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Jeevan was 8 months old when his mother noticed a swelling in the groin region appearing only when he cried. As it was rarely seen and did not seem to cause the baby any symptoms, she was not concerned until one day when he started crying excessively and vomited all the feeds. The swelling was more prominent this time and hard to touch with redness slowing developing. He was rushed to the hospital and the Pediatric Surgeon confirmed the presence of a hernia which was now complicated, requiring urgent surgery. Jeevan underwent an emergency laparoscopic surgery and recovered normally to the great relief of his parents. Most of us would have heard of the term HERNIA which is known in adults and the need for an operation to cure it. However, many people are surprised to learn that hernias are fairly common in kids and that sometimes babies can even be born with them.
What is Hernia?
When part of an organ or tissue in the body (such as a loop of intestine) pushes through an opening or weak spot in a muscle wall, it can protrude into a space where it does not belong. This protrusion is a hernia, which may look like a bulge or lump. Unlike hernias seen in adults, these areas are not always considered a weakness in the muscle wall, but a normal area of muscle wall openings that should have closed, that are only meant for blood vessels or other tissues to come out.
What are the symptoms of Hernia?
Sometimes the swelling may be constantly seen without any change in size which means the protruding structures are not easily reducible. In this situation, the intestine protruding outside can get blocked leading to severe pain and vomiting of feeds. If treatment is delayed, the blood supply of the affected intestine may get blocked and the intestine may become black. The area will be extremely painful and will appear reddish. This is a very serious complication of untreated hernia. In girls, the ovary can come out through the hernial opening and undergo the same complications as the intestine.
Types of Hernias
The two most common hernias in kids are inguinal hernias in the groin area and umbilical hernias in the navel or belly-button area.
In infants, an inguinal hernia is most often caused by a protrusion of a loop or portion of intestine or in girls, from an ovary or fallopian tube through an opening into the groin (the area where the abdomen meets the top of the thigh). It affects 1%-5% of full-term babies and more commonly seen in premature babies (7%-30%). Boys are 4-8 times more likely than girls to have an inguinal hernia.
Before birth the testes in boys are initially located in the abdomen. Around the seventh month of pregnancy, the testes migrate down into the scrotum via a passage called the inguinal canal. This canal begins to close before birth and is normally completely fused or shut by the first year of life. If this canal does not close completely and the muscles in the wall of the abdomen do not cover the opening well enough, a hernia may develop. Though less likely, girls can also develop an inguinal hernia. They have a similar but smaller passage.
There is nothing you did or did not do that caused the hernia to develop. The opening in the abdominal wall is present from birth and a hernia may develop at any time. It is usually picked up in newborns or within the first year of life. It may, however, go unnoticed for many years. There is no routine treatment of newborns that prevents development of a hernia.
Some babies are born with a weakness or opening in the abdominal muscles around the belly button (under the skin) through which some abdominal membrane or small intestine protrudes. The soft bulge this creates is an umbilical hernia and is most obvious when the baby cries, coughs, or strains. They can be very small to very large swellings. In most instances an umbilical hernia causes no discomfort. Usually, a doctor can easily push it back in. An infant's umbilical hernia (unlike an adult's) rarely obstructs or strangulates. In fact, most umbilical hernias, even the larger ones, tend to close up on their own by age 2. That's why the doctor usually advises waiting and watching for this kind of hernia in an infant rather than operating.
Surgery is necessary only if the hernia is very large; grows in size after age 1 or 2; fails to heal by the age 4 or 5; or the child develops symptoms of obstruction.
A Pediatric Surgeon can usually make the diagnosis based on your description and his/her examination of the groin on both sides. The examination may include feeling the hernia and trying to reduce it. If the hernia is not visible at the time of the visit, your doctor may try to bring it out by pressing lightly on your child's abdomen or making your child cough or strain. A picture or video of the swelling whenever it appears will aid the surgeon to diagnose the condition even if there is no swelling at the time of examination.
No scans or diagnostic tests are required for the diagnosis.
Is surgery the best form of treatment?
Yes. Surgery by a Pediatric Surgeon is necessary in all cases, even if it has not caused the child any problem. Even a simple hernia carries a risk because it can become complicated. Once a hernia is complicated, if it is not treated fairly quickly, it can lead to immediate life-threatening events including bowel obstruction, hole in the intestines and even death. Long term complications involving the reproductive organs can occur from delayed or non-treatment. These include the testes in the male and ovaries in the female, both of which can have the blood supply cut off and therefore waste away.
Once the diagnosis of a hernia is made, surgical repair (herniotomy) should be performed. Surgery to correct inguinal hernias is performed on kids of all ages, sometimes even on premature babies. During surgery, the herniated tissue is put back into its proper space, and the opening or weakness that permitted it to form is closed or repaired. Mesh coverings used in adult hernia repair are generally not required in children. In general, an uncomplicated hernia should be fixed as soon as is practical. If the hernia is incarcerated a more urgent operation may be needed.
Can the surgery be done by Laparoscopy?
Yes. Laparoscopy can be done safely even in small babies. This involves operating through three small holes (3mm diameter), visualized by a telescope and two instruments for closing the hernial openings from inside. The advantages would be that the opposite side hernial opening if seen from inside, can be operated at the same time, thus avoiding a second surgery later on. (Especially when the hernia is seen in girls) The other advantages are that the scar and operative pain will be much less after laparoscopy.
In girls, a hernia can be a presentation of a rare condition where there is no uterus or ovaries, but testis like structures inside the hernial sac. This condition can be diagnosed accurately by laparoscopy.
What does the surgery involve?
The child comes to the hospital two hours prior to the planned procedure with fasting as advised by the Pediatric Surgeon. The Anaesthesiologists will do a pre-anaesthesia checkup and basic simple blood tests are done. The child will be given a sedative in the presence of the parents before being shifted to the operating room to prevent separation anxiety and avoid fear of the new unfamiliar surroundings. The surgery either open or by laparoscopy lasts for less than an hour after which the child will be shifted to the recovery and will be with his parents when awake from anaesthesia. He/she will be allowed oral feeds an hour later and can be allowed normal activities like sitting and walking. They can go home the next day and are not allowed strenuous activities for 2 to 3 weeks.
Recurrence rates are less than 1% in an uncomplicated hernia.
(original article published in print daily)
MBBS, MS, MCH
Rainbow Children's Hospital, Banjara Hills, Hyderabad