From the Guidelines
For a 3-month-old with an inguinal hernia, surgical repair (inguinal herniorrhaphy) is recommended as the definitive treatment to prevent complications such as incarceration or strangulation, which can significantly impact morbidity, mortality, and quality of life. This should be performed as an elective procedure soon after diagnosis. The decision to operate is based on the high risk of incarceration in infants, with rates of 30-40% in those under 6 months 1. While awaiting surgery, parents should be taught to gently reduce the hernia by applying gentle pressure when it appears. If the hernia becomes hard, painful, discolored, or irreducible, this constitutes a medical emergency requiring immediate medical attention.
Key Considerations
- Inguinal hernias in infants result from incomplete closure of the processus vaginalis during fetal development, allowing abdominal contents to protrude through the inguinal canal, and they will not resolve spontaneously without surgical intervention 1.
- Surgical repair in infants is typically performed as an outpatient procedure under general anesthesia, with excellent outcomes and low complication rates.
- The procedure involves identifying and isolating the hernia sac, removing or reducing it, and closing the defect.
- Recovery is usually rapid in infants, with minimal post-operative pain managed with acetaminophen (10-15 mg/kg every 4-6 hours as needed).
Approach to Repair
The approach to inguinal hernia repair in infants can vary, with both open and laparoscopic techniques being used. However, the choice of approach should be individualized based on the patient's specific needs and the surgeon's expertise. Laparoscopic repair has been shown to be effective in preterm infants and may offer benefits in terms of reduced post-operative pain 1.
Timing of Repair
The timing of inguinal hernia repair in preterm and term infants represents a balance of the risks of inguinal hernia incarceration and of postoperative respiratory complications. While the literature does not clearly define these risks, early repair is generally recommended to prevent complications 1.
Contralateral Exploration
The utility of contralateral inguinal exploration in children is an area of debate, with some studies suggesting that routine exploration may not be indicated due to the risks associated with it 1. However, the decision to perform contralateral exploration should be individualized based on the patient's specific needs and the surgeon's expertise.
From the Research
Diagnosis and Management of Inguinal Hernia in Infants
- Inguinal hernias are a common presentation in pediatric surgical settings, and young patients under the age of three months require urgent referral 2.
- The differential diagnosis of inguinal masses in infants is broad, with inguinal hernia being the most common diagnosis in both males and females 3.
- A female infant with suspected inguinal hernia should be thoroughly evaluated to determine whether ovarian content is present 3.
Risk of Strangulation
- The cumulative probability of strangulation for inguinal hernias is 2.8 per cent after 3 months, rising to 4.5 per cent after 2 years 4.
- Patients with a short history of herniation should be referred urgently to hospital and given priority on the waiting list 4.
- The risk of strangulation is higher in femoral hernias, with a cumulative probability of 22 per cent at 3 months and 45 per cent at 21 months 4.
Treatment Options
- Laparoscopic approach to incarcerated and strangulated inguinal hernias is a feasible procedure with acceptable results, but its efficacy needs to be studied further 5.
- Inguinal hernia repair is the most common operation performed in infants and children, and specific attention should be directed to topics such as incarcerated hernia, hernias in girls, and anesthetic considerations 6.