Congenital inguinal hernia.

Congenital inguinal hernia is a protrusion of nearby elements of internal organs into the inguinal canal, which is an anomaly from birth. Most often, an intestinal loop and part of the omentum can get into the inguinal sac, less often - a testicle, a round uterine ligament, a section of the bladder, etc. Such pathology can occur independently or in combination with other anomalies. For example, with such defects as hydrocele or pathology of the spermatic cord.

ICD 10 code

• K00-K93 Diseases of the digestive system.
• K40-K46 Hernias.
• K40 Inguinal hernia.
• K40.0 Bilateral inguinal hernias with obstruction.
• K40.1 Bilateral inguinal hernias with gangrenous complication.
• K40.2 Bilateral inguinal hernias, uncomplicated.
• K40.3 Unilateral or undiagnosed inguinal hernias with obstruction.
• K40.4 Unilateral or undiagnosed inguinal hernias with gangrenous complication.
• K40.9 Unilateral or undiagnosed inguinal hernias without complications.

Causes of congenital inguinal hernia and pathogenesis

A congenital inguinal hernia is formed due to the existence of an inguinal canal inside the human body. The canal originates in the middle of the abdominal cavity, passes inside along the anterior wall of the abdominal press, then is located inward and downward, forming an opening slightly above the scrotum in the male body, or above the labia in the female body.

This opening is considered a pathology. The inguinal canal is formed from muscles and ligaments. Under normal circumstances, the male spermatic cord or the female round uterine ligament passes through it. However, in some cases, a hernial sac can come out through this canal. What contributes to this:

• congenital weakness of the abdominal wall;
• failure of tissue to heal after the testicle has descended into the scrotum.

As is known, congenital inguinal hernia is found in boys approximately 20 times more often than in girls. This is explained by the peculiarities of the male body anatomy. At the same time, the percentage of pathology in premature babies is much higher.

Firstly, the vaginal peritoneal process, which can be imagined as a tubercle of the parietal region of the peritoneum (blind sac), plays a major role in the development of hernia. This process, together with the testicle, must move into the scrotum, and all these actions take place during the growth of the fetus in the womb. The listed processes largely depend on hormonal changes in the body, and if any disorders occur, non-closure of the vaginal process and retention of the testicle in the inguinal canal may be observed. As a result, the child develops a hernia, and at the same time, as a rule, a hydrocele or cystic formation of the spermatic cord occurs.

Congenital inguinal hernia in girls is extremely rare. This can be explained by the fact that in girls the lumen of the inguinal canal is much narrower, and there is already a round uterine ligament in it. However, in rare situations the vaginal process may not close, and the opening will remain free. This phenomenon is called "formation of the Nuckie canal" and it is in it that the ovary may end up.

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Symptoms of congenital inguinal hernia

The first signs of a hernia appear in children immediately after birth. The main thing that can be noticed when examining a child is an incomprehensible protruding lump in the groin area, which looks like an elongated swelling running along the inguinal canal. The hernia has a soft and elastic consistency, is painless and practically does not cause discomfort to the baby.

At rest and in a lying position, the protrusion "hides", creating the appearance of the absence of pathology. In such a situation, the disease can be recognized by the compaction of the spermatic cord, which can be noticed during a thorough examination. This symptom is called the "silk glove symptom".

However, when the child takes a vertical position, or strains, laughs, cries, the inguinal hernia becomes much more noticeable.

In girls, the protrusion may appear as unilateral or bilateral swelling of the labia majora.

An incarcerated inguinal hernia may manifest itself with the following symptoms:

• it becomes difficult to palpate the hernia (the child cries and screams);
• the hernia cannot be reduced on its own;
• the child experiences nausea (regurgitation), then vomiting, increased gas formation and constipation.

In boys, the object of strangulation is usually a loop of intestine, and in girls, an appendage.

Consequences

Complications of congenital inguinal hernia may include the following:

• infringement is the most common consequence, which can only be eliminated surgically;
• necrosis of organs trapped in the strangulated hernial sac - intestinal loops, sections of the omentum, appendage or fallopian tube;
• peritonitis - an inflammatory reaction affecting the entire abdominal cavity (can also occur as a result of strangulation);
• acute attack of appendicitis – an inflammatory reaction in the appendix, which occurs as a result of compression of the vessels of the appendix by the inguinal ring;
• Symptomatic consequences of an inguinal hernia may include digestive disorders, bowel dysfunction, flatulence, etc.

The most serious complication is considered to be strangulation of the hernia - such a situation requires urgent medical attention, with hospitalization and emergency surgery.

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Diagnosis of congenital inguinal hernia

Diagnostic procedures for congenital hernia begin with an examination by a pediatric surgeon. The doctor will evaluate the problem from the outside, perform palpation in different positions of the child.

By palpation, the nature of the internal composition of the hernial protrusion is determined:

• the intestinal loop has an elastic and flexible consistency, and a rumbling sound may be heard during palpation;
• the omentum area is softer, with a lobular structure;
• The testicles that are trapped in the hernial sac, on the contrary, are the most dense.

The doctor determines the possibility of reducing the hernia using a finger. When listening to the area of the protrusion containing the intestinal loop, peristaltic movements can be felt.

The type of contents can be clarified using X-ray of the gastrointestinal tract, as well as ultrasound of the hernia.

Instrumental diagnostics may also include the following types of research:

• ultrasound examination of the scrotum, which allows you to determine the contents of the sac (fluid or intestinal section). Additionally, ultrasound can be used to distinguish a hernia from a hydrocele;
• Diaphanoscopy is a procedure for transilluminating the scrotum - a simple and accessible diagnostic method. If the contents of the sac are liquid, the rays penetrate through it without problems. A denser structure will not let the rays through, and the light will look dim and uneven.

In addition, before starting treatment, the doctor will prescribe general clinical tests:

• blood and urine analysis;
• blood biochemistry;
• blood for hepatitis, AIDS, syphilis;
• blood clotting analysis.

Differential diagnosis is mainly carried out with hydrocele or enlargement of the inguinal lymph nodes.

With hydrocele, there is a marked increase in the swollen part of the scrotum. The cough impulse is not confirmed. The scrotum increases in size during the day, and at night (during rest) its volumes normalize.

The enlargement of the lymph nodes is accompanied by their compaction, and at the same time the temperature rises. The skin over the affected lymph nodes turns red and becomes hot to the touch.

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Treatment of congenital inguinal hernia

During the examination, the doctor must decide whether to treat the child's hernia immediately or postpone it for several years. Optimally, the operation should be performed at the age of 6 to 8 months, or after 5 years.

Treatment of hernia is mandatory, since this disease does not go away on its own. That is why conservative and folk treatment of hernia is considered a waste of time and money - the only radical means of getting rid of the pathology is surgical intervention.

A century ago, doctors confidently declared that they had found a conservative method for treating inguinal hernia. They provided specially developed medications that were supposed to be injected into the hernial sac, causing its walls to collapse and scar. This method was difficult to use, quite expensive and time-consuming. However, doctors were later forced to abandon this procedure, as numerous side effects of this conservative method were discovered:

• development of inflammation after injection;
• the appearance of cicatricial changes also in the spermatic cord;
• the possibility of simultaneous damage to nearby vessels.

After a number of unsuccessful attempts, specialists were forced to admit that the only successful procedure for eliminating an inguinal hernia would be surgery.

The only method of conservative therapy that is still used today is the use of a bandage.

Indications for wearing a bandage are:

• impossibility of carrying out the operation at the given time;
• recurrence of hernia after surgery;
• the presence of contraindications to surgery (for example, poor blood clotting).

The bandage does not cure the hernia radically, but only serves as a preventative measure against its further growth and strangulation.

Surgery for a congenital inguinal hernia in a child is most often performed in the following way:

• General anesthesia is administered;
• an incision is made in the groin at the site of the inguinal ring where the hernial sac descends;
• the doctor separates the sac and the testicle, since they are basically glued to each other;
• The surgeon then makes an incision in the hernial sac and examines it to ensure that it is empty;
• after this the sac is cut off and the part that comes out is tied;
• The doctor stitches up the wound – the operation is over.

If there are no individual complications, the operation does not take long – about half an hour.

Surgery in childhood has its own characteristics, which the surgeon always takes into account:

• The inguinal ring of a child is usually not yet fully formed, so over the years it can decrease in diameter. For this reason, the doctor only cuts off the sac in a child, without performing a procedure to strengthen the inguinal ring. In this regard, the operation is faster and easier;
• surgery in childhood is always performed under general anesthesia;
• in a child, the operation can be performed by making a very small incision - no more than 10-15 mm;
• For girls, the operation is even simpler. As a rule, it takes only up to 15 minutes.

Prevention

It is quite difficult to designate any preventive measures to prevent congenital inguinal hernias, since it is not known for certain what exactly and at what point in intrauterine development causes the weakening of connective tissue. Moreover, in approximately 18% of cases, congenital hernia is caused by a genetic predisposition, that is, family heredity.

During pregnancy, a woman is recommended to eat a balanced diet, avoid taking any medications without a doctor's recommendation, and eliminate all bad habits that can negatively affect the healthy development of the fetus (alcohol, smoking, drugs). It is recommended to walk more in the fresh air, eat more vegetables and fruits, and not overwork or get nervous.

Forecast

The child spends the postoperative period in the hospital under the surgeon's supervision. The doctor examines and bandages the wound daily.

As a rule, there is no need to remove the stitches: children usually have self-dissolving cosmetic stitches, which in most cases leave no scars at all.

The child fully recovers within 3-6 months after surgery.

It is important to understand that a congenital inguinal hernia cannot disappear on its own. The hernia appears due to the vaginal peritoneal process, which does not heal and does not turn into a cord. Without surgery, it will not disappear on its own and will not resolve.

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