[Inguinal hernia in children: easily incarcerated]

Inguinal hernia in children is caused by an incomplete obliteration of the vaginal process during the embryological development. The vaginal process can thus become a hernia sac that often contains bowel and in girls, an ovary. The diagnosis of inguinal hernia is made by history and physical examination. According to current guidelines surgical repair should be performed without delay to avoid incarceration, which gives a high risk of complications, including testicular atrophy and ischemia of vital organs. However, patients are regularly not referred adequately. We present three cases of children who developed complications of a non-repaired inguinal hernia. Additionally, the data of all children with a congenital inguinal hernia, surgically treated from January 2018 until August 2019 show that out of 243 children 13.6% presented acutely with an incarcerated inguinal hernia. Another 6% received a wrong advice from their primary care doctor and was not referred to a (pediatric) surgeon.

Urinary bladder herniation through inguinal ring in a female cat

A 7-month-old spayed female domestic shorthair cat was referred for lethargy, stranguria, and a fluctuant mass of varying size in the right inguinal region. Computed tomographic imaging revealed the urinary bladder partially herniated through the right inguinal canal. Primary herniorrhaphy was performed and re-placement of the urinary bladder was confirmed via laparotomy.

[Pathologies of peritoneo-vaginal canal in pediatric surgery at the teaching hospital Gabriel Touré]

The closure anomalies of the peritoneal-vaginal canal include several clinical entities, which are at the origin of various symptomatology.

OBJECTIVE

To study the anatomo-clinical and therapeutic aspects of pathologies of the peritoneal-vaginal canal.

MATERIALS AND METHOD

This was a prospective study from January 1^st to December 31^st, 2015 carried out in the pediatric surgery department of University Hospital Gabriel Touré. It covered all children aged 0-15 years old with a pathology of the peritoneal-vaginal canal operating in the department during the study period. This study did not include cases that were not operated on or not seen during the study period.

RESULTS

During the study period, 2,699 children were treated in pediatric surgery, of which 150 cases of pathology of the peritoneal-vaginal canal had a hospital frequency of 5.5%. The average age was 3.25 ± 9.63 years. The sex ratio was 14. The reason for consultation was intermittent or permanent inguinal or inguino-scrotal swelling in all children. The pathology was discovered by the parents during the pushing efforts in 46.7%. Inguino-scrotal swelling was found on physical examination in 40% of cases. The right side was reached in 60% of the cases. Hernia accounted for 80.6% of these pathologies. We recorded 31 cases of strangulation and 11 cases of craze. Immediate operative follow-up was simple in 92% of patients. This rate was 96% after 6 months.

CONCLUSION

Pathologies of the peritoneal-vaginal canal are very common in pediatric surgical practice. The first place of these pathologies is occupied by hernia. They preferentially affect male infants.

Irreducible Indirect Inguinal Hernia in Premature Infant with Ectopic Uterus and Bilateral Adnexa

Indirect inguinal hernia is one of the most common congenital anomalies in children, with a reported prevalence of 0.8-4.4%.1 About 15-20% of hernias in female infants contain ovary, and in rare cases a fallopian tube.2 However, only a few cases contain the uterus and both ovaries in the hernia sac.3 The normal anatomy is altered when an ovary is trapped in a hernia sac, and these changes make torsion more likely and increase the risk of infertility. Although an irreducible ovary is not at great risk of compression of its blood supply, in these occurrences, ovarian torsions have been reported in 2%-33%, emphasizing the importance of early surgical repair in irreducible hernias, even in asymptomatic patients.4 The presentation of an asymptomatic palpable movable mass over the labium major always suggests sliding hernia with ovary. To our knowledge, only a few reports of hernia sac containing uterus, fallopian tube, and ovary in a female patient have appeared in the literature. We suggest that sonography be performed routinely in female infants with an inguinal hernia containing a palpable movable mass. We present a rare case of premature female infant with a labial mass containing the uterus, both ovaries, and fallopian tubes.

Mucopolysaccharidosis type II with inguinal hernia

Mucopolysaccharidosis Type II (Hunter syndrome) is a rare X-linked recessive storage disorder caused by deficiency of lysosomal enzyme iduronate-2-sulfatase, causing excess accumulation of glycosaminoglycans in the lysosomes resulting in cellular damage, organ failure and death. Severe subtype develops characteristic clinical features and cognitive impairment early and die in second decade of life. In a resource poor setting, we report a case of Hunter syndrome, severe subtype, based on global development delay, coarse facies, short stature, hepatosplenomegaly and dysostosis multiplex on X-ray with unusual large congenital inguinal hernia. The diagnosis was important because of risk of recurrence of hernia after repair.

Inguinal herniotomy in children: a one year survey at Nepal Medical College Teaching Hospital

This was a prospective study done at Nepal Medical College Teaching Hospital from July 2008 to June 2009 which covers our experience in inguinal herniotomy in children. Our study included 63inguinal hernia repairs in 61 children up to the age of 15 years. Out of 61 patients 2 had bilateral inguinal hernia and 59 had unilateral. Among 59 patients with unilateral hernias, 7 patients had emergency presentation. In children with unilateral hernias, it was found that it is more common at right side and regarding complication it is more common in emergency group. There were 5 recurrences and 5 wound infection among all patients.

Amyand's hernia in premature twins

Amyand's hernia (AH) is the presence of a normal or inflamed vermiform appendix in an inguinal hernia sac. This condition is unusual in neonates and in infants, and it has not been described in premature twins. We present two 32-day-old biovular twins with a right AH, treated with sparing of the appendix and herniotomy. The correct management of AH is discussed via a brief review of the literature.

Traitement par cœlioscopie des hernies inguinales de l'enfant: 212 patients

OBJECTIVES

Laparoscopic treatment of inguinal hernias in children remains controversial. The inguinal approach is the only recommended procedure nowadays. The aim of our series was to precise the results of this technique and its advantages.

POPULATION AND METHODS

We report our preliminary experience in laparoscopy for inguinal hernias in 212 children.

RESULTS

Laparoscopy allowed us to discover 26 controlateral hernias not previously diagnosed, 3 direct hernias with 1 of them associated with a patent process vaginalis, 2 femoral hernias associated with a patent process vaginalis, 1 double pouch hernia and 1 volvulus of a cyst developed from a patent process vaginalis. In case of recurrence after an inguinal approach, laparoscopy seemed to be helpful to evaluate the anatomical lesion. We observed only 1 recurrence.

DISCUSSION

Indications for laparoscopy in case of inguinal hernia in children are reviewed and discussed in the literature. Laparoscopic diagnosis for a precise diagnosis is no more discussed. Various techniques were proposed in case of laparoscopic treatment of inguinal hernias in children: most of surgeons realized only a suture of the sac. We prefer to dissect all the sac in order to avoid any recurrence. Advantages of laparoscopic approach become more obvious after the age of 2 years when the opening of the parietal wall is required in case of an inguinal approach and when local anaesthesia is no more recommended. The opportunity to diagnose a bilateral hernia when non diagnosed before surgery or to discover a femoral or a direct hernia, or in case of recurrence after an inguinal approach, the atraumatic dissection of the vas and spermatic vessels at the level of the internal inguinal ring, are the main advantages for laparoscopy.

[Focusing of inguinal hernia in children]

Abnormal persistence of the processus vaginalis in children predisposes to a complication that is strangulated inguinal hernia. The inguinal hernia is a frequent pathology because global incidence varies from 0,8 to 4,4% for children of any age and reaches about 30% in premature children. Strangulated inguinal hernia is rare (from 1,5 to 8%) and constitutes a surgical emergency. More frequently, reduction following sedation is possible (from 25 to 33%), and normally leads to delayed surgery. Current practice is to operate early in these children, including preterm infants, before any complication arises. This early surgery requires use of regional anaesthetic techniques such as spinal anaesthesia, ileo-inguinal ileohypogastric nerve blocks and caudal anaesthesia. However, although this pathology may appear to be routine commonplace it requires a specialized surgical and anaesthetic approach and specialized environment.

Laparoscopic flip-flap technique versus conventional inguinal hernia repair in children

BACKGROUND AND OBJECTIVES

Inguinal hernia repair is one of the most frequently performed pediatric surgical operations. Several pediatric laparoscopic inguinal hernia repair techniques have been introduced. But debate is unresolved regarding the feasibility of laparoscopy for treating pediatric inguinal hernias.

METHODS

A retrospective cohort study enrolled 33 patients who underwent congenital inguinal hernia repair by either the new laparoscopic flip-flap technique or conventional open repair. Patients were divided into 2 groups according to the type of surgery: Group A included those who underwent the new laparoscopic technique, and Group B included those who underwent conventional open repair.

RESULTS

Group A comprised 15 patients (mean age, 39 months), and group B comprised 18 (mean age, 44 months). Mean operative time was 47.5 minutes for Group A versus 27.5 minutes for Group B. Intraoperative complications for Group A included 1 case (7%) of vas deferens injury, and 3 cases (20%) in which the flaps were torn during suturing. In Group B, no intraoperative complications were encountered. In both groups, the mean postoperative hospital stay was 5.5 hours. Postoperative follow-up of 3 months revealed recurrence in 4 patients in Group A (27%), while there were no recurrences in Group B.

CONCLUSION

Our preliminary experience shows unsatisfactory outcomes with laparoscopic flip-flap hernia repair in children. In spite of advancement in the application of laparoscopy in pediatric surgery, conventional open hernia repair is still the gold standard for children, in our experience. Future studies with more numbers and longterm follow-up should be conducted.

Presence of both testes in an inguinal hernial sac

A unique case with fully developed testes and epididymis on the same side has been presented. The hypothesis to explain such a rare occurrence is a failure of the development of one-sided gubernaculums coupled with intra-abdominal adhesions of both the cords resulting in unilateral descent of both the testes. In females, the Mullerian ducts fuse to form the uterus; such a phenomenon in the case of Wolffian ducts is an impossibility, but fusion of vasa deferens and cords in this case point to such a happening.

Spinal anesthesia in infants with ventriculoperitoneal shunt: report of five cases and review of literature

We describe five cases of children with ventriculoperitoneal shunt who underwent abdominal and perineal procedures under spinal anesthesia. Four of them had been born prematurely, and all had suffered from severe neonatal complications. All of our patients suffered from severe respiratory impairment, that had required mechanical ventilation, and three of them suffered additionally from apnea of prematurity. Four patients had ventriculoperitoneal shunt inserted because of obstructive hydrocephalus and one because of congenital central nervous system anomalies. Two underwent subsequently shunt revision. The benefits of spinal anesthesia in this high-risk population are described. The risks of spinal anesthesia in the presence of a ventricular shunt device, especially infection and dural leakage, are discussed, and the literature about this topic briefly reviewed.

Clonidine added to bupivacaine in neonatal spinal anesthesia: a prospective comparison in 124 preterm and term infants

BACKGROUND

Spinal anesthesia (SA) remains the 'gold standard' in neonatal anesthesia for inguinal herniorrhaphy but its short duration impedes its usefulness. We previously demonstrated that clonidine prolongs neonatal SA without immediate side effects.

METHODS

We conducted a prospective observational study of 124 infants undergoing herniorrhaphy under SA with bupivacaine and clonidine. Two cohorts, term (n = 57) and former preterm (n = 67) infants, were evaluated and compared with regard to episodes of apnea, desaturation, and bradycardia within 24 h of SA.

RESULTS

In both groups, postoperative desaturation episodes were unchanged after SA, compared with the 12 preoperative hours, despite significantly increased apnea (P < 0.003 and <0.011 respectively). Transient bradycardias occurred in former preterm infants (P < 0.014): they spontaneously resolved in all cases. Mean arterial pressure did not vary during the study. Upper sensory level of SA, sedation on entering the postanesthesia care unit (PACU) and duration of stay in the PACU were similar in both groups.

CONCLUSIONS

The clinical significance of short apneas, recovering spontaneously without desaturation, remains debatable. It is concluded that addition of clonidine to neonatal SA results in acceptable side effects. Side effects must be compared with the potential advantages before future recommendations.

A case of brittle bone disease

Brittle bone disease--synonym, osteogenesis imperfecta is a rare genetic disorder of collagen synthesis associated with broad spectrum of musculoskeletal problem, where bones break easily. Recently we got a case of OI, whose name is Babu, 3 days old, full term bay with uneventful home delivery. The baby had multiple fractures in all the extremities with deformities with blue sclera with bilateral inguinal hernia. Other systems were found normal. On 10th day of life he was operated for inguinal hernia with satisfactory postoperative recovery and subsequently he was referred to the orthopedic department for further management.

A case of bilateral inguinal hernia recurrence in infancy: investigations on collagen metabolism

BACKGROUND

Recurrent inguinal hernias in early infancy are rare. We report on a case of a 3-month-old male infant suffering bilateral inguinal hernia recurrence (RINGH). Due to previous observations of an altered collagen metabolism in hernia patients, a severe connective-tissue pathology in the infant was hypothesised.

METHODS

Hernial sac tissue of the infant was analysed and compared to specimens from five children operated upon one-sided primary inguinal hernias (controls). In paraffin-embedded sections, we determined the distribution of collagen types I and III by crosspolarisation microscopy and the expression of matrix metalloproteinase 2 (MMP-2) by immunohistochemistry. In fibroblast cultures, expression of collagen types I and III and of MMP-2 was investigated by RT-PCR (real-time polymerase chain reaction) and zymography. Electron microscopical investigations were performed exemplarily in two fibroblast cultures to compare cell morphology.

RESULTS

No differences in collagen I/III ratios between RINGH and controls were found either on protein or on mRNA level. Immunohistochemical and RT-PCR analysis of MMP-2 showed a lowered expression in the RINGH patient, as compared to controls, whereas the gelatinolytic activity of MMP-2 did not differ between the groups. Electron microscopical investigations showed similar cell arrangement and morphology.

CONCLUSIONS

To conclude, a marked biochemical correlate to a severe connective-tissue pathology in the infant suffering inguinal hernia recurrence could not be found. With regard to the slight differences in the expression of MMP-2, a possible role in the genesis of inguinal hernia recurrence cannot be ruled out.

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.