Hernias in Children

Interviewer: Dr. Slasgouth, what is that hernia? Dr. Slasgouth: A hernia is anytime there is unnatural hole in a layer of muscle, anywhere is your body. Now, there are some hernias that occur commonly in children. You may have heard of an umbilical hernia. That is a hernia, an opening in the umbilicus, the belly button. You may have heard of an inguinal hernia. That is a hernia in the groin that can occur in boys or girls. It is more common in boys and it is a hernia that is slightly more dangerous. We actually have to fix inguinal hernias. Umbilical hernias do not need to be repair. The fast majority of umbilical hernias will close by themselves by the time the kid is 4 to 5-year-old. So what we do is about parents comes to us with a child with umbilical hernia, we will get it. If it is not very, very large or if there is no breakdown of the skin over the umbilical hernia, if the baby is not having any pain or discomfort from the umbilical hernia, we will tell them to go home and just watch it. They say 80% close of age 5 and then another 10% or so close over the subsequent five years. So we usually refuse to close umbilical hernias until the kids are 4 or 5-years-old. If it is quite large then, if there is still symptomatic then sometimes will go ahead and do the surgery. Surgery for an umbilical hernia is actually quite simple because overdoing is making a little incision, just below the hernia itself going to the muscle layer where there is an opening and sawing the opening close so that nothing can come through. But umbilical hernias are generally not very dangerous and because we know that fast majority close, it general we do not fix them in little babies. Inguinal hernias are different. I am going to draw a picture of what happens in an inguinal hernia. An inguinal hernia is a hernia that occurs in the groin. So if you imagine a little baby, and I am going to use a boy as an example, if you imagine a baby boy developing inside his mother. The testes start out in development, I will turn this so that you can see, start out in development just below the kidneys on each side. The testes as the baby is growing, is still inside his mom, what happen is the testes move down in the belly. They come around to the front and it come down into the scrotum. So the testes come down around to the front and down into the scrotum. One of the things that pediatricians do, the first time they meet a new baby in the nursery if they feel to see if the testes have come down, to see if the testes has descended properly. Sometimes the testes stop somewhere along the way, that is called the undescended testes. There is a problem that I can to talk to you about some other time, but it is one of the first things that it is examine for a baby boy. Well, if you think about it to get from inside in the back to what essentially outside of the belly in the front, the testes has to go through different layers of muscle and tissue. What happens is as it goes through, it actually pulls that tissue along behind it and it makes a little hole and it pulls a little pocket of tissue down behind it. So there is a little opening that is connected to the inside of the belly. That opening and than pocket is called the processus. Now, if there is normal development what suppose to happen is you are suppose to have the testes descend, a processus forms on each side and then before the baby is born, the processus is suppose to close up. So a normal baby has testes and scrotum and no connection to the inside of his belly. Unfortunately, in premature babies and even relatively frequently the in full term babies that does not happen properly. What happens is the opening to the inside, the processus does not close. Now, if the processus does not close completely but closes partly and I will draw it separately over here. Look there is a small opening to the inside and then a pocket of tissue that comes down below. What happens is that liquid from inside your belly, usually always a small amount of liquid inside your belly can come through the opening and it collect in the processus and blows up almost like a water balloon. When that happens it is called the hydrocele. So a baby boy who is born with hydrocele, sometime is called water in the testes actually has a little opening in the processus which allows liquid from belly to come down. Interviewer: Do all hydroceles lead to hernias? Doctor Slasgouth: The answer is no. Sometimes the hydrocele opening is so small that it closes by itself even after the baby is born. So if we see a baby who is born or has a hydrocele, what we do is we wait until they are about 1-year-old. At age 1, if the hydrocele is still there we would operate to fix it. If it is gone away by itself, if the fluids have been absorbed then it is not swelling up, if it is not swelling up from time to time and swelling up from time to time we just leave it alone. Now the other possibility is that opening is not so small that it stays quite large. So you have an opening processus, a pocket of tissue an opening to the inside of the belly. And in the situation, what happen is your internal organs, mostly in intestine in boys and little girls when they have a hernia it is almost always the ovary can slip into the hernia sack. So if you imagine the intestine is a tube within the belly and if a loop of the intestine slips into an opening in the processus, into the hernia sack what happens is that loop of intestine causes the hernia to swell up. Now hernias are different from hydroceles because you actually have a loop of intestine inside the hernia sack and there is a danger that the loop of the intestine will get stock. If it get stock, that is called incarcerated hernia. You a loop of intestine stock inside the hernia sack, it is called the incarcerated hernia. Now the danger there is that the blood supply either to the testes itself or the blood supply to the intestine can be cant by the intestine stock in the processus vaginalis, in the hernia sack. And even the testes can be damage or die or a loop of intestine can be damage and die. So when we have a baby who has what we know to be an inguinal hernia rather than a hydrocele. We would schedule a surgery to fix it hoping to repair it before it incarcerates, before the intestine gets stock. Interviewer: If a child has an inguinal hernia on one side, is there a chances of having it in the other side? Doctor Slasgouth: The answer is that it depends at what age the baby first presents with inguinal hernia. If you have premature baby who in the nursery has an inguinal hernia on one side, it is virtually a 100% certain that there is a hernia on the second side even if you do not see it. So when we operate on premature babies with hernias, we almost always operate on both sides. If you have a full term baby that risk baby down to 96%, 97%. And as you get older and older, the chance that there is a hernia on the asymptomatic side, in other words baby presents with a hernia on one side, but nothing on the other that you can see or feel. The chance that there is a hernia on the side where you see nothing drops. So if a baby has not had a hernia that anybody has seen, mother changing diapers, father changing diapers, pediatrician and the baby gets to age 1 and a hernia appears. The risk that there is a hernia on the asymptomatic side is about 60%. At age 2, the risk is about 40%. So pediatric surgeons have over the course of time come to slightly different decisions, and have slightly different opinions about what is the right thing to deal with. I think that it is safe to say that the majority of pediatric surgeons probably three quarters of pediatric surgeons with operate on both sides of this tiny who has an inguinal hernia. The reason for this debate and the discussion is you are making a balance judgment about two different risks. The risk that there is a hernia that is there that is going to need an operation in some point anyway. Meaning another trip to the operating room, another anesthetic versus what is the risk of doing two sides at once and the answer is the risk of doing two side of once is relativel