Just a Simple Hernia? Brief Insights into a Complex Topic

Inguinal hernias affect between 1 and 6 out of 100 children. They are treated surgically. The aim of this review is to present the most relevant aspects of pediatric inguinal hernia. Special emphasis is placed on the differences between boys and girls and the special features of small infants. Classical works, studies on anatomy and developmental human biology as well as new aspects of the last decade have been evaluated. Infantile inguinal hernias are almost invariably the result of a failure of spontaneous closure of the vaginal peritoneal process. As a general rule, the younger the child, the more frequent the hernia. There is a wide range of anatomical variants. The most important complication of a hernia is incarceration with the risk of gonadal damage or hemorrhagic bowel infarction. The urgency for surgical correction of a hernia or hydrocele depends on the likelihood of incarceration. The principle of inguinal herniotomy is to close the hernia sac at the inner inguinal ring and, if possible, to cut through it. There are some important gender-associated differences. Childhood inguinal hernias are much more common in boys than in girls. Ovarian prolapse is an important special form in girls. For open surgery the spermatic cord (round ligament) with hernia sac can be exposed via opening of the external oblique aponeurosis (Ferguson/Gross, Grob, Rehbein, and others) or peripherally of the intact external ring (Czerny, Potts, Mitchell-Banks). Simple sac ligation and dissection seem appropriate for most hernias. The following rule of thumb applies in clinical practice: the smaller the infant and the smaller the hernial orifice, the greater the risk of incarceration. The risk of bilateral or contralateral inguinal hernia differs significantly between girls and boys. The main advantage of the laparoscopic procedure is the possibility of assessing the opposite side. Laparoscopic repair provides similar outcomes to open but may shorten the operative time in bilateral cases. For hydroceles, the laparoscopic approach provides some substantial new insights into anatomy. The timing of surgery in premature babies is the subject of controversial debate. There is currently a trend to delay hernia repairs in premature babies until after discharge to reduce the risk of respiratory distress and recurrence. Operations under regional anesthesia are associated with faster postoperative recovery and improved patient comfort.