Regarding Management Of Congenital Inguinal Hernias

The mother of a 2-month-old boy comes to surgery as she has noticed a soft lump in his right groin area. There is no antenatal or postnatal history of note. He is breast feeding well and is opening his bowels regularly. On examination you note a 1 cm swelling in the right inguinal region which is reducible and disappears on laying him flat. Scrotal examination is normal. What is the most appropriate action?
A. Refer to paediatric surgery
B. Refer to orthotics for fitting of a Pavlik harness
C. Reassure mother + ask her to return if not resolved by 6 months
D. Reassure mother + ask her to return if not resolved by 12 months
E. Reassure mother + ask her to return if not resolved by 2 years

Answer:
A. Refer to paediatric surgery.

Discussion:

Congenital inguinal hernias have a high rate of complications and should be repaired promptly once identified.

Hernias: 
The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.
Risk factors for abdominal wall hernias include:

• obesity 
• ascites 
• increasing age 
• surgical wounds 

Clinical Features include:

• palpable lump 
• cough impulse 
• pain 
• obstruction: more common in femoral hernias
• strangulation: may compromise the bowel blood supply leading to infarction.

Inguinal hernia: Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia. Above and medial to pubic tubercle Strangulation is rare.

Femoral hernia: Below and lateral to the pubic tubercle More common in women, particularly multiparous ones High risk of obstruction and strangulation Surgical repair is required.

Umbilical hernia: Symmetrical bulge under the umbilicus.

Paraumbilical hernia: Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus.

Epigastric hernia: Lump in the midline between umbilicus and the xiphisternum Most common in men aged 20-30 years.

Incisional hernia: May occur in up to 10% of abdominal operations.

Spigelian hernia: Also known as lateral ventral hernia Rare and seen in older patients A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally).

Abdominal wall hernias in children:

Congenital inguinal hernia: Indirect hernias resulting from a patent processus vaginalis Occur in around 1% of term babies. More common in premature babies and boys 60% are right sided, 10% are bilaterally Should be surgically repaired soon after diagnosis as at risk of incarceration.

Infantile umbilical hernia: Symmetrical bulge under the umbilicus More common in premature and Afro-Caribbean babies The vast majority resolve without intervention before the age of 4-5 years Complications are rare.