What is Inguinal Hernia in Children?
Hernia refers to the abnormal protrusion or bulging of organs and tissues through a weakened point in the surrounding wall. Within the abdomen, there are natural weak points where certain structures can enter or exit, and the belly and groin regions are such natural weak points. The most common hernias in childhood are inguinal hernia and umbilical hernia. Inguinal hernia in children occurs when the tissues and organs within the abdomen protrude through a congenital opening called the processus vaginalis in the inguinal canal. Intestines usually enter the hernia sac, and in girls, ovaries or fallopian tubes can also frequently enter.
Inguinal hernia is the most common problem in the groin region in children. The incidence of inguinal hernia in infants and children is approximately 1-3%. In full-term newborns, the incidence is 0.8-5%, but this rate can increase up to 30% in premature and low-birth-weight babies. The risk is higher in twins and in families with a history of hernias. In boys, inguinal hernia is six times more common than in girls. Sixty percent of inguinal hernias occur on the right side, 30% on the left side, and 10% on both sides.
How Does Inguinal Hernia Develop in Children?
In a developing male fetus in the mother's womb, the testicles (testes) begin to form near the kidneys inside the abdomen. As the baby grows, the testes migrate from the abdomen towards the scrotum and settle in the scrotum by passing through the inguinal canal. During the descent of the testicles from the abdomen to the scrotum, they move along with an extension of the abdominal membrane called the processus vaginalis, resembling a glove finger. This extension, known as the processus vaginalis, facilitates the descent of the testicles from the abdomen to the scrotum in boys and the placement of the round ligament, one of the uterus's main ligaments, in the groin area in girls. The processus vaginalis, which ceases its function at birth, normally closes spontaneously. However, if it does not close, inguinal hernia can occur as organs from the abdomen enter the groin region. Therefore, the belief that hernia occurs in a child because of crying is not accurate.
What are the Symptoms of Inguinal Hernia in Children?
Most inguinal hernias do not show symptoms and are often detected during routine medical examinations or by chance, reported by families. The initial symptom of inguinal hernia is a bulge intermittently observed in the groin area. This bulge becomes more noticeable during crying, straining, or coughing. In boys, the swelling may extend to the scrotum, and in girls, it may reach the genital area. The swelling usually decreases or completely disappears when the child is calm or lying down.
The incarceration of organs entering the hernia sac can lead to 'strangulation' (incarceration). The risk of strangulation in inguinal hernias in children is 3-16%, with two-thirds occurring under the age of one. Normally, a hernia does not cause pain unless it is incarcerated; however, it can sometimes lead to restlessness and discomfort. During hernia strangulation, as the circulation of organs is compromised, the child is generally inconsolable, experiencing severe pain in the groin and abdomen, nausea/vomiting, feeding difficulties, and bloody stools.
How is Inguinal Hernia Diagnosed in Children?
The diagnosis is primarily based on the history and physical examination. Families often consult a doctor due to complaints of swelling in the groin area, or a pediatrician may detect the hernia during a routine examination. The diagnosis of inguinal hernia in children can be easily made through a physical examination by an experienced pediatric surgeon. Sometimes, a hernia may not be detected during a physical examination. In such cases, the history provided by the family or a photograph taken during the swelling may be sufficient for the diagnosis. In most cases, additional tests are not necessary for a hernia diagnosis. If there is suspicion of hernia strangulation, an ultrasound may be performed to assess the incarcerated organ and its circulation.
When and How is Inguinal Hernia Treated in Children?
Inguinal hernias observed in childhood do not resolve spontaneously. Due to the risk of strangulation in such hernias, surgical repair is necessary. If there is suspicion of inguinal hernia in a child, evaluation by a pediatric surgeon is essential, and children whose diagnosis is confirmed should undergo surgery at the most suitable and earliest possible time for their health. There is no need to wait for a specific age for surgical repair after the hernia is detected. There are two types of hernias that can occur in the groin area: direct hernia and indirect hernia. Inguinal hernia in children is classified as indirect. Direct hernias are more common in adults, and the treatment methods for both types differ. Childhood hernia repair is easier and simpler than in adults.
While placing a patch (graft) may be necessary during hernia repair in adults, it is usually not required in children. The operation is performed under general anesthesia in an operating room. The procedure can be carried out through an open or closed (laparoscopic) method. In the open method, a small incision is made in the groin area, while in the closed method, surgery is performed with the aid of a camera inserted through the navel. The surgery is typically performed on an outpatient basis, and the patient is usually discharged on the same day.
