Pediatric Inguinal and Femoral Groin Hernia Repair

A hernia is strangulated if the intestine is trapped in the hernia pouch and the blood supply to the intestine is decreased. This may cause sharp abdominal pain and vomiting and is a surgical emergency requiring immediate treatment.²

The hernia sac may sometimes contain intestine or abdominal tissue that can be pushed back into the abdomen. This means the hernia is reducible. If the tissue cannot be pushed back in, the hernia is irreducible or incarcerated.³

• Visible bulge in the scrotum or groin area, especially with coughing or straining
• Burning or pressure at the hernia site

• Inguinal hernias occur in 6 of 100 boys, less than 1 in 100 girls, and in up to 30 of 100 premature infants³
• 60 of 100 hernias occur on the right side.⁴
• Incarceration can occur in about 4 of 100 boys or girls and is twice as likely in premature infants

Other medical disorders that have symptoms similar to hernias include: enlarged lymph nodes, cysts, and testicular problems such as scrotal hydrocele.⁵

There are two types of groin hernias:

Inguinal hernias are the most common type of all hernias. They appear as a bulge in the groin or scrotum of boys or labia majora of girls. They are more common in boys.

Femoral hernias appear as a bulge in the groin, upper thigh, or labia (skin folds surrounding the vaginal opening). They are more common in girls and are always repaired because of a high risk of strangulation.¹

Benefits

An operation is the only way to repair a hernia. Your child can return to normal activities in a short amount of time.

Rare Risks Include:

• Return of the hernia
• Infection
• Injury to the bladder, blood vessels, intestines, or nerves
• Difficulty passing urine
• Continued pain and swelling of the testes or the groin area

Risks of Not Having an Operation

The hernia may cause pain and can increase in size. The intestine may become incarcerated (trapped) in the hernia pouch or strangulated, causing reduced blood supply to the testes in boys.

Undescended testicles

In males, the testicles move (descend) from the abdomen into the scrotum. The testicle remains in the abdomen in 4 of 100 full-term infants and 30 of 100 premature infants. In about half of babies, the testicle descends into the scrotum by 6 months. In rare cases, failure to replace the testicles back in the scrotum during hernia can occur.⁷

Inguinal hernia repair is performed in 4 of 100 children and is the most common pediatric surgery.⁸ Repair of an inguinal hernia is always recommended in children. Premature infants may be operated on before leaving the neonatal intensive care unit (NICU) because the risk of the hernia becoming incarcerated is greatest in early infancy.³

Open Hernia Repair

The open suture (sewn) repair is done most often in young children. The surgeon makes an incision above the hernia site, and the sac protruding through the gap in the muscles is tied off. An open repair can be done with local anesthesia. Pediatric repair is usually done as an open repair without mesh. Mesh may be used to repair hernias in older children and teenagers.⁹ If needed, orchiopexy (moving an undescended testicle down into the scrotum) will be done with the hernia repair.¹⁰

Laparoscopic Hernia Repair

The surgeon inserts small ports (hollow tubes) through punctures or small incisions in the abdomen. The abdomen is inflated with carbon dioxide gas to make it easier for the surgeon to see the internal organs. Surgical tools and a light are placed into the ports. The muscle at the hernia site is sutured together. The surgical incision size is reduced, and the other side of the groin can be inspected for a potential hernia.¹¹
The recurrence rate is the same as the open repair.⁴ A single port may be used. The complication rate and recurrence rate is the same as an open procedure. Single port has the advantages of preventing a contralateral (opposite side) hernia and leaves a less visible scar.¹²

Nonsurgical Procedure

Watchful waiting is not recommended because of the high risk of incarceration, especially in young infants.³

Let your anesthesia provider know if your child has allergies, neurologic disease (epilepsy), heart disease, stomach problems, lung disease (asthma), endocrine disease (diabetes, thyroid conditions), or loose teeth. If your child is having local anesthesia, they will usually go home the same day. They may need to stay longer if they have had laparoscopic surgery with general anesthesia, a larger hernia with mesh repair, an incarcerated hernia, a history of premature birth, nausea, or vomiting. All hospitals allow a parent to stay the night in a room with their child.

Contact your child’s surgeon if your child has:

• Pain that will not go away
• Pain that gets worse
• A fever of more than 101°F or 38.3°C
• Vomiting
• Swelling, redness, bleeding, or bad-smelling drainage from their wound site
• Strong or continuous abdominal pain or swelling of their abdomen
• No bowel movement 2 to 3 days after the operation

The data has been averaged per 1,000 cases.

References

1. Zamakshary M, TO T, Guan J et al. Risk of incarceration of inguinal hernia among infants and young children awaiting surgery. Canadian Medical Association Journal. 2008;179:1001-1005.
2. Lao OB, Fitzgibbons RJ Jr, Cusick RA. Pediatric Inguinal Hernias, Hydroceles, and Undescended Testicles. Surgical Clinics of North America. 2012;92(3):487-504.]

3. Chang SJ, Chen JY, Hsu CK, Chuang FC, Yang SS. The incidence of inguinal hernia and associated risk factors of incarceration in pediatric inguinal hernia: a nation-wide longitudinal population-based study. Hernia. 2016 Aug. 20 (4):559-63.
4. Hebra H. Pediatric Hernias, Nov. 2012 Medscape. Retrieved from http://emedicine.medscape.com/ article/932680-overview.
5. Lau ST, Lee YH, Caty MG. Current management of hernias and hydroceles. Seminars in Pediatric Surgery. 2007;16:50-57.
6. O’Neill, 2013, Umbilical Hernia. In Principles of Pediatric Surgery. Retrieved from http://www.pediatricsurgerymd.org.
7. Pan ML, Chang WP, Lee HC, et al. A longitudinal cohort study of incidence rates of inguinal hernia repair in 0 to 6-year-old children. J Pediatr Surg. 2013 Nov;48(11):2327-31.
8. Fitzgibbons RJ Jr., Filipi CJ, Quinn TH. Inguinal hernias. In Brunicardi FC, Anderson DK et al. Principles of Surgery (8th edition). New York, NY: McGraw Hill, 2005

9. Parelkar SV, Oak S, Gupta R et al. Laparoscopic inguinal hernia repair in the pediatric age group experience with 437 children. Journal of Pediatric Surgery. 2010;45(4):789-792.
10. Manoharan S, Samarakkody U, Kulkarni M et al. Evidence-based change of practice in the management of unilateral inguinal hernia. Journal of Pediatric Surgery. 2005;40(7):1163-1166.
11. Ein S, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: A 35 year review. Journal of Pediatric Surgery. 2006:41(5):980-997.
12. Hizuru A, Yujiro T, Hiroshi K, et al. Comparison of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) and open repair for pediatric inguinal hernia: a single-center retrospective cohort study of 2028 cases. Surg Endoscopy (2017) 31: 4988-4995.
13. Glick P and Boulanger S. Inguinal Hernias and Hydroceles. In Pediatric Surgery, (7th edition) Philadelphia, PA: Saunders. 2012: 987-988
14. Kristensen AD, Ahlburg P, Lauridsen MC et al. Chronic Pain after inguinal hernia repair in children. BR J Anaesth. 2012. Oct; 109 (4): 603-8. doi: 10.1093/bja/aes250.]
15. Taylor k, Sonderman KA, Wolf LL et al. Hernia recurrence following inguinal hernia repair in children. J Pediatric Surg, 2018; 53 (11): 2214.]
16. Sonderman KA, Wolf LL, Armstrong LB, Taylor K, Jiang W, Weil BR, et al. Testicular atrophy following inguinal hernia repair in children. Pediatr Surg Int. 2018 May. 34 (5):553-560. [Medline].
17. Aasvang EK, Kehlet H. Chronic pain after childhood groin hernia repair. Journal of Pediatric Surgery. 2007;42(8):1403-1408.
18. Treef W, Schier F. Characteristics of laparoscopic inguinal hernia recurrences. Pediatric Surgery International. 2009;25:149-152.
19. Murphy JJ, Swanson T, Ansermino M, et al. The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit? J Pediatr Surg.]2008;43:865–868. doi: 10.1016/j.jpedsurg.2007.12.028.
20. Massoud M, Khulmann AY, Rosalie MD, et al. Does the Incidence of Postoperative complications after Inguinal Hernia Repair Justify Hospital Admission in Prematurely and Term Born Infants? Anesthesia & Analgesia; April 11, 2018.
21. Gollin G, Bell C, Dubose R, Touloukian RJ, Seashore JH, Hughes CW, Oh TH, Fleming J, O’Connor Predictors of postoperative respiratory complications in premature infants after inguinal herniorrhaphy. Journal of Pediatric Surgery. 1993;28(2):244-247.
22. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures; Updated by the American Society of Anesthesiologists Committee on Standards and Practice Parameters: Approved by the ASA House of Delegates on October 26, 2016

Disclaimer

This information is published to educate you about your specific surgical procedures. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation. It is important to remember that each individual is different, and the reasons and outcomes of any operation depend upon the patient’s individual condition. The American College of Surgeons (ACS) is a scientific and educational organization that is dedicated to the ethical and competent practice of surgery; it was founded to raise the standards of surgical practice and to improve the quality of care for the surgical patient. The ACS has endeavored to present information for prospective surgical patients based on current scientific information; there is no warranty on the timeliness, accuracy, or usefulness of this content.