What is the recommended management for a 2-year-old boy with an inguinal mass, approximately olive-sized, in the groin area and an empty scrotum?

Surgical Intervention is Recommended

A 2-year-old boy with an inguinal mass and empty scrotum (undescended testis with inguinal hernia) requires surgical intervention within 2-4 weeks, not observation until age 5 years. 1

Rationale for Early Surgical Repair

• All inguinal hernias in infants and young children require surgical repair to prevent life-threatening complications including bowel incarceration, strangulation, and gonadal infarction/atrophy. 2, 1, 3

• The American Academy of Pediatrics recommends semi-urgent repair within 2-4 weeks of diagnosis to minimize the risk of incarceration and strangulation. 1

• Inguinal hernias in infants are commonly repaired shortly after diagnosis specifically to avoid incarceration, which can lead to bowel necrosis and testicular damage. 2

• Waiting until age 5 years is not evidence-based and exposes the child to unnecessary morbidity risk from potential hernia incarceration during the observation period. 1

Why "Wait and Observe" is Inappropriate

• The recommendation to wait until age 5 years confuses inguinal hernia management with cryptorchidism (undescended testis) management—these are distinct conditions requiring different approaches. 4

• While spontaneous testicular descent may occur before 6 months of age, the presence of an inguinal hernia changes management entirely and mandates surgical intervention regardless of age. 4

• The estimated childhood risk of developing complications if a patent processus vaginalis (the anatomic defect causing inguinal hernias) is present ranges between 25-50%, making observation unacceptably risky. 2

Surgical Approach: Herniotomy

• Herniotomy (high ligation of the hernia sac) is the recommended procedure for infants and young children, not mesh repair. 1

• Pediatric inguinal hernias are indirect hernias caused by patent processus vaginalis, requiring only high ligation of the sac with a complication rate of 1-8%. 1

• During the same operation, orchiopexy (surgical fixation of the undescended testis into the scrotum) should be performed to address both conditions simultaneously. 5

Contralateral Evaluation

• Consider laparoscopic evaluation of the contralateral (opposite) side during surgery, as contralateral patent processus vaginalis occurs in 64% of infants younger than 2 months and remains present in 33-50% of children younger than 1 year. 2, 3

• Laparoscopic evaluation with prophylactic closure reduces the risk of developing a second hernia on the opposite side by 5.7% and eliminates the need for a second anesthesia exposure. 1

Critical Pitfalls to Avoid

• Do not delay repair until school age (5-6 years)—this outdated approach is not supported by current evidence and increases the risk of hernia incarceration requiring emergency surgery with higher complication rates. 1, 3

• Do not simply observe reducible hernias in children—unlike in adults where watchful waiting may be appropriate for asymptomatic hernias, all pediatric inguinal hernias require surgical correction. 1

• Do not confuse this with isolated cryptorchidism management—while isolated undescended testis may be observed until 6-12 months for potential spontaneous descent, the presence of an inguinal hernia mandates earlier surgical intervention. 5, 4