CHILDHOOD HERNIAS

INGUINAL HERNIA

Inguinal hernia is an extension of the processus vaginalis, which fails to close during foetal development. Through this opening abdominal content can herniate to varying extents into the inguinal canal and scrotal sac. The communicating type is the most common form and extends down into the scrotum;the non-communicating one is less common.

Clinical Features

1. A bulge presents at either the internal or the external rings, or scrotum for males and inguino labial region for females, that increases in magnitude with straining.
2. There may be associated pain and discomfort, or it may present as an acute abdomen.

IMPORTANT:Examination findings reveal a reducible mass but cases of irreducible incarceration may occur. Trans-illumination tests may assist in differentials.

Management

1. Inguinal hernias do not heal and must be corrected by elective herniorrhaphy for uncomplicated cases, to avoid complications.
2. Emergency surgery if complications like obstruction have set in.

 

ABDOMINAL HERNIA

This is a protrusion through the abdominal wall due to one of the following:

1. Omphalocele, which is due to the failure of development of the anterior abdominal wall at the area of insertion of the umbilicus,with the abdominal contents herniated out with only a peritoneal covering. There may be other associated anomalies. This is the most severe of these types of hernia.
2. Gastrochesis, which is a herniation of small bowel contents with no covering at all and is often paraumbilical. Unlike omphaloceles,this condition does not have many associated anomalies.
3. Umbilical hernia, which is a mild condition as a result of a defect in the linea alba. The herniated bowel has a covering of subcutaneous tissue and skin.

Clinical Features

There is protrusion of bowel contents through the abdominal wall to varying extents with or without other organs. Covering of the hernia varies and strangulation is a possibility.

Investigations

1. Usually a clinical diagnosis is sufficient for the conditions.
2. Ultrasound has a role in the antenatal period.

Management

1. Conservative management for small umbilical hernias with expectant observation. Suggest referral to a higher center if not sure of conservative management.
2. Surgical management is best at specialized facility.
3. Surgery for omphaloccoel and gastrochesis on the first day if possible.
4. Surgery for strangulations or other surgical complications arising from the hernia.
5. Counseling and attending to associated conditions.

 

IMPERFORATE ANUS

This is failure of the anal opening to canalize and is the commonest cause of intestinal obstruction in the newborn. It presents with a wide variation in anatomical anomalies.

Clinical Features

There is failure to pass meconium, or may pass meconium per urethra or vagina.

Investigation

1. Invertogram
2. Check for other anomalies

Management

1. Surgical management is best at specialized facility even for apparently simple malformations.
2. Details investigations will be performed.
3. Definitive surgical intervention, which may range from minor annuloplasty(dilatation, incision) to more complicated pull through procedures at the appropriate facility.

• Continued dilatation at home
• Sitz baths
• Colostomy closure if needed

1. For level 4 and 5 without the necessary surgical facilities, perform a colostomy if indicated and refer to level 6 facility.
2. Counseling and attending to associated conditions.

 

INTUSSUSCEPTION

This occurs when a piece of, usually small, bowel invaginates into itself. This invagination may cause strangulation that leads to gangrene formation in the affected portion of the bowel.

Clinical Features

There is onset of acute abdominal pain sometimes associated with red currant jelly stools.

Clinical examination reveals a mass of the interssuceptus in the right hypochondrium.

Investigation

1. Plain abdominal radiograph may show evidence of obstruction but misses still in identifying intussusceptions in early disease.
2. Ultrasound gives better detection rates.

Management at Levels 4 to 5

1. Stabilize the patient adequately.
2. As appropriate, initiate conservative or surgical management.
3. If facilities are lacking, refer to level 6.

Management at Level 6

1. Enema in the radiology unit may be attempted. Ensure that bowel gangrene has not set in.
2. Definitive management

 

INGUINAL HERNIA (ADULT)

 

This is usually an acquired condition and is often linked with activity associated with increase of abdominal pressure.

 

Complications

Complications of this condition include obstruction(when a hollow viscus goes through a ring of variable size and cannot be reduced),and incarceration (when a non-hollow organ, for example omentum, goes through a ring of variable size and cannot be reduced).

Nota Bene: Strangulation is a process in which blood flow into the obstructed viscus is compromised, and if not corrected culminates in ischaemia of the viscus supplied  by the involved blood vessels. Plain and tenderness over the hernial area are ominous signs. Sudden change from reducible to irreducible status especially if discoloration of tissues over the area is present is an ominous sign.

Clinical Features 

Protrusion in the groin of the bulge, initially straining and later maybe  spontaneous. There may also be a nagging or painful sensation in the groin or a strangulated, painful groin mass.

Examination

Observation of the bulge with the patient coughing while standing and when lying down, and with a finger invaginated into the external ring, repeating the same examinations. This examination is able to differentiate femoral from inguinal hernia. There is no great advantage of differentiating indirect from direct inguinal hernia, pre-operatively.

Management

Admit for

1. Emergency surgery if obstructed or incarcerated.

• Urgent surgery for children under 1 year.
• Elective admission for others

1. Emergency surgery after resuscitation (if emergency surgery is not possible at the hospital refer to next level).
2. Preoperative preparation as for the preoperative section.
3. In strangulation, with obstruction of viscus,  especially bowel the usual resuscitative measures are carried out/continued before and after surgery. (see details as per obstruction above).
4. Elective surgery for non complicated cases.
5. Surgical repair is necessary for non complicated cases.
6. Surgical repair is necessary for all inguinal hernias.
7. Umbilical, incisional, and lumbar hernias require similar treatment as above.

 

LOWER GASTROINTESTINAL BLEED

This may be frank bleeding depending on the cause. Common causes are:

1. Haemorrhoids
2. Anal fistulae and fissures
3. Tumours: Bening(leiomyoma, fibromas, polyps) or malignant
4. Trauma
5. Angiodysplasia
6. Bleeding disorder

Investigations

1. Haemoglobin, white blood count, packed cell volume.
2. Stool for microscopy, culture and sensitivity
3. Abdominal ultrasound.
4. Barium enema(double contrast)
5. Proctoscopy/Sigmoidoscopy and biopsy

Management

1. Do blood group cross match and transfuse if necessary.
2. Continue with resuscitation.
3. Identify and treat primary pathology.