Background

A hydrocele is a collection of fluid within the processus vaginalis (PV) that produces swelling in the inguinal region or scrotum. An inguinal hernia occurs when abdominal organs protrude into the inguinal canal or scrotum. Inguinal hernia and hydrocele share a similar etiology and pathophysiology and may coexist. In the healthy male neonate, the testicle is surrounded by a closed cavitythe tunica vaginalis (TV) of the scrotum. In postnatal life, this is a potential space that should not communicate with the peritoneal cavity of the abdomen.

Pathophysiology
During fetal development, the testicle is located below the kidney, within the peritoneal cavity. As the testicle descends through the inguinal canal and into the scrotum, it is accompanied by a saclike extension of peritoneum, otherwise known as the PV. After the testicle descends, the PV obliterates in the healthy infant and becomes a fibrous cord with no lumen. The distal tip of the PV remains as a membrane around the testiclethe tunica vaginalis. Normally, the inguinal region and scrotum should not connect with the abdomen. Neither abdominal organs nor peritoneal fluid should be able to pass into the scrotum or inguinal canal. If the PV does not close, it is referred to as a patent processus vaginalis (PPV). If the PPV is small in caliber and only large enough to allow fluid to pass, the condition is referred to as a communicating hydrocele. If the PPV is larger, allowing ovary, intestine, omentum, or other abdominal contents to protrude, the condition is referred to as a hernia. Multiple theories exist regarding the failure of PV closure. Smooth muscle has been identified in PPV tissue but not in normal peritoneum. The amount of smooth muscle present may correlate with the degree of patency. For example, higher amounts of smooth muscle have been found in hernia sacs than in the PPV of hydroceles. Investigation continues to determine the role of smooth muscle in the pathogenesis of this condition.

Epidemiology
Frequency
United States The incidence of hernias is 10-20 per 1000 live births and is much more common following premature birth. While hernia location is more common on the right side, as many as 10% are bilateral.

Mortality/Morbidity
The greatest risk associated with a hernia involves an intra-abdominal organ becoming trapped within the hernia sac. This condition is referred to as incarceration of the organ. If bowel becomes incarcerated, it may become edematous. The increased pressure may impair venous drainage, leading to more edema, which may impair arterial inflow of the bowel. This can ultimately cause bowel ischemia and possible rupture.

In a male, pressure on the spermatic cord by an incarcerated hernia may affect blood flow to the testis. When perfusion of the bowel is affected, a strangulated hernia exists. A strangulated hernia can lead to perforation of the entrapped bowel, peritonitis, sepsis, and even death. As such, an incarcerated or strangulated hernia is a surgical emergency. If a strangulated bowel is reduced surgically at an early stage, viability may be preserved, and bowel resection may be avoided. In children with a painful nonreducible hernia, incarceration should be suspected, necessitating emergency evaluation. The omentum may become entrapped in a hernia, causing chronic abdominal pain with a persistent inguinal mass. In females, the ovary or fallopian tube can enter hernia sacs and become incarcerated or strangulated. An incarcerated ovary is an urgent problem that may result in inguinal pain and infarction of the ovary. An incarcerated ovary does not carry the same risk of sepsis as is seen with bowel incarceration and perforation.

Sex
Hernias are 6 times more common in boys than in girls. Bowel incarceration is more common in females than in males. In females, an ovary or fallopian tube incarcerates more frequently than bowel. Therefore, the overall incidence of bowel strangulation is lower in females than in males.

Age
The incidence of PPV decreases with age. In newborns, 80%-94% have a PPV. Hernias are 20 times more common in premature infants who weigh less than 1500 g than in babies born at term. As many as 30% of adults are discovered to have a PPV at autopsy. Why all PPVs do not develop into a hernia or hydrocele is not understood.

History
A bulge in the groin or scrotal enlargement is the classic presentation of hernia or communicating hydrocele. Pain is generally not a prominent feature but may occur if a hydrocele expands quickly; tension in the wall may cause milder pain. Severe pain raises concern about a strangulated hernia. Very rarely, a hydrocele may become infected and cause pain. Frequently, parents report an intermittent bulge. The bulge may reduce at night in the supine position. A history of vomiting, colicky abdominal pain, or obstipation suggests bowel obstruction, which may occur with an incarcerated or strangulated hernia.

Physical
Examine the child in the supine and standing positions. If a bulge is apparent in the standing position, lay the child in the supine position. Resolution of the bulge in the supine position suggests a hernia or a hydrocele with a patent processus vaginalis (PPV).

If the bulge is not readily apparent, perform a maneuver to increase intraabdominal pressure. For example, have the child simulate blowing up a balloon, cough, or press firmly on the abdomen. Restraining a baby's hands above his or her head causes the baby to struggle, potentially revealing an occult bulge that is not visible otherwise. Transillumination of the scrotum displays fluid in the tunica vaginalis, suggesting a hydrocele. However, this test does not fully exclude a hernia, as the bowel may also transilluminate. Bowel sounds in the scrotum are strongly suggestive of a hernia. A bulge below the inguinal ligament is suggestive of lymphadenopathy. Examiners may try to elicit the "silk glove" sign. Gently passing the fingers over the pubic tubercle may reveal a PPV. The thickened cord of a hernia or hydrocele sac within the spermatic cord provides the feel of 2 fingers of a silk glove rubbing together. Unless a PPV results in hernia or hydrocele, it often goes undetected during physical examination.

Causes
Most hernias and hydroceles in children are due to idiopathic failure of the PV to close. Any condition that increases intraabdominal pressure can delay or inhibit this closure.

The following is a list of conditions associated with a higher incidence of hernia or hydrocele: o Cryptorchid testis o Hypospadias o Ambiguous genitalia o Epispadias and exstrophy of the bladder o Ventriculoperitoneal shunt o Liver disease with ascites o Abdominal wall defects o Continuous ambulatory peritoneal dialysis o Prematurity o Low birth weight o Family history of hernia or hydrocele o Hydrops o Meconium peritonitis o Chylous ascites o Cystic fibrosis o Connective tissue disease o Mucopolysaccharidosis Reactive hydroceles result from inflammation and fluid accumulation in the tunica vaginalis around the testicle, even though the PV is closed. A reactive hydrocele can result from the following factors: o Trauma o Torsion o Infection (eg, epididymo-orchitis) o Abdominal or retroperitoneal operations that impair lymphatic drainage Hernia classification o Indirect hernias protrude through the internal inguinal ring, lateral to the inferior epigastric vessels. They are caused by failure of the PV to obliterate.

Most inguinal hernias in children are the indirect type. The hernia may extend down the inguinal canal toward the labia or scrotum. o Complete inguinal hernias are indirect hernias that extend into the scrotum. The anatomic defect is similar to the defect of a communicating hydrocele, although the PPV is more widely patent in hernias. o Direct hernias protrude directly through the floor of the inguinal canal and are medial to the inferior epigastric vessels. In children, these hernias are rare and are usually observed only after prior inguinal surgery. Hydrocele classification o Communicating hydroceles involve a PPV that extends all the way into the scrotum. In this case, the PPV is continuous with the tunica vaginalis, which surrounds the testicle. The anatomic defect is identical to the defect with an indirect hernia; however, the communication is smaller, so only fluid can pass into the PPV. o Noncommunicating hydroceles contain fluid confined to the scrotum within the tunica vaginalis. The PV is obliterated so the fluid does not communicate with the abdominal cavity. Such hydroceles are common in infants, and the hydrocele fluid is usually reabsorbed before the infant is aged 1 year. o Reactive hydroceles are noncommunicating hydroceles that develop from some inflammatory condition in the scrotum, such as trauma or infection. o Hydrocele of the cord occurs when the PV obliterates above the testicle. A small communication with the peritoneum persists, and the PV may be open as far down as the top of the scrotum. A saclike area within the inguinal canal fills with fluid. The fluid does not extend into the scrotum. o Hydrocele of the canal of Nuck occurs in girls when fluid accumulates within the PV in the inguinal canal. o Abdominoscrotal hydrocele results from a miniscule opening in the PV. Fluid enters the hydrocele and becomes trapped. The hydrocele continues to enlarge and eventually bulges upward into the abdomen, causing a fluid-filled mass in the abdomen.

Laboratory Studies
Laboratory evaluation is generally not essential to the evaluation of hydroceles and hernias.

Leukocytosis may be a sign of a strangulated hernia. Leukocytosis with a higher percentage of neutrophils suggests an infectious and/or inflammatory process (eg, epididymo-orchitis).

Imaging Studies
Indications for scrotal or inguinal ultrasound

Suggestion of torsion of a testicle or ovary (use duplex ultrasonography to evaluate blood flow) Suggestion of tumor of the spermatic cord Suggestion of tumor of the testicle Trauma and concern about testicular rupture

Role of ultrasonography in the evaluation of asymptomatic patent processus vaginalis (PPV)

As noted above, PPV can be difficult to diagnose with physical examination. When a unilateral inguinal hernia is discovered on physical examination, the chance of PPV on the contralateral side can be as high as 63% in children younger than 2 months. This prevalence decreases with age. Up to 20% of patients develop an inguinal hernia on the contralateral side, but it is controversial whether to proceed with any type of imaging preoperatively or exploration at the time of surgery. This has encouraged interest in ultrasonography to assess a contralateral PPV in the preoperative period. Research studies have shown a positive correlation between ultrasonography findings of PPV and intraoperative findings of PPV. The false-negative rate (ie, ultrasonography findings are normal, even when a proven PPV exists) is unknown. Further research with this modality may clarify the risk of developing a contralateral hernia later, but, at present, ultrasonography is not considered to be routine in the evaluation of any type of PPV.

Abdominal plane films are used to rule out bowel obstruction due to an incarcerated or strangulated hernia.

Procedures
Manual reduction of incarcerated hernias: Necrotic bowel is usually so swollen that it cannot be reduced manually. An incarcerated hernia can progress to perforation in as few as 2 hours. For these two reasons, parents and primary care physicians are encouraged to reduce hernias. Surgical consultation is critical even if the hernia is reduced successfully. In the emergency department, manual reduction of incarcerated hernias incorporates the following procedure:

Administer sedation to the child. Elevate the child's buttocks and apply a padded ice pack to the inguinal area to reduce swelling. Slowly compress the hernia at its most distal aspect while holding 2 fingers of the opposite hand at the neck of the hernia sac, at the level of the internal inguinal ring. This technique prevents the hernia from being pushed alongside the inguinal canal. Maintain pressure continuously. Ten or more minutes of slow continuous pressure is often required. The hernia should slide slowly back into the abdomen. A child who has undergone incarcerated hernia reduction should be observed closely after this procedure. Rarely, necrotic bowel can be reduced back into the abdomen. This bowel may then perforate and result in peritonitis, which requires emergency exploration with resection of the necrotic bowel to avoid sepsis.

Medical Care
No medical therapy is effective for a hernia or a communicating hydrocele. Aspiration and injection of sclerosing agents have been recommended for noncommunicating hydroceles in adults, but this therapy is relatively contraindicated in children. Because most hernias and hydroceles in children are associated with a patent processus vaginalis (PPV), sclerosing agents may damage intraabdominal contents and are not likely to correct the underlying

pathology. Anti-inflammatory agents may be used in the setting of a reactive hydrocele. Antibiotic therapy is often prescribed for infectious epididymo-orchitis with a reactive hydrocele. Hydroceles following varicocelectomy: A recent study found that hydroceles can develop in up to 12% of children undergoing surgery for varicocele, and the incidence varies with the type of procedure performed. Preservation of the lymphatic vessels at the time of surgery reduces the risk of later hydrocele. Conservative management (observation or aspiration) results in resolution of 80% of these hydroceles. Surgical correction was required in only one third of these hydroceles that occurred following varicocelectomy.[1]

Surgical Care
Hernias and hydroceles are similar, but their natural histories differ. Spontaneous closure does not occur in frank hernias, and the risk of incarceration is significant. In particular, a great risk of incarceration exists in premature children. As many as 60% of hernias in premature infants incarcerate within the first 6 months after birth and thus hernias should be corrected as soon as possible in these babies. For these reasons, surgical repair is generally accepted as the appropriate treatment for an inguinal hernia in children and adults.[2, 3, 4] Unlike hernias in infants, many newborn hydroceles resolve because of spontaneous closure of the PPV early after birth. The residual noncommunicating hydrocele does not wax and wane in volume, and no silk glove sign is present. The fluid in the hydrocele is usually reabsorbed before the infant reaches age 1 year. Because of these facts, observation is often appropriate for hydroceles in infants.

The following factors indicate hydrocele repair: o Failure to resolve by age 2 years o Continued discomfort o Enlargement or waxing and waning in volume o Unsightly appearance o Secondary infection (very rare) A hernia or hydrocele may protrude intermittently. Not infrequently, a bulge in the child's groin is noted by the parents or a primary care physician. Often, this bulge cannot be reproduced during a consultation, but thickening of the spermatic cord structures on the same side with a history of a bulge or a "silk glove" sign is suggestive of a PPV. Such a situation is sufficient indication for inguinal exploration. A photograph of the area when the bulge is present may help clarify the diagnosis. Specific conditions or demographics and timing of surgery o If an incarcerated hernia cannot be reduced or signs suggest that the hernia is strangulated, schedule surgery emergently. o In full-term infants with no history of incarceration, schedule surgery as soon as possible on an outpatient basis. o For preterm neonatal intensive care unit (NICU) infants weighing 1800-2000 g, schedule surgery before hospital discharge. o For formerly premature infants younger than 60 weeks postconceptual age, schedule surgery as soon as possible with 24-hour postoperative monitoring for apnea and other anesthesia-related complications. Intraoperative details o Examine the child to confirm presence of testes.

Make a small inguinal incision. Enter the inguinal canal and dissect the PV, which is the hernia sac or hydrocele sac, free of the vas deferens and vessels. Optical magnification is beneficial especially in premature infants and small children. o Reduce the sac contents (ie, abdominal organs, fluid) into the abdomen if the sac contents appear normal. o If the contents of the sac appear compromised or cannot be reduced, open the sac and enlarge the inguinal ring. Ischemic bowel may show improvement in vascularity. Necrotic contents should be resected. o Ligate the sac at or above the internal ring. o If the lesion involves the testicle, the testicle is delivered into the incision, and the distal end of the sac is excised or everted around the testes (Bottle operation). These procedures are advised to avoid the later development of a postoperative noncommunicating hydrocele. o Reposition the testis in the scrotum. If the testis does not remain in the bottom of the scrotum, cryptorchidism may be present and orchiopexy should be performed at that time. o Inspect the internal ring to ensure that any abdominal contents are reduced completely. o Reinforce the internal ring if it was opened or if it appears larger than normal caliber. o Local anesthesia may be injected subcutaneously, or an inguinal nerve block may be performed. o Sew the fascial layers and skin closed. Contralateral exploration with inguinal hernias is performed as indicated. o When an inguinal hernia is present, some urologists and surgeons perform a contralateral groin exploration. This is intended to detect an occult PPV (5% of cases) that may lead to a hernia on the opposite side (metachronous contralateral hernia.) o The Goldstein test can be used to determine when to perform a contralateral exploration, but this may not be conclusive. In this test, the abdomen is insufflated with air or gas through the hernia sac, which is opened during surgery. Crepitus in the opposite groin is a positive test result, suggesting a contralateral PPV and warranting a contralateral exploration. Alternatively, a laparoscope can be used to detect an occult contralateral PPV. Laparoscopy has an evolving role in hydrocele and hernia surgery. o As mentioned above, exploratory laparoscopy may be carried out through a separate incision at the umbilicus or through the hernia sac, once it has been opened. This allows inspection of the contralateral inguinal ring and assessment of patency. Additional procedures may then be performed as needed. o Laparoscopic hernia repair in children is not performed as commonly as in adults. Several European centers have used a technique in which the hernia sac is not excised but rather simply closed at the neck with suture. Mesh is not used as commonly in children as it is in adults. Results to date are favorable, although recurrence rates are higher than with open repair. o A series by Kaya et al from Germany (2006) reported favorable results with the laparoscopic approach compared with reduction and repair of incarcerated inguinal hernias in children. They reported no complications and no

o o

recurrences. However, the details and length of follow-up were not clearly defined.[5]

Activity
Convalescence following hernia or hydrocele surgery is usually straightforward.

Pain control o Infants - Ibuprofen 10 mg/kg every 6 hours; acetaminophen 15 mg/kg every 6 hours; avoid narcotics in young babies because of the risk of apnea o Older children - Acetaminophen with codeine (1 mg/kg of codeine) every 6 hours For 2 weeks after surgery, straddle positions (eg, bicycle) should be avoided to prevent displacement of the mobile testes out of the scrotum, which could become entrapped by fibrous tissue, causing secondary cryptorchidism. In children of ambulatory age, vigorous activities should be limited as much as possible for 1 month. In children of school age, strenuous activities and active sports should be limited for 4-6 weeks. Because most hernia and hydrocele surgeries are performed on an outpatient basis, the patient may return to school as soon as comfort level allows (usually 1-3 days postoperatively).

Further Inpatient Care

Postoperative details: Formerly premature infants younger than 60 weeks postconceptual age should be admitted for 24 hours to monitor for apnea and other anesthesia-related complications.

Complications
The overall operative complication rate associated with hydroceles and hernias is 1.7%-8%.

Infertility may result from bilateral injury to the vas deferens or injury to the vas of a solitary testis. Presence of a vaslike structure in the pathology specimen does not necessarily indicate injury to the vas, as up to 6% of specimens contain mllerian ductal remnants with a histologic appearance very similar to the vas. An incarcerated hernia may compromise blood flow to the testicle prior to surgery. The rate of testicular atrophy after repair of an incarcerated hernia can be as high as 19%. Testicular atrophy may also result from intraoperative injury to the testicular blood supply. As with any surgery, hematomas may occur. A hematoma usually does not need to be explored unless the hematoma continues to enlarge or becomes infected. Scrotal elevation is encouraged, and analgesics are administered. As in any surgery, wound infections can occur. Hypesthesia and neuropathic pain can result from nerve entrapment or injury. Secondary cryptorchidism may result from excessive scar formation and ascent of the testicle with growth.

Recurrence of the hydrocele may be seen in less than 5% of cases. If the hydrocele does not disappear spontaneously after one year, reoperation is indicated.

Prognosis
With open surgery, ipsilateral recurrence rates are less than 1%. The ipsilateral recurrence rate following laparoscopic inguinal hernia repair is 3.4%. Recurrences are usually associated with comorbid conditions. The occurrence of a metachronous contralateral hernia is inversely related to age and can be as high as 12%.
http://emedicine.medscape.com/article/1015147-followup#showall

Pediatric Hydrocele and Hernia Surgery Follow-up

Author: Joseph Ortenberg, MD; Chief Editor: Marc Cendron, MD