Pediatric Surgery: Hernias

• Pediatric Surgery: Surgical Calendar Part 1 covers several pediatric surgical conditions

Epigastric Hernia

• Results from a defect in the linea alba between the xiphoid process and the umbilicus
• Palpable or visible mass in the abdominal linea alba, which may cause intermittent pain or pain upon palpation
• Typically involves herniation of preperitoneal fat
• Incidence of 5% in children, presenting in multiple forms with sizes varying from 0.5 to 1 cm
• Diagnosed clinically without requiring routine images
• Does not resolve spontaneously and requires referral to pediatric surgery for evaluation once diagnosed

Umbilical Hernia

• Occurs due to the persistence of a permeable umbilical ring, allowing abdominal contents to protrude because of a failure in the spontaneous closure of the abdominal fascia
• The abdominal fascia typically closes after birth, completing by age 5 in most children
• More common in children with Down syndrome, Ehlers-Danlos syndrome, Beckwith-Wiedemann syndrome, and hypothyroidism
• Diagnosed clinically without routine imaging; most cases are asymptomatic
• 90% close spontaneously, warranting observation until age 5, but surgery is considered if the diameter exceeds 1.5 cm
• Spontaneous closure is unlikely if the defect is small
• Surgery recommended at age 5 if the defect is <1.5 cm in diameter, and earlier if >1.5 cm
• Risk of complications is low
• Surgery is indicated in asymptomatic children under 5 if the umbilical hernia is complicated, occurs in the context of genetic syndromes or predisposing conditions, or is large and doesn't reduce in size by age 2

Inguinal Hernia

• 95% are indirect due to the persistence of the peritoneal-vaginal duct
• More common in males (3-4:1 ratio), with peak incidence in the first year of life and highest presentation in the first month
• More frequent on the right side
• May be found in children with abdominal wall defects like Prune-Belly syndrome, Ehlers-Danlos syndrome, or conditions increasing intra-abdominal pressure such as peritoneal dialysis, ascites, or chronic respiratory diseases
• Clinical diagnosis based on an intermittent inguinal mass that appears with strain (coughing, crying), reduces spontaneously or with manual pressure, and may present with nonspecific symptoms like loss of appetite
• "Silk glove sign" involves palpating a silky consistency parallel to the inguinal canal
• Ultrasound is used only if there are doubts in the diagnosis
• Treatment involves surgery
• Premature infants should undergo surgery when they reach a weight of 1,800-2,000 grams
• Infants symptomatic <3 months should have surgery at the time of diagnosis
• Infants asymptomatic >3 months should be evaluated for pediatric surgery and ambulatory surgery

Inguinal Hernia Complications

• Incarceration and strangulation occur mainly in the first year
• Incarceration is the primary complication, indicated by inconsolable crying, irritability, abdominal distension, and vomiting with pain upon palpation of an inguinal mass that doesn't reduce on its own, accompanied by edema and erythema of the surrounding skin; it requires urgent intervention
• Imaging or paraclinical tests not required for its evaluation
• Pediatric surgery consultation is crucial for management
• Strangulation involves incarceration with vascular compromise, necessitating immediate surgery
• Complications include testicular atrophy, gonadal infarction, intestinal obstruction, and intestinal gangrene

Cryptorchidism (Undescended Testicle)

• Testicle is located along its normal path of descent but not in the scrotum; 80% of the time, it's found in the inguinal canal
• The testes descent to the scrotum around 3-4 months after birth
• Descent after 4 months is unlikely
• A family history of undescended testicles exists in 4% of fathers and up to 10% of brothers
• Most cases are unilateral
• Classification is based on the location of the undescended testicle: intra-abdominal, intracanalicular (inguinal canal), superficial, suprapubic, or infrapubic
• Clinical diagnosis through physical exam
• Diagnostic and therapeutic confirmative test: diagnostic laparoscopy
• Untreated cryptorchidism can lead to infertility and increase the risk of testicular cancer (seminoma)
• Orchiopexy (surgery) should be performed if spontaneous descent does not occur by one year of age, with a 90% success rate