1. Groin or Inguinal Hernias
A paediatric inguinal hernia can occur at any age, but the peak incidence is during infancy and early childhood with 80-90% occurring in boys.
About 3-5% of healthy, full-term babies may be born with an inguinal hernia and one third of infancy and childhood hernias appear in the first 6 months of life. In premature infants the incidence of inguinal hernia is substantially increased, up to 30%. In just over 10% of cases, other members of the family have also had a hernia at birth or in infancy.
Right side hernias are commoner than left. The figures are as follows:
The occurrence of an inguinal hernia in boys is related to the development and descent of the testes. The testes develop within the abdomen and at around the seventh month of pregnancy, they descend into the scrotum. On their way through the abdominal wall, they pass through the inguinal canal. After they reach the scrotum, the opening behind should close. Failure to close adequately results in a hernia with an opening remaining in the abdominal wall at this point.
A hernia in an infant or a child will be seen as a bulge or a swelling in the groin. In boys the swelling might be seen in the scrotum.
In many cases the swelling may only be seen during crying or straining. This may lead parents to assume that the crying is because of the hernia, whereas it is more often the case that the hernia appears because the child is crying for some other reason.Inguinal hernias in children are prone to get stuck, i.e. the lump does not go away when the child relaxes. This is called incarceration.
Because incarceration is quite common most experts advise that groin / inguinal hernias should be repaired as soon is practicable after they are diagnosed. However, an incarcerated or irreducible hernia (that does not reduce or go back in) should be seen by a doctor urgently.
In an acute situation, the child or infant should be admitted to hospital and given some pain relief and sedation. Initial attempts are made by the doctors to gently negotiate the hernia back inside.
If the hernia does not go back, or the child is ill, the irreducible hernia should be operated upon urgently as it may contain intestine that is in danger of strangulating. Strangulation is extremely serious and must be avoided at all costs. If the hernia does go back without any emergency operation it should still be operated on at an early stage.
The surgery is carried out under general anaesthetic. This may be carried out as a day case or the child may stay overnight. Even a technique that could be done under local anaesthesia (as we do routinely with adult patients at The British Hernia Centre) should be done using general anaesthesia with children. The main reason is to avoid subjecting a young person to what may frighten them if they are awake.
A small incision is made in the groin and the hernia sac is found. In children and babies it is sufficient to remove the hernia sac. The hole in the abdominal muscle does not usually need to be repaired, i.e. does not need stitching or mesh. The hole will close itself as the child grows.
The incision in the skin is usually closed with dissolving stitches.
Strangulated hernias can prove fatal. At best they can be extremely painful and are surgical emergencies. That means they require urgent professional attention.
2. Umbilical Hernia (the navel)
This is one of the most common paediatric surgical conditions affecting 1 in 5 of all children.
Umbilical hernias are more common in premature babies and children with Down’s Syndrome and there is a slight familial tendency.
They appear as a bulge at the umbilicus (the navel), which can vary from the size of a pea up to the size of a small plum. They are not usually painful and are much more obvious when the child cries or strains.
Do they need an operation if they are not treated?
There is a general agreement that most infantile umbilical hernias will eventually close spontaneously, though experts disagree over what period of time. Probably 80-90% of umbilical hernias will have closed by the time the child is 3, but the larger ones may be present up to 11 years before finally closing. The time taken to close probably depends on the size of the hole with 95% of umbilical hernias less than 0.5 cm in diameter, closing by the age of 2 years. Umbilical hernias present after puberty will probably not close spontaneously.
In the case of infantile umbilical hernias, problems (particularly strangulation where a portion of intestine becomes trapped in the hernia) rarely occur, so that surgery is rarely required. However the presence of pain in the hernia, particularly if associated with vomiting or constipation, requires an urgent surgical opinion and possible operation.
NEVER ignore signs of pain or distress or any bulge in an infant or child. Seek a proper professional opinion as soon as possible.
See also the section specifically on Umbilical Hernias.
Where to get treatment
Unlike the case of adult hernias, which are very demanding in terms of achieving completely reliable repair and which benefit greatly from hernia specialisation, paediatric hernias can be very successfully treated by any good paediatric surgeon.