Inguinal hernias are the most common congenital conditions requiring surgical repair.1,2 During the third month of gestation, the processes vaginalis follows the course of the ligament of the metanephros and gubernaculum into the scrotum or labia. Following the descent of the testis in males and prior to birth in both males and females, the processes vaginalis begins to obliterate. At birth there is approximately an 85% patency rate, which decreases to approximately 60% at 1 year and ranges from 15% to 35% in adults. By definition, an indirect inguinal hernia is not present until an intra-abdominal structure protrudes into the patent processes vaginalis. Forty percent of inguinal hernias in children occur in the first six months of life and they are eight times more common in boys than in girls. Approximately 10% of inguinal hernias in infants and children of all ages are bilateral. The younger the patient at the time the hernia first appears, the more likely one is to appear on the opposite side. For this reason, most pediatric surgeons perform inguinal herniorrhaphy and contralateral exploration in boys up to 2 years of age.3'6 Many extend this age in girls because there is no chance of injuring the vas deferens or the vasculature of the testis and because the incidence of bilaterality is greater in females than in males.
An inguinal hernia is diagnosed by observing an inguinal or scrotal mass that is reducible. Other diagnostic studies, such as peritoneography, are not commonly used.7 In modern hospitals, outpatient repair is the norm8 except in premature infants who are more prone to experience apnea following general anesthesia.9·10 In these situations, infants are frequently kept overnight for observation. Most pediatric surgeons prefer to delay repair until the patient weighs 10 pounds although this is not always possible in premature infants who develop bronchopulmonary dysplasia, which makes incarceration more likely.11·12 The recurrence rate should be quite low in skilled hands.
In most instances, incarcerated hernias can be reduced, allowing them to be repaired during regular operating hours during the day. If it is difficult to reduce a hernia, placing an ice pack on the scrotum, sedating the child, and elevating the feet will frequently allow manual reduction. Early surgical consultation is advised.13
Special care should be taken in females with inguinal hernias: 2% of phenotypic females with inguinal hernias will be found to have the testicular feminization syndrome.14 Rather than obtaining a karyotype or performing buccal smears preoperatively, most surgeons prefer to open the hernia sac. If ovaries and fimbriated fallopian tubes are found, the diagnosis is excluded; if a testis or indeterminant gonad is found, a biopsy is obtained. In the past, gonadectomy has been delayed until puberty. Since malignant degeneration has been seen at younger ages, there is a tendency toward earlier bilateral gonadectomy. In any event, gonadectomy is undertaken if the patient starts to masculinize.
Although femoral hernias are rare at all ages, they occasionally occur in children.15 The mass of the femoral hernia is palpable in the femoral region and is another variety of inguinal hernia. The anatomic fault that permits a femoral hernia to develop is inguinal; however, whereas the usual inguinal hernia in an infant or child is indirect, a femoral hernia is a direct inguinal hernia. Repair of this hernia and the unusual direct hernia of the infant and child requires an anatomic repair similar to that used in adults employing Cooper's ligament.
A hydrocele is a collection of fluid in the patent processes vaginalis. It may occur as an isolated lesion within the cord, or, more commonly, surround the testes. In the female it is called a hydrocele of the canal of Nuck. If the size of the hydrocele changes, it can be assumed to communicate with the peritoneal space and is called a communicating hydrocele. Hydroceles are common in boys and may be associated with inguinal hernias, and like inguinal hernias they are more common on the right than on the left. Although transillumination helps to determine the intrascrotal contents, it should not be used as a total discriminate between a hydrocele and an incarcerated inguinal hernia. Since the natural history of a patent processes vaginalis is closure, many hydroceles will disappear by the time an infant is 9 or 12 months of age. Hernias that communicate or persist beyond this age should be repaired. Repair is similar to an inguinal herniorrhaphy in approach and technique. Aspiration of a hydrocele with a syringe and needle is not only ineffective treatment but is potentially dangerous if an inguinal hernia is mistaken for a hydrocele.
A true understanding of undescended testes depends on precise definitions. The term "undescended testes" applies to all instances in which the testes are not in the scrotum but excludes retractile testes. Retractile testes can be brought into the scrotum by manipulation although they routinely reside outside of the scrotum. The term "cryptorchidism" is used synonymously with undescended testis. Testes may be ectopic, absent (anorchism), or multiple (polyorchism). Absent testes may be either developmental or more likely acquired due to a vascular accident in utero.
Testes form from the medial portion of the urogenital ridge, which extends from the diaphragm into the pelvis. In arrested descent, they may be found from the kidneys to the internal inguinal rings. The gubernaculum testis, a broad fan of immature mesenchymal tissue, forms to attach the testis and epididymis to the scrotum, perineum, pubopenile, and femoral areas. Not all portions of this broad mesenchymal tissue persist, but a prominence of any one portion can lead to undescended testis or ectopic testis. Prior to descent, the testes enlarge, the cord elongates, and rapid testicular descent starts at the 28th week, the left testis preceding the right. 16 The scrotal portion of the gubernaculum normally remains. In the usual patient with undescended testis that portion of the gubernaculum attached to the pubic tubercle predominates, a fact attested to by the operating surgeon.
At operation, the testes may be small, softer, and more elongated. The epididymis is loosely attached and frequently separate. A patent processes vaginalis is present in association with undescended testes 90% of the time when retractile testes are excluded. The incidence of undescended testis was found to be approximately 0.3% in 12,000,000 military recruits.17·18 Half were noted on the right, one fourth on the left, and one fourth were found to be bilateral. This, of course, coincides with the order of testicular descent. Prematures have an eight times greater incidence of undescended testes than term infants.
The clinical approach to patients and their families with undescended testis requires a calm and unhurried examination. Warm hands are essential because the cremaster reflex may be initiated when the patient is touched with cold hands. Complete cooperation of the patient and his family are required. In the supine position, the contents of the inguinal canal are "milked" into the scrotum. If this fails, the cross-leg position may take enough tension off the cord so that the testis can be brought into the scrotum. Although it may return to a nonscrotal position upon release, if the testis can be brought down into a true scrotal position it is considered a retractile testis and not an undescended testis and thus surgical therapy is not warranted. 19 As the boy gets older, the testis will assume a constant pendulous scrotal position. Except under most unusual circumstances, treatment is surgical. There is a growing body of evidence to indicate that the child may benefit from early repair; the current recommendations of the Urology Section of the American Academy of Pediatrics is that repair should be undertaken prior to school age.20 Most pediatric surgeons now recommend repair sometime after 1 year of age but before 2 years. This will allow those testes that will descend on their own to descend, thus avoiding unnecessary surgery. There seems to be a lower incidence of infertility in men who have had early repair. 2I
The usual indications for surgical repair include the maintenance of spermatogenesis. Parents seeking surgical correction expect fertility after repair. This should be the surgical goal, although it cannot always be achieved, and should determine the optimal time of correction. From a teleological point of view, the scrotal position serves to protect the testis from exposure to higher temperatures: the longer repair is delayed, the longer the exposure. Also, repair prevents malignant change. Although the incidence of malignant change in the undescended testis is low, adequate evidence documenting this association makes it a prime consideration. The incidence of malignant testicular tumors is thought to be 0.0021% in the adult male population.17,18 The incidence in the undescended testis is approximately 2.8 per 1,000. The clinical association of malignant testicular tumors in cryptorchid testes is real; however, the population at risk is unknown. This incidence is the same as in the past, when repair was undertaken at an older age. However, surgical repair does make early changes detectable. Long term follow-up will determine if earlier repair reduces the incidence. The normal testis in its pendulous scrotal position is at little risk for trauma; when it is fixed in an abnormal location it is prone to trauma and represents another indication to perform orchiopexy. There is also an increased incidence of torsion of the undescended testis. Perhaps most important are the cosmetic considerations that prompt parents to seek repair, which, in the author's opinion, is a legitimate reason to perform orchiopexy. When a hernia sac is found in association with an undescended testis, herniorrhaphy should be performed. Orchiopexy should also be undertaken at the time of herniorrhaphy when an inguinal hernia is the indication for operation.
The surgical approach is the same inguinal approach used for inguinal herniorrhaphies and hydrocelectomies: the hernia sac is removed, the vas and blood supply to the testis are mobilized, and scrotal fixation performed. The various surgical techniques are beyond the scope of this article. There is an occasional role for orchiectomy when orchiopexy cannot be performed.
Early and accurate diagnosis will not only prevent the catastrophe of gangrenous bowel in infants and children with inguinal and femoral hernia, but in the case of hydrocele will also avoid unnecessary parental anxiety. An accurate diagnosis and knowledge of the natural history of inguinal conditions can avoid unnecessary referral to surgical consultants. Finally, an understanding of the surgical expectations, ie, orchiopexy for the undescended testis, will provide parents and patients with realistic expectations.
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