Prof. Dr. Hamit OKUR

INGUINAL HERNIAS IN CHILDREN
The most common surgical diseases in the inguinal region are inguinal hernia, hydrocele and testicular-related pathologies. Since most of the surgical pathologies seen in the inguinal region are related to the descent of the testicle, pathologies in this region are more common in boys.
SURGICAL ANATOMY OF THE GUINAL REGION

The inguinal region is a triangular area in both lower quadrants of the abdomen, bounded by the line connecting the spina iliaca anterior superiors from above, the lateral edge of the rectus abdominus muscle from the middle, and the ligamentum inguinale from below. The inguinal canal in this region is an anatomical structure located in the medial aspect of the ligamentum inguinale, obliquely from top to bottom, from back to front and from outside to inside. The inner ring, located at the end of the inguinal canal facing the abdominal cavity, is deep within the transversalis fascia. The outer ring, which forms the lower entrance of the canal, is a superficial structure located under the skin and consisting of the external oblique muscle aponeurosis. In newborns and infants, the distance between the inner and outer rings is quite short. In older children, the inner and outer rings are far from each other and there is a distinct canal structure. In boys, the spermatic cord passes through the inguinal canal and reaches the testicle. The spermatic cord contains the ductus deferens, testicular artery and vein, plexus pampiniformis, nerve fibers, lymphatics and patent processus vaginalis. In girls, the round ligament passes through the inguinal canal.

INGUINAL HERNIA

Inguinal hernia is the most common surgical pathology in children. Its incidence is 1% in the normal child population. This frequency is around 30% in premature babies. Since the formation of inguinal hernia is related to the descent of the testicle, inguinal hernia is approximately 6 times more common in boys than in girls. The majority of inguinal hernias seen in children are indirect inguinal hernias. Processus vaginalis patency plays a role in the etiopathogenesis of indirect inguinal hernia. The peritoneum evaginates symmetrically in both lower quadrants in the 3rd month of embryonal life. These protrusions are called processus vaginalis. Meanwhile, the testicles have begun to develop in a position adjacent to the kidneys in both lumbar regions. In addition to other factors, the testicles descend downwards under the influence of the hydraulic force created by the processus vaginalis and are placed in the scrotum at birth. After the testicle completes its descent in this way, the proximal processus vaginalis becomes obliterated. The distal part continues its existence throughout life as a double membrane (tunica vaginalis) surrounding the testicle. If the proximal part of the processus vaginalis does not close but remains open, this results in the formation of a hernia or hydrocele. If the opening in the processu vaginalis is wide enough to allow the passage of intra-abdominal organs, indirect inguinal hernia, If it is narrow enough to only allow peritoneal fluid to pass through, a hydrocele develops.

The descent of the gonads is similar in girls. However, in girls, this descent ends in the intra-abdominal period and the gonads remain in the abdomen. However, in girls, a peritoneal extension similar to the processus vaginalis progresses into the inguinal canal along with the round ligament, which is called Nuck Diverticula. This formation is equivalent to the processus vaginalis in men. The patent processus vaginalis and Nuck diverticulum are potential hernias. These two conditions alone are sufficient for the development of hernia without any additional pathology. The incidence of hernia is higher in cases where intra-abdominal pressure increases, such as ascites, ventriculoperitoneal shunt, cystic fibrosis, and collagen tissue diseases. 60% of hernias are seen on the right, 30% on the left, and 10% on both sides. The reason why it is more common on the right is that the right testicle completes its descent later than the left testicle. Inguinal hernia also has familial characteristics. In 5-20% of children with inguinal hernia, family members also have a hernia.
Symptoms

The main symptom of inguianal hernia is a swelling in the groin area that appears spontaneously or as a result of crying and straining. This swelling either disappears on its own or may disappear with gentle pressure. This swelling may be limited to the groin area or extend to the scrotum. The patient is either brought to the physician when this swelling is first seen, or is brought to the physician with an anamnesis of recurrent swelling.
Diagnosis

The most important element in the diagnosis of inguinal hernia is anamnesis. The child who was brought with the complaint of a swelling in the inguinal region most likely has a hernia. No obvious swelling may be visible during examination. However, upon palpation of the inguinal region, the cord and its elements are compressed between the index finger and the pubic bone, and the silk glove sign, which gives the sensation of thickening due to the sac and silk soup melting together, is combined with the anamnesis, and the diagnosis of hernia is made. Diagnosis of hernia in adults by coughing and straining or by inserting the index finger into the inguinal canal is not often performed in children. Anamnesis and silk glove symptom are sufficient for diagnosis. During the examination, it should be checked whether the testicle is in place.
Differential diagnosis
Undescended testicle
Dermoid cyst
Inguinal lymphadenopathy
Inguinal abscess
Treatment

When inguinal hernia is diagnosed, surgery should be planned unless the child has a more serious disease at the same time. The surgery is performed in outpatient surgery without the child being hospitalized. If a hernia is detected even in a newborn baby, the surgery is planned and performed at an appropriate time, if the patient's health conditions are suitable, without waiting for the child to grow up to a certain age. Surgery should be planned when a hernia is diagnosed due to serious complications such as incarceration or strangulation. It is not possible for the hernia to heal by waiting. The surgery is performed under general anesthesia through a transverse incision in the lower right inguinal region. After passing the skin and subcutaneous layers, cutting the external oblique muscle aponeurosis and opening the anterior wall of the inguinal canal, the spermatic cord is located and the hernia sac is explored.

The general technique is ligation of the hernia sac at the level of the internal inguinal ring (high ligation). A surgery performed in this way is defined as the Modified Ferguson method. In children younger than two years of age, the hernia sac can be found without opening the inguinal canal, and without opening the canal, the hernia sac is dissected down to the internal inguinal ring and tied at this level. This type of surgery is also described as Mitchell Banks. In both techniques, the distal part of the sac is not removed to avoid damaging the cord and other vascular structures. Ligating the hernia sac at the level of the internal inguinal ring is an adequate and safe technique. The child is fed orally 3 hours after the surgery and is discharged from the hospital on the same day.
Complications
Iatrogenic undescended testicle
Scrotal edema and hematoma
Wound infection
Recurrent hernia
Inguinal hernia surgery is extremely safe when performed in appropriate centers and by appropriate persons, and the complication rate is extremely low. surgery.
Incarceration and Strangulation

Incarcerated hernia is a condition in which the sac content cannot be easily reduced. There is no circulatory disorder in the intestines inside the pouch. Strangulation is an advanced stage of incarceration and is a strangulated hernia in which circulatory dysfunction begins in the sac content. The rate of incarcerated hernia varies between 5-19%. The majority of incarcerated hernias occur in children under 1 year of age. There is an inverse relationship between age and incarceration. Intestines, omentum, appendix, Meckel's diverticulum within the hernia sac; In girls, the intestines, ovaries and Fallopian tubes may also become compressed. A pediatric patient diagnosed with incarcerated hernia is admitted to the clinic, sedated, and waited for about 2 hours. Spontaneous reduction often occurs during this period. If the contents of the sac are not reduced, urgent surgery is required. If the contents of the sac are reduced, surgery is performed after 48 hours. The reason for waiting this period is to resolve the edema in the sac wall and to perform the surgery more safely. The complication rate after emergency surgery for incarcerated hernia or strangulated hernia is much higher than elective hernia surgery. For this reason, surgery is planned as soon as the diagnosis is made, especially in infants.

HYDROCELE
Hydrocele develops as a result of the processus vaginalis, which should normally close after birth, not closing and being so narrow that only peritoneal fluid can pass through. If the hydrocele is limited to the tunica vaginalis surrounding the testicle, it is defined as testicular hydrocele, and if it is limited to a cystic structure along the cord, it is defined as cord hydrocele or cord cyst. If the hydrocele is associated with the peritoneal cavity, it is also defined as communicating hydrocele.
Hydrocele causes the symptom of a painless, water-filled mass in the inguinal region or scrotum. Fizik muayenede hassas olmayan, su dolu bir kistik yapı palpe edilir. Transillumination is positive. İnkarsere herniden ayırıcı tanısında kitlenin proksimal ucunun palpe edilebilmesi önemli bir bulgudur.

Since spontaneous closure of the processus vaginalis may be delayed until the age of 2, surgical treatment of communicating hydroceles is waited until the age of 1.5-2. In cases of cord cysts or testicular hydroceles, surgery may be performed earlier depending on the size of the mass. Surgical treatment of hydrocele is similar to the treatment of indirect inguinal hernia. Ligating the processus vaginalis at the level of the inner inguinal ring and evacuating the contents of the hydrocele is a sufficient procedure.
DIRECT INGUINAL HERNIA
Direct hernia is very rare in children. Direct hernia originates from the Hasselbach triangle. This is the area where the posterior wall of the inguianal canal is weakest. Direct hernia may occur either congenitally or as a result of weakening of this area as a result of excessive dissection of the posterior wall of the canal in indirect inguinal hernia surgery. In its treatment, reinforcements (Mc Vay etc.) are placed to strengthen the back wall of the canal.

INGUINAL HERNIAS IN CHILDREN