal cousin due to epidermolysis bullosa. Our diagnosis was based on electron microscopy and immunofluorescence evidence. This patient is reported because of the rarity of this constellation of findings.

Multiple herniae: a defect in the celomic mesoderm?

We report on a child with congenital bilateral cervical lung herniation with associated retrosternal (Morgagni), posterolateral (Bochdalek), esophageal hiatal, and inguinal herniae, and with multiple urinary bladder diverticuli. These multiple herniations may be secondary to a defect in the embryonic celomic mesoderm.

Routine bilateral exploration for inguinal hernia in infancy and childhood

Whether to explore the contralateral side is a real question regarding the management of unilateral inguinal hernias in infants and children. The surgeon can easier make a decision if he knows the true incidence and prevalence of the bilateral involvement in different ages. During the years 1982 to 1991 the authors could find 138 contralateral hernias developed after unilateral herniorrhaphy in 2554 children (5.4%). Fifty-five percent of these children (76 patients) were younger than 1 year of age, 74% of them (102 patients) were younger than 3 years of age at the time of the initial repair. The interval between the operations was less than 1 year in 54% of the cases. To get more precise data, we explored 148 children younger than 3 years of age bilaterally during 1992. The result was positive in 104 cases (70.3%). The bilateral involvement was most frequent under the first 6 months of life (83.5%), then it dropped gradually. We found a patent processus vaginalis on the asymptomatic side in 74.3% of girls and in 61.1% of boys. The overall contralateral involvement of unilateral hernias was 64.8%, independently of which side the hernia had appeared on. The patent processus vaginalis can be regarded as a precursor of indirect hernias, so the contralateral exploration can prevent the development of a later hernia. The authors conclude that bilateral exploration is mainly justified during infancy, but in case of girls they suggested applying it until three years of age.

True complete diphallia

In a case of true complete diphallia, the orthotopic penis was normal in length, shape and urethra, whereas the ectopic, perianal, penis had a blind-ending urethra, the significant distance between the two making the malformation of an extremely rare type. Right renal agenesis and orthopaedic malformations were also present.

Congenital testicular maldescent: significance of the complete hernial sac

OBJECTIVE

To test the hypothesis that testicular maldescent is rarely congenital in the absence of a complete hernial sac.

PATIENTS AND METHODS

The study comprised 110 boys undergoing orchidopexy. Operative findings (complete hernial sac versus no hernial sac) were compared with recorded testicular descent at birth.

RESULTS

Among 70 testes recorded as maldescended neonatally there was no example without a complete hernial sac at orchidopexy. Among 60 recorded as descended neonatally, 43 had no sac at orchidopexy.

CONCLUSIONS

The findings are consistent with the hypothesis, though not with the proposition, that the presence of a complete hernial sac at orchidopexy constitutes proof of congenital testicular maldescent.

Genetic study of indirect inguinal hernia

We performed a genetic analysis of 280 families with congenital indirect inguinal hernia ascertained in Shandong province. The multifactorial threshold model and segregation analysis were applied to these families to investigate the mode of inheritance of congenital indirect inguinal hernia. Our results indicate that congenital indirect inguinal hernia is not compatible with a multifactorial threshold model, and the frequent vertical transmission and high segregation ratio suggest autosomal dominant inheritance with incomplete penetrance and sex influence. Through further pedigree analysis of the multiple case families with at least two closely related affected members, we noted preferential paternal transmission of the disease gene, which might suggest the role of genomic imprinting in the aetiology of this condition.

Is contralateral exploration necessary in infants with unilateral inguinal hernia?

Between 1973 and 1985, 165 infants (aged 1 week to 6 months) underwent unilateral inguinal herniotomy at our hospital. An attempt was made to trace these 165 children. It proved possible to contact and examine 116 children (104 boys and 12 girls). Age at follow-up ranged from 5 to 17 years. Parents were asked whether their children had attended any hospital for the treatment of contralateral hernia. All children were examined for the evidence of contralateral hernia. Boys were also examined for the position and size of the testis. Testicular volume was assessed with the help of Prader's Orchidometer. Twelve children (10.3%), 11 boys and 1 girl, subsequently developed contralateral inguinal hernia. The mean time interval between initial hernia operation and subsequent development of contralateral hernia was 164 days (range, 7 days to 18 months). Diminished size of testes was observed on the side of the operation in six patients and one patient had complete testicular atrophy. Three boys had a testis in the groin, presumably hitched up at operation and all three required orchidopexy. In view of the relatively low incidence of contralateral hernia and increased risk of damage to testes, we feel that routine contralateral exploration is not justified.

[Spinal anesthesia for surgery of inguinal hernia in infants at risk for respiratory complications. Initial experiences with 12 patients]

11 former premature babies born at a mean gestational age of 32 weeks (range 27-34 weeks) and one baby born at term with congenital diaphragmatic hernia scheduled for inguinal hernia repair were selected to receive a spinal anaesthesia after informed written consent was obtained from one of the parents. At birth, 10 infants were intubated and received assisted ventilation; the remaining two were on nasal CPAP for 24 hours after birth. The mean post-conceptual age of the former premature infants on the day of surgery was 39 weeks (range 36-43 weeks), the mean weight was 2.2 kg (range 1.8 to 3.6 kg). One boy with congenital diaphragmatic hernia who was intubated for 19 days after birth aged 4 months on the day of operation and weighed 5.3 kg. None of the children was oxygen-dependent on the day of surgery. Spinal anaesthesia was performed in 3 children in the lateral decubitus and in 9 children in the sitting position. In each group, there was one case when spinal anaesthesia could not be performed due to a bloody spinal tap. These children received general anaesthesia, one of them in combination with a caudal block. The 9 former premature received 0.6 ml isobaric bupivacaine 0.5%, and the child born on term with diaphragmatic hernia 0.8 ml isobaric bupivacaine 0.5%. The onset of the motor blockade in the former preterm infants was within 60-90 seconds, while in the older child the onset was 10 minutes. With the given dose, the operation could be performed without any problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Inguinal hernias in very low birth weight infants: incidence and timing of repair

Although the increased occurrence of inguinal hernias (IH) in premature children is well known, its incidence in the very low birth weight (VLBW, < 1,500 g) subpopulation has not been previously established. Additionally, because of associated problems, these children present the surgeon with a dilemma in regards to the most appropriate time for repair. We sought to determine the incidence of IH, rate of incarceration, perioperative problems, and to possibly define the ideal time for correction. Between 1977 and 1987, 1,933 children under 1,500 g birth weight were admitted to our neonatal intensive care unit. Of these, 1,391 lived for at least 28 days and were followed until 20 months corrected age. IH was diagnosed in 222 of 1,391 (16%) of those who survived 28 days or more. IH occurred in 174 of 670 (26%) of the boys and 48 of 721 (7%) of the girls. The incidence by side was right 19.8%, left 14.9%, bilateral 61.7%, and was unclear 3.6%. Of the 222 infants with IH, 192 were operated at our institution at a mean postnatal age of 28 weeks (range, 5 to 110 weeks). Of these, 35 were operated prior to neonatal discharge. One or more incarcerations occurred in 35 VLBW operated at this hospital. In only one infant, an emergency operation was needed because of irreducibility. There was no operative mortality and minimal morbidity. Five recurrences occurred during the 20 months' follow-up. This series establishes the incidence of IH in VLBW (during the first 20 months). The wide range in age at operation suggests that no single criterion can be established for ideal timing of repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital parainguinal hernia in a heifer

A 2-day-old heifer was examined for a pendulous mass in the left inguinal region. The calf also had moderate brachygnathia. The mass was determined to be a parainguinal hernia, which was surgically repaired. Parainguinal hernias can be confused with other hernias in the inguinal region. Because of lack of previous reports, the hereditary aspects can only be postulated.