Testes — The testes appear in 5 to 6 week of gestation & By the 10th week, they have descended through

the coelomic cavity and can be found close to the groin. The processes vaginalis forms during the 3rd
month of gestation from an outward protrusion of the peritoneum and forms a diverticulum at the internal
ring.

Between the 7th and 9th months of gestation, the testes descend through the internal canal and into the
scrotum, pushing the processus vaginalis ahead and protruding into its cavity. Once this process is
complete, the processus vaginalis obliterates spontaneously, usually by age two years.

Ovaries — The descent similar to testes except ovaries do not leave the abdominal cavity. The
diverticulum of Nuck in girls corresponds to the processus vaginalis in boys.

anatomy
the inguinal canal is oblique channel through the abdominal wall through which the spermatic cord passes
from the abdomen into the scrotum in boys and the round ligament passes from the abdomen into the labia
majora in girls.
It is formed by the aponeurosis of the external oblique muscle (anteriorly) and the transversus abdominus
muscle and the transversalis fascia (posteriorly)
Hesselbach's triangle, bounded by the inferior epigastric vessels, the inguinal ligament, and the rectus sheath,
is an area of the posterior wall at particular risk for direct herniation.
The external inguinal ring is formed by the external oblique muscle just superior and lateral to the pubic
tubercle. The internal inguinal ring is located in the transversalis fascia and composed of the transversus
abdominus and internal oblique muscles

In infants, the inguinal canal is short and crosses the abdominal wall perpendicularly rather than
obliquely so that the external ring is situated almost directly over the internal ring. This anatomic
alignment places infants at particular risk for development of inguinal hernia, especially
premature infants in whom intraabdominal pressure may be increased by mechanical ventilation
( preterm is a risk factor and in OR we rather do it while they are still in NICU if he got
discharged and came back with hernia ‫) شوي يتعقد الموضوع‬
Inguinal Hernia

A congenital inguinal hernia (CIH) is an indirect hernia related to failure of closure of the patent
processus vaginalis (PPV) at the deep inguinal ring. Intra-abdominal contents pass within a PPV,
through the deep inguinal ring, inguinal canal, superficial inguinal ring and potentially into the
scrotum (male) or via the canal of Nuck to the labium (female). (we call the canal in boys inguinal
canal, and in girls canal of nuck, they're the same )

1. definition of hernia? protrusion moving between two spaces projection or protrusion of peritoneal
covering from ( patent process vaginalis this causes communication between peritoneal cavity
and testis and depend if it was wide or narrow ( wide enough to allow solid content such as
intestine , omintum , ovaries if she’s female – known as inguinal hernia , narrow will allow fluid
to pass– hydrocele ), we have inguinal, femoral and diaphragmatic> know two spaces of each

Incarceration — Incarceration describes a hernia that cannot be reduced by manipulation. An

incarcerated hernia may or may not be strangulated.

Strangulation — Strangulation refers to vascular compromise of the contents of an incarcerated

hernia, caused by progressive edema from venous and lymphatic obstruction. Strangulation can
occur within two hours of incarceration. Prolonged strangulation may rarely lead to necrosis and,
in the case of bowel, perforation.

Various types of inguinal hernias and hydroceles may occur depending on where and to what
degree the processus vaginalis becomes obliterated. This is illustrated in the following examples:

●A widely patent processus vaginalis that permits herniation of the bowel through the
internal inguinal ring results in an indirect inguinal hernia
●A narrowly patent processus vaginalis that only permits passage of peritoneal fluid
results in a communicating hydrocele.
●A hydrocele of the cord occurs when the processus vaginalis is obliterated proximally
and distally but remains patent in the midportion along the spermatic cord.

2. then see whether the hernia is reducible or not, beware that reducible does not equal
compressible, and identify presence of communication Inguinal hernia could be reducible then
might become unreducible, then strangulated giving signs of ischemia, lastly might be necroses.

3. Cause of inguinal hernia? patent processus vaginalis, normally it closes in third trimester

Associated conditions — Inguinal hernias are more common in children with abdominal wall
defects (eg, Eagle-Barrett [prune belly] syndrome), conditions that increase intraabdominal
pressure (eg, continuous ambulatory peritoneal dialysis, ventriculoperitoneal shunts, ascites,
chronic respiratory disease), connective tissue disease (eg, Ehlers-Danlos syndrome),
 abnormalities of the genitourinary system (eg, ambiguous genitalia, hypospadias, bladder
exstrophy, cryptorchid testis), or a family history of inguinal hernia .

4. what does hernia sac contain? hernia sac generally contains peritoneal fluid (as in a
communicating hydrocele) or bowel. In girls, the ovary is commonly involved. Indirect
inguinal hernias, the most common type in children, pass lateral to the deep epigastric
vessels through the inguinal canal. Direct inguinal hernias are medial and inferior to the
deep epigastric vessels and do not go through the inguinal canal Direct inguinal hernias
are rare in children and usually follow an indirect inguinal hernia repair. Femoral hernias
rare in children, below the inguinal ligament and medial to the femoral artery.

Presentation

Children with an inguinal hernia may present with clinical features that include history of an
intermittent mass, a mass that is reducible, or incarceration.

No mass — Most children with an inguinal hernia have a history of an intermittent bulge in the
groin that may have been noted at times of increased intraabdominal pressure, such as straining
or crying. They are usually asymptomatic when this occurs.
An inguinal mass is frequently not present on examination. Maneuvers to increase
intraabdominal pressure and demonstrate the hernia are often unsuccessful. The "silk sign" is a
palpable silky thickening of the cord that may sometimes be appreciated by placing a single
finger parallel to the inguinal canal at the level of the pubic tubercle and rubbing it from side to
side. This is not a reliable finding.
Reducible mass — Often, parents or primary caregivers seek medical care because an inguinal
mass has developed that has not spontaneously reduced. Nonspecific symptoms such as
irritability and decreased appetite may be reported. The inguinal mass can extend into the
scrotum. It should not be tender on examination.
Incarcerated mass — Infants with an incarcerated inguinal hernia usually are irritable and
crying. Vomiting and abdominal distention may develop, depending on the duration of
incarceration and whether or not intestinal obstruction has occurred.
Physical examination of children with incarcerated inguinal hernias usually is diagnostic. A firm,
discrete inguinal mass, which may extend to the scrotum or labia majora, can be palpated in the
groin. The mass usually is tender and often is surrounded by edema with erythema of the
overlying skin. The testicle may appear dark blue because of venous congestion caused by
pressure on the spermatic cord.

How does the child with inguinal hernia present ?

- Bulging shown when we have increase in abdominal pressure “crying , changing diaper”
in the begging its reducible whenever we remove the pressure , but it can be irreducible
- Irreducibly or Incarcerated “this is emergency” associated w/ Tenders , Irritability
Bowel obstruction and this will present with vomiting “ bilious greenish content “ if
it progress it may come with strangulation “ ischemia “ when the ring is tighten on the
organ or content it will be edematous and ischemic.
Treatment: The definitive management of inguinal hernia is surgical repair. Referral to a surgeon
and the timing of the repair depend on whether or not the hernia is reducible.
Inguinal hernia you need to operate once diagnosed wither it’s simple or complicated, reducible or
not, do elective surgery next available within 1 month.
In addition, incarcerated hernias must be reduced as quickly as possible to avoid strangulation of
the contents of the hernia sac.

Surgery Herniotomy not herniorrhaphy ( we due ligation at level of internal ring )

in adult we do hernioplasty with mesh repair because they have muscle weakness, however, in
pediatric we do herniotomy, edison of hernia sac without mesh

Patient came with reducible hernia what is the next step?

- Schedule for elective surgery recommended within 2 weeks but” we do it in the
next elective list “ , cause hernia is a clinical diagnosis even if the radiology is done it
might not be helpful if the patient isn’t crying and it will take a long time

the surgery is simple reduction, then resection + anastomosis

herniotomy surgery risk:

clean surgical wound “ it all throw skin “ infection rate very low 2%
spermatic cord injury “vas deferens + vessels “
recurrence 2% if we don’t have risk factor like “preterm baby , ventriculoperitoneal shunt, ‫فهذا‬
‫“ دايما عنده سوائل في البطن ترفع الضغط‬

if the baby is ACS 1

if the baby is preterm in NCIU “or have associated comorbidities “ we do the hernial surgery
before he is discharged home

if he was in a NICU but discharged and then come with inguinal hernia here we have to wait 60
week gestational age completion “to avoid apnea of prematurity “ then we can do surgery , or if
the patient condition require immediate surgery and he is not 60 week gestational age after
surgery that he must be admitted to NICU/PICU to observe for 24 hours after surgery

No mass, reducible mass — A convincing history of intermittent groin swelling or a reducible

inguinal mass are indications for referral to a surgeon. Consultation should be obtained promptly
but is not emergent. Once the diagnosis is made, however, repair should be performed soon to
avoid complications, such as incarceration.
Inguinal mass in a female — Hernias in females are caused by the persistence of the
diverticulum of Nuck and contain the suspensory ligament of the ovary . A significant number of
these hernias also contain the ovary and/or fallopian tube [34]. Because of the significant
likelihood that reproductive organs are within the hernial sac, the clinician should attempt a
gentle reduction and then obtain an ultrasound (US) if not successful. If the US indicates that
reproductive organs are not present, then further efforts at reduction are appropriate . In patients
in whom an incarcerated ovary is suspected, ultrasound first, if available, is an alternative
approach. Ultrasound examination of the hernial sac is also helpful in identifying the contents
prior to surgical repair of irreducible inguinal masses in girls.
Incarcerated inguinal hernia — An incarcerated inguinal hernia must be emergently reduced,
either manually or surgically. Once the diagnosis has been made, children should have nothing
by mouth, since emergent surgery may be required to reduce the hernia.
Manual reduction — Unless the child appears extremely ill and has signs of peritonitis,
intestinal obstruction, or toxicity from gangrenous bowel, manual reduction should be attempted.
Manual reduction is successful in 95 to 100 percent of patients. Elective repair after successful
manual reduction has a lower complication rate than emergent operative reduction.

One technique of manual reduction of incarcerated inguinal hernias is as follows :

●Pressure is applied along the proximal inguinal canal with one hand, while the other hand
attempts to "milk" the gas or contents out of the incarcerated bowel with gentle pressure,
for up to five minutes.
●After reducing the contents of the incarcerated bowel, pressure should be slightly
increased over the distal aspect of the hernia to reduce the bowel.

Alternatively, the examiner uses the thumb and index finger of one hand to form a funnel where
the mass exits the inguinal ring and then exerts steady, circumferential pressure with the other
hand on the inferomedial aspect of the mass. A "hiss" of air and a decrease in the size of the mass
may accompany a successful reduction. Success is indicated by a reduction of the mass.

Alternatively, the practitioner sweeps along the inguinal hernia into the scrotum and applies
longitudinal tension, while providing traction that opens the internal and external hernial rings.
The hernia is then walked through the opening.
If the above steps are not successful, a surgeon should be consulted. Most authorities would then
recommend procedural sedation, Trendelenburg positioning, and an ice pack to the groin,
followed by another attempt at manual reduction [42]. Up to 40 minutes of continuous pressure
may be necessary to achieve reduction.
Attempts at manual reduction of a prolapsed ovary are painful and should be performed only
with sedation. In addition, torsion of the ovary within the hernia sac can occur.
Surgical reduction — In the small percentage of cases where manual reduction is not
successful, the hernia must be reduced surgically. Repair is generally performed at that time

Surgical repair — The following procedures may be used for the repair of inguinal hernias in
children:
●High ligation and excision of the processus vaginalis, the most common procedure, is
used when the hernia is small and of recent onset. In girls, confirmation that the hernia sac
does not contain the ovary, fallopian tube, or uterus is necessary before it is ligated.
●In addition to ligation and excision, plication of the floor of the inguinal canal (the
transversalis fascia) may be necessary when the inguinal ring has been enlarged by
repetitive herniation.
●Complete reconstruction of the floor of the inguinal canal using the conjoint tendon is
occasionally required in small infants who have large hernias that have gone untreated,
causing progressive enlargement of the inguinal ring and total breakdown of the
transversalis fascia .
Boys who have an associated undescended testis should have orchidopexy at the same time as
inguinal hernia repair
Timing of repair — Immediate surgical repair after successful manual reduction of
incarceration eliminates the risk of repeated incarceration. However, if performed immediately,
the repair can be technically difficult, increasing the risk for development of a direct hernia as a
complication.
Many pediatric surgeons hospitalize children after successful manual reduction of incarcerated
inguinal hernia and repair the hernia within 24 to 48 hours. The short delay allows the involved
tissues to return to their normal texture before surgery. To minimize the risk of recurrence,
definitive hernia repair should be performed within five days (within two days for infants born
prematurely) of the manual reduction .
In children with asymptomatic inguinal hernias, longer waiting time for elective surgery is also
associated with increased risk for incarceration, especially in infants less than one year of age .
This finding suggests that a waiting time less than 14 days is advisable for asymptomatic
inguinal hernias in this pediatric age group.
one-third of preterm infants with birth weight less than 1000 g have inguinal hernias. These
infants can be observed in the (NICU) as long as the hernias are reducible. Regardless of timing
of repair, preterm infants who are at risk for apnea and bradycardia should be monitored closely
in the postoperative period.
1st scenario: you’re in clinic, mother came with 2 year old boy with a chief complain of hernia since 1
month
start with the history: take gestational age, mode of delivery -it doesn’t affect inguinoscrotal-, and
analyze the complain: inguinal swelling, make sure it’s inguinal which means above the inguinal canal, if
it’s below we call it femoral. if the mother pointed to junction between abdomen and thigh nwe call it
groin, then see if the swelling increases while crying
and reduce while sleeping or not, associated symptoms could be abdominal distention, vomiting…
Physical examination: we only have inspection and palpation and the exposure is from umbilical to the
knee
inspection: Oval swelling downward, forward, medially
Palpation: Gurgling sensation, try to squeeze it and reduce it upward, backward and laterally, then
sustained pressure for seconds and see if it completely disappear
Investigation:
1. ultrasound is the gold standard when you need it but we don’t need it
2. lap: only preoperative (CBC, PT, PTT, and sickle screen if the patient is >6 month)
Inguinal hernia you need to operate once diagnosed wither it’s simple or complicated, reducible or
not, do elective surgery next available within 1 month
Surgery: in adult we do hernioplasty with mesh repair cause they have muscle weakness, however, in
pediatric we do herniotomy, edison of hernia sac without mesh

2nd scenario: same case, but upon inspection there was no swelling, we need to increase
abdominal pressure to make sure there is no swelling,
we increase it first by hand pressing and pushing downward or we try doing “ silk sign touching
the cord itself and you feel it thickened but not reliable and it’s not subjective = ‫" يحسه زي الحرير‬
which is very painful ,
if the mother is sure and she describe hernia book a surgery
or we could give her next follow up / or ask her to take picture

1. neonate & infants: make them cry

2. 1-4 year: make them stand up
3. >6 year: ask them to cough

3rd scenario: same scenario but even after we tried to make the swelling occur it didn’t, we
don’t like US here because it’s operative dependent, instead we do special test, we hold the
scrotum and roll the spermatic cord, normal finding is soft non palpable, an abnormal finding
would be thick and slippery Silk glove sensation

4th scenario: same case but even after special test we didn't find swelling, here it’s either the
mother is wrong, or she is right, so we tell her to return home and once she see the swelling again
take video of it with appropriate exposure, and no need for surgical exploration

5th scenario: now it’s in the ER we can do sedation and manual reducing and relax the patient
so I can make sure he is fasting and he is comfort and buy me time
If the patient didn’t response I will rush to OR because he might lose bowel content and causes
necrosis / necrotic testicles due to the pressure on the testicular vessels and vas deferens and the
blood supply will be abrupted or spot
it could be one of the following complication:
1. irreducible
2. obstruction
3. edema + strangulation> can’t reduce it> need surgery
4. ischemia> irreversible loss> it’s incarcerated
5. perforate