Inguinal Hernia

An inguinal hernia is a bulge or protrusion that is seen or felt in the groin area or the scrotum (for boys). Inguinal hernias occur in boys more frequently than in girls. Infants who are born prematurely are at an increased risk of having an inguinal hernia. For example, about one-third of baby boys born at less than 33 weeks gestation will have an inguinal hernia.

There are two types of inguinal hernias:

1. Indirect inguinal hernias: Indirect inguinal hernias are the most common type of inguinal hernia in children and are present at birth. During fetal development, all babies have a canal (called the inguinal canal) that goes from their abdomen to their genitals. In boys, this canal allows the testicles (which develop in the abdomen) to travel to the scrotum. In both boys and girls, the canal is supposed to close off prior to birth. An indirect hernia occurs when the inguinal canal fails to completely close during fetal development, leaving an opening for abdominal contents to protrude through the defect.
2. Direct inguinal hernias: Direct inguinal hernias are very rare in children. This type of hernia is caused by a weakness in the abdominal wall that allows intestines to protrude through. These hernias are more frequent in males.

In some cases, boys with an inguinal canal that fails to close may also develop a hydrocele, a collection of fluid around the testicles that occurs when fluid drains from the abdomen into the scrotum, causing it to swell.

Another type of hernia that can occur in the groin area is a femoral hernia. Femoral hernias are also very rare in children, and are caused by a weakness in the femoral canal that allows bowel or tissue to protrude from the upper thigh near the groin. This type of hernia is more common in females.

Inguinal hernias are diagnosed by a thorough health history and physical examination.

Inguinal hernias are often more noticeable during times when the child is bearing down — crying, coughing, or straining to have a bowel movement. The bulge may seem to disappear when the child is quiet or resting. Inguinal hernias do not usually cause pain.

Unlike some umbilical hernias, inguinal hernias will not resolve on their own. Surgery is required to correct the defect and prevent any harm to the hernia contents.

Incarceration of the hernia occurs when the hernia contents (usually the intestine) get trapped in the defect and are unable to go back into the abdomen. An incarcerated hernia will often cause a painful, firm bulge. The blood supply to the incarcerated contents can become compromised (a strangulated hernia), and your child can become very sick.

If your child has signs of an incarcerated hernia, he or she should be brought to the Emergency Department for immediate evaluation by a pediatric surgeon to minimize any damage to the contents of the hernia.

Surgical repair of inguinal hernia

The surgery to repair an inguinal hernia is usually a day surgery, meaning your child will go home the same day as the procedure. Premature babies who are less than 60 weeks post-conception age may require an overnight stay for post-anesthetic apnea (breath holding) monitoring. The procedure will be done under general anesthesia. Your child’s surgeon will discuss with you the surgical procedure that is best for your child.

The surgical approach for repair of an inguinal hernia depends on the clinical situation:

• Open repair: A tiny incision is made in the groin (along the skin crease) and the hernia is closed using sutures. The overlying skin is sealed with DERMABOND, a sterile, liquid adhesive that will hold the edges of your child’s wound together and act as a waterproof dressing.
• Open repair with laparoscopic evaluation of the other side: The procedure is done in the same manner as the open repair; however, prior to closing the hernia, a small camera (laparoscope) is used to check for the presence of a hernia on the opposite side of the groin or scrotum. If a second hernia is present, another tiny incision is made on the opposite side of the groin and the other hernia is repaired.
  Using a laparoscope to evaluate the opposite side for a hernia is done in certain situations depending upon the patient’s age, since hernias on both sides are more common in babies and small children. The overlying skin is sealed with DERMABOND.
• Laparoscopic repair: A small camera (laparoscope) is placed through an incision in the belly button. The hernia repair is done using surgical instruments that are inserted through one or two tiny incisions in the lower portion of the abdomen. All sutures that are used are dissolvable and the overlying skin will be sealed with DERMABOND.

DERMABOND usually stays in place for 5 to 10 days before it starts to fall off. You should not pick, peel, or rub the DERMABOND, as this could cause your child’s wound to open before it is healed.

Once it sets, the adhesive can get wet (as in a shower) the same day as the procedure, but should not routinely be submerged under water (as in swimming) for seven days. Do not apply any ointments such as Vaseline or Neosporin to the incision while the DERMABOND is in place until seven days after surgery.

Visit our Guide to Your Child’s Surgery to learn more about what to expect when your child has surgery at The Children’s Hospital of Philadelphia.

After surgery, your child’s incision may appear to be slightly swollen. In boys, the scrotum may also appear swollen. This will go away over the next few weeks. Your child will not be able to participate in physical education or sports for 2 to 3 weeks after surgery.

We will schedule your child for a follow-up appointment in our surgery clinic 2 to 4 weeks after the procedure, at which time we will evaluate the repair and your child’s recovery. In selected circumstances, we will do telephone follow-up in an effort to spare your family another trip to Children’s Hospital or a CHOP Specialty Care Center.

Please call the Division of Pediatric General, Thoracic and Fetal Surgery at 215-590-2730 if your child has any of the following symptoms after an inguinal hernia repair:

• Fever (a temperature of 101.5 degrees or higher)
• Any signs of infection, including redness, swelling or pain
• Any drainage from the incision
• Any pain that is not controlled with the prescribed pain medicine
• Any further questions or concerns

Seek medical care immediately if your child has any signs or symptoms of incarceration:

• A hernia that is stuck out and not able to be reduced (gently pushed back into the abdomen)
• A painful, firm bulge

The world-class, board-certified pediatric general surgeons at The Children’s Hospital of Philadelphia (CHOP) perform approximately 800 inguinal hernia repairs each year. The operations are performed in patients ranging from tiny premature babies up to 21-year-old young adults.

Inguinal hernia repairs are performed at the Main Hospital in Philadelphia, and also at CHOP’s three Ambulatory Surgery Centers in Voorhees, NJ, Exton, PA and Bucks County (Chalfont), PA. Surgery at all locations is performed in conjunction with CHOP’s board-certified pediatric anesthesiologists and our compassionate, skilled surgical nurses.