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360 Inguinal and Femoral Hernias and Hydroceles Inguinal and Femoral Hernias and Hydroceles
361
An obstructed or strangulated IH, especially where the contents
of the sac are intestines, will lead to abdominal pain, vomiting, and
constipation. If the obstruction is not relieved quickly, it may progress
to bowel ischaemia, gangrene, perforation, and sepsis. There may also
be compression of the spermatic cord, leading to ischaemia, necrosis,
and secondary atrophy of the ipsilateral testis with the possibility of
subfertility or infertility if, for one reason or another, the contralateral
testis is abnormal. As such, incarceration of an IH should be taken
seriously and steps initiated to exclude either an obstruction or
strangulation. If an obstruction or strangulation is considered present,
Figure 58.3: Bilateral reducible hernias. Both testes are in the scrotum. then the child should be admitted to hospital and managed appropriately
to prevent complications.
The differential diagnoses of IH include: hydrocele, inguinal
adenitis, femoral hernia, femoral adenitis, undescended testis, retractile
testis, varicocele, torsion of the testis, testicular tumour, lipoma, and
lymphangioma of the inguinal area.
Investigations
The diagnosis of IH in an overwhelming majority of cases is clinical
(history and examination). In the few cases where the diagnosis cannot
be made immediately, the child needs to be re-examined over a period
of time to make a definitive diagnosis. Although imaging studies are
generally not indicated for the diagnosis of IH, in the literature, ultra-
sonography has been used to confirm IH in selected patients; however,
Figure 58.4: Reducible left inguinoscrotal hernia.
this is not the gold standard for diagnosing IH in children.
Other laboratory and radiographic investigations to determine the
In the case where there is no bulge but there is the suspicion that a presence of IH in a child are usually not necessary or even indicated.
hernia sac may be present, gently but firmly palpate the cord structures In the African subregion, a full blood count with the determination of
in the male child or the round ligament of the ovary in the female the sickling status of the child is usually all that is required to treat a
child, sliding the structure over the pubic bone beneath the index finger child with a reducible, uncomplicated IH. If the hernia is complicated
medially and laterally. This will elicit a palpable thickening of the cord (obstructed or strangulated) and the child is being prepared for
(or ligament of the ovary), usually referred to as the silk glove sign; this surgery, it is advisable to add blood urea, creatinine, and electrolytes
is suggestive of the presence of a hernia sac. determination to the investigations required before operation, especially
An inguinal hernia, if present, may be reducible or irreducible, if the obstruction or strangulation has been present for 24 hours or more
complicated or uncomplicated. A reducible IH is one in which the (a frequent occurrence in the subregion).
contents of the sac return spontaneously to the peritoneal cavity or will Complications of an inguinal hernia include incarceration, intestinal
do so with gentle manual pressure when the child is recumbent. In such obstruction, strangulation, gangrene of bowel, perforation of bowel,
situations, there is usually no pain associated with the mass. For an peritonitis, septicaemia, intraabdominal abscess formation, infarction
irreducible IH, the lump will not reduce spontaneously when the child of the testis, testicular atrophy, gangrene of the ovary and/or fallopian
lies supine, but may sometimes be reduced if some amount of pressure tube, and infertility.
is exerted. The contents of the sac are trapped by a narrow neck. An Treatment
irreducible hernia may or may not be tender. Inguinal hernias are not known to resolve spontaneously and must
In the case of an incarcerated IH, an example being the incarceration therefore be repaired surgically shortly after diagnosis on an elective
of the ovary with the fallopian tube in a hernia sac, the mass does not basis; the definitive treatment for IH is early operation, a herniotomy.
reduce spontaneously when the child lies down, and most often cannot This will reduce the risks of incarceration with its attendant compli-
be reduced by the physician examining the child. Note here that the mass cations, such as obstruction and strangulation. A well-administered
is not tender and the contents (ovary and a portion of the fallopian tube) general anaesthesia is preferable and can be safely done by an anaes-
are usually a sliding component of the sac. In children, incarceration of thesiologist experienced in the care of infants and children. Ketamine
inguinal hernias occurs at the external inguinal ring, whereas in adults, can also be used and is well tolerated by children.
the hernia is normally obstructed at the internal inguinal ring. The procedure (Figure 58.5) involves a herniotomy through a
The term “incarceration” does not imply obstruction, inflammation, transverse or oblique incision made in the lowest inguinal skin crease
or ischaemia of the herniated mass, although incarceration is necessary (Figure 58.5A).
for obstruction or strangulation to arise. When an incarcerated hernia
becomes painful and the examiner can elicit tenderness, then the IH is 1. The incision is deepened through the Camper’s fascia, subcutaneous
either obstructed or strangulated. When it is bowel that is trapped in the fat, and Scarpa’s fascia (in the process, one will encounter the
sac and the mass becomes tender and irreducible, then signs of intestinal superficial epigastric and the external pudendal vessels, which may be
obstruction will eventually occur. In such circumstances, there is usually retracted aside, coagulated, or tied with a suture) until the aponeurosis
no interference with the blood supply of the contents of the sac. Rectal of the external oblique abdominal muscle (Figure 58.5B) is reached.
examination in infants and small children may be diagnostic if the After clearing it of overlying fat, the external inguinal ring is identified.
incarcerated bowel is palpated at the internal inguinal ring. At this stage, depending on the size of the hernia and the age of the
Strangulation is said to arise when the obstruction progresses to cause child, a decision is made whether to open the aponeurosis. In neonates
compromise to the blood supply of the contents (e.g., bowel or omentum); and infants, the external inguinal ring almost overlies the internal
then bowel infarction leading to severe tenderness of the bulge will occur, inguinal ring, so there may not be the need to open the aponeurosis of
and oedema and erythema of the overlying skin will appear. In such a the external oblique muscle to get to the hernia. In large hernias, it is
case, the child may pass a bout of one or two bloody stools. advisable to incise the aponeurosis of the external oblique to open into