Chapter 89 Hernia (Inguinal) and Hernia Repair
PATHOPHYSIOLOGY
An inguinal hernia is generally the result of a patent processus vaginalis caused by congenital weakness or failure of the processus vaginalis to close. Normally the layers of the proximal portion of the processus vaginalis atrophy around the eighth month of gestation, and the peritoneal cavity is then closed off from the inguinal canal. Failure of the processus vaginalis to close allows abdominal fluid or contents (such as intestine) from the abdominal cavity to enter the inguinal ring and possibly the scrotum.
A communicating hydrocele is present if only fluid from the peritoneal cavity enters the scrotal sac. Although present at birth, the hernia may not be detected for several weeks, until enough abdominal pressure is built up and opens the sac. The child is initially seen with an intermittent lump or bulge in the groin, the scrotum, or the labia. It becomes prominent with intraabdominal pressure such as that resulting from crying or straining. Contents of the hernia sac usually can be reduced with gentle pressure. Surgical repair (herniorrhaphy) is usually performed on an outpatient basis. Early repair eliminates the risk of incarceration.
INCIDENCE
1. Of full-term newborns, 3.5% to 5% will have an inguinal hernia. Incidence of bilateral hernias approaches 50% in premature and low birth weight infants. The majority of infantile inguinal hernias are diagnosed in the first month of life.
2. If premature infants, incidence ranges from 9% to 11% and as high as 30% in very low birth weight infants.
3. Incidence is highest during infancy (more than 50%), with the remaining cases generally occurring before 5 years of age.
4. Boys are affected more frequently than girls at a ration of 5:1 or 6:1.
5. Sixty percent of hernias occur on the right side, 30% on the left side, and 10% bilaterally.
SURGICAL MANAGEMENT
Children with reducible hernias are scheduled for elective surgery on an outpatient basis. A 1- to 2-cm transverse incision is made in the area overlying the inguinal canal. Children with suspected incarcerated hernias are admitted to the hospital, with immediate surgical repair performed to avoid bowel necrosis and, in boys, testicular infarction. Postoperatively these children are observed for at least 24 hours to be assessed for adequate return of gastrointestinal function and to receive prophylactic intravenous antibiotics. Analgesic medications are used for pain management, oral feedings are begun when adequate peristalsis is established, and the wound is often covered with a protective sealant after surgery.
NURSING INTERVENTIONS
Postoperative Care
1. Monitor child’s clinical status.
2. Monitor for signs and symptoms of complications.
3. Promote nutritional and fluid intake.
4. Promote and maintain respiratory function.
5. Alleviate child’s pain as needed.
6. Provide and reinforce information given to parents about child’s condition.
Discharge Planning and Home Care
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Hockenberry MJ, et al. Wong’s nursing care of infants and children, ed 7. St. Louis: Mosby, 2004.
McCollough M, Sharieff GQ. Abdominal pain in children. Pediatr Clin North Am. 2006;53(1):107.
McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am. 2003;21(4):909.
