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364 Inguinal and Femoral Hernias and Hydroceles Inguinal and Femoral Hernias and Hydroceles
365
fluid collection in the hemiscrotum. To diagnose a mass in the scrotum • Wound infection. Antibiotics may be necessary to treat the infection,
as a hydrocele, the following should be present: depending on its severity.
1. One should be able to get above the mass. This is usually the case, • Recurrence of the hydrocele. Recurrence is rare.
except for the rare infantile hydrocele, which may extend into the
internal inguinal ring. Prognosis and Outcome
The prognosis is excellent for groin hernias and hydroceles if they are
2. The mass must be fluctuant. Always test for fluctuancy in two planes.
diagnosed and repaired early in childhood. Hernia surgery is safe and
3. The mass must brilliantly transilluminate, especially when this test very effective in eliminating the problem; the outcome is usually good,
is done in a darkened environment. It must be remembered that hernias and recurrence is rare (about 1%). Complications occur mostly in the
in infants can also transilluminate due to the thin walls of the bowel. difficult cases, such as in obstructed or strangulated hernias. An ingui-
4. The mass cannot be emptied on applying pressure; this is very nal approach to the repair of hydroceles is extremely successful and
true for the noncommunicating hydroceles (Figure 58.8). For the should lead to less than a 1% recurrence rate.
communicating hydrocele (Figure 58.7A), on applying pressure, the Prevention
mass empties very slowly; in the case of a reducible inguinoscrotal
Groin hernias and hydroceles are congenital in nature, so prevention is
hernia, the emptying is relatively very fast and intestines are usually
geared towards preventing their complications and not towards prevent-
palpated in the scrotum.
ing the occurence of these pathologies, per se. Complications of groin
Hydroceles in infants are often bilateral; like hernias, they are
hernias can be prevented if they are treated timely, during childhood, on
more common on the right than the left. Most hydroceles will resolve
diagnosis. The risk of incarceration of inguinal hernias is high in chil-
spontaneously by the age of 1 to 2 years, on the average by one and
dren, and therefore elective repair is the treatment of choice. Premature
a half years of age. Therefore, hydroceles still in existence by this age babies with hernias should have an elective repair of the hernia done
should be electively repaired. before discharge from hospital or as soon as practicable because their
The diagnosis of a hydrocele in a child is usually clinical. There hernias are more prone to incarceration. A well-timed elective operation
are no known imaging studies that are used routinely to diagnose the will prevent incarceration.
problem. However, ultrasonography may be used as a screening tool During laparoscopic repair of a groin hernia on one side, the
if a testicular tumour is considered as being a cause of the hydrocele. contralateral side can be inspected for the presence of a metachronous
The differential diagnosis of a hydrocele will include: an inguinal hernia and a repair carried out as a preventive measure.
hernia, a testicular tumour, and epididymo-orchitis. The last two may
have an associated hydrocele, which is usually reactive. For testicular Evidence-Based Research
tumours, such as malignant teratomas, measuring serum α-foetoprotein Table 58.1 presents a retrospective review of the incidence of complica-
and human choriogonadotropin levels may help to establish the tions following inguinal hemiotomy in newborns weighing 5 kg or less.
diagnosis. In the case of epididymitis and orchitis, urinalysis and urine
culture and sensitivity may be of help in diagnosis and treatment.
Table 58.1: Evidence-based research.
Treatment
Hydroceles that are asymptomatic should be observed until the child is Title The incidence of complications following primary inguinal
about 2 years old, at which time the PPV should close spontaneously. If herniotomy in babies weighing 5 kg or less
a hydrocele does not resolve spontaneously by then, surgery is advised. Authors Nagraj S, Sinha S, Grant H, Lakhoo K, Hitchcock R,
The operation is performed through an inguinal approach, as in inguinal Johnson P
hernias, using one of the lowermost skin creases in the groin. Surgery Institution Department of Paediatric Surgery, Children’s Hospital
involves, in the case of the communicating hydrocele, high ligation of Oxford, John Radcliffe Hospital, Oxford, UK
the PPV within the internal inguinal ring. For encysted hydrocele of the Reference Pediatr Surg Int 2006; 22(12):1033
spermatic cord, the hydrocele is usually easily dissected out without Problem Complications following inguinal hernia surgery in
much of a problem. Care should be exercised, however, not to trauma- newborns.
tise the vas deferens and its vessels. If the hydrocele is infantile or vagi- Intervention The aim of this study was to quantify the incidence of
nal, then hydrocelectomy is carried out, also through a groin incision, complications following inguinal herniotomy in small babies
with care not to traumatise the spermatic cord structures. In both cases, weighing 5 kg or less.
the PV proximal to the hydrocele is usually obliterated. Comparison/ This was a retrospective review of inguinal herniotomies
The child should be placed on analgesics after the surgery; Tylenol control (quality performed between December 1997 and March 2002
on babies weighing 5 kg or less. A total of 154 patients
or a paracetamol suppository three times daily suffices in most cases. of evidence) underwent hernia repair, of which 81% (125 patients; 221
No antibiotics are required. Hydroceles in children should not be hernias) were available for review. The median weight at
aspirated as a method of treatment because they have a natural history surgery was 3.6 kg (range, 1.7–5 kg). Eighty-four patients
(67%) were classified as premature (<36 weeks gestation).
of resolution and will recollect after aspiration. Thirty-three patients presented with an irreducible hernia,
Postoperative Complications in whom all but one were successfully reduced prior to
surgery. Patients were reassessed at a clinic following
The following complications are possible postoperatively: surgery, and follow-up data were obtained from the clinic
• Injury to the spermatic cord. Careful surgery and avoidance of rough notes after a median follow-up of three months (range,
1–60 months). Five cases (2.3%) of hernia recurrence
handling of the spermatic cord structures will prevent trauma to them. occurred in 4 patients, and 6 patients (2.7%) experienced
testicular atrophy. In the testicular atrophy group, 4 of the
• Bleeding with possible scrotal haematoma formation. This can be 6 patients presented with an incarcerated hernia, and
prevented if bleeding is meticulously controlled at every step dur- of these, 3 were noted to have evidence of ischaemia
ing surgery. A diathermy machine (especially a bipolar diathermy), at operation. There were 6 cases (2.7%) of high testes
if available, is of great help, with careful avoidance of excessive requiring subsequent orchidopexy.
burning of the tissues in order not to injure the vas deferens and its Outcome/effect Although neonatal inguinal herniotomy is a technically
elements. Haematomas will resolve spontaneously in 3–5 weeks demanding procedure, this series has demonstrated a low
complication rate. Testicular atrophy was associated with a
without surgery; if they persist beyond this period, surgical drainage history of preoperative incarceration in the majority of cases
may be necessary.