Incarcerated Inguinal Hernia Revisited

 

Inguinal hernia is the common surgical condition in children affecting almost 30% of premature infants. Inguinal hernia results from an incomplete obliteration of the processus vaginalis developed around the 6th month of fetal development. Most inguinal hernia in children are indirect. Incarcerated inguinal hernia is a common and serious emergent situation in pediatric patients. The risk of incarceration in children with inguinal hernia fluctuates between 3 and 16% with the highest incidence of 30% in premature. The rate of inguinal hernia strangulation is also higher in prematurely born infants.  The median age of presentation of inguinal hernia is two years. Incarcerated inguinal hernia occurs in 12% of all cases at a mean age of 1.5 years, mostly in boys and mostly on the right side. Due to the significant incidence of incarceration of inguinal hernia, once diagnosed inguinal hernias in children should be repair within the next two weeks. The management of incarcerated inguinal hernia is manual reduction which is successful in most cases, followed by open repair of the hernia in the next 48-72 hours once the edema of the cord has subsided. The procedure can also be done laparoscopically. The advantage of laparoscopic incarcerated inguinal hernia repair include excellent visual exposure, reduction of the incarcerated viscera and inspection for gangrene, immediate repair of the defect, the ability to evaluate the contralateral side, minimal dissection and avoidance of access trauma to the vas deferens and the testicular vessels, iatrogenic ascent of the testis and decreased operative time specially in obese and recurrent cases. The cons are that a subcutaneous procedure is converted into a transabdominal procedure with the incidence of adhesions and later bowel obstruction development. In the case of female patients the possibility of having an incarcerated ovarian inguinal hernia is high. The use of US to determine if an ovary is incarcerated can provide evidence of flow and plan urgent surgery before torsion occurs. Both open herniotomy and laparoscopic repair offer safe surgery with comparable outcomes for incarcerated inguinal hernia in children.      

References:
1- Ksia A, Braiki M, Ouaghnan W, et al: Male Gender and Prematurity are Risk Factors for Incarceration in Pediatric Inguinal Hernia: A Study of 922 Children. J Indian Assoc Pediatr Surg. 22(3):139-143, 2017
2- Jun Z, Juntao G, Shuli L, Li L: A comparative study on trans-umbilical single-port laparoscopic approach versus conventional repair for incarcerated inguinal hernia in children. J Minim Access Surg. 12(2):139-42, 2016
3- Yan XQ, Yang J, Zheng NN, Kuang HF, Duan XF, Bian HQ: Treatment for incarcerated indirect hernia with "Cross-Internal Ring" inguinal oblique incision in children. J Res Med Sci. 22:106, 2017
4- Choi KH, Baek HJ: Incarcerated ovarian herniation of the canal of Nuck in a female infant:
Ultrasonographic findings and review of literature. Ann Med Surg (Lond). 9:38-40, 2016
5- Yin Y, Zhang H, Zhang X, Sun F, Zou H, Cao H, Wen C: Laparoscopic surgery in the treatment of incarcerated indirect inguinal hernia in children. Exp Ther Med. 12(6):3553-3556, 2016
6- Chan YY, Durbin-Johnson B, Kurzrock EA: Pediatric inguinal and scrotal surgery - Practice patterns in U.S. academic centers. J Pediatr Surg. 51(11):1786-1790, 2016


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