Hernia repair or herniotomy
Has your child been diagnosed with a hernia or communicating hydrocele?
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Then it’s possible they have been scheduled for a procedure called a herniotomy or hernia repair.
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Why repair a hernia or communicating hydrocele?
As you may know, a “hernia” or “communicating hydrocele” in children arises when a connection between the abdomen and the scrotum/groin, which was supposed to close around the time of birth, has not closed.
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As a result, some fluid from the inside of the abdomen can make its way into the groin or even down to the scrotum. This is called a communicating hydrocele.
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Sometimes, it’s not just fluid but actual abdominal contents that can go into the groin or scrotum (or the labia in females). Frequently this involves a piece of small intestine or bowel, or fat (“omentum”) from the abdomen. Sometimes this can even involve other organs like the bladder, or the ovaries in female patients. When an organ, and not just fluid, travels into the groin, scrotum, or labia, this is called a hernia.
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Because of this, parents and patients can notice the following:
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A recurring bulge in the groin, labia, or scrotum
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The bulge often starts as something that can be “reduced” or put back into the abdomen
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The bulge can be painful sometimes, particularly after heavy activity or prolonged standing
In urgent or emergency situations, the bulge cannot be reduced or put back. This then involves the risk of an organ, like a piece of intestine, getting stuck (“incarceration”) and losing its blood supply (“strangulation”). The patient’s gut also becomes blocked. This is very painful, and very dangerous.
When should the hernia or hydrocele be repaired?
Often, when a child is diagnosed with a hernia or with a large communicating hydrocele, we already advise to do a herniotomy.
This is precisely to avoid emergency situations of incarceration or strangulation.
In cases of large or obvious hernias, this should be repaired soon after diagnosis. In some centers, repairs are even done shortly after birth for neonates due to the high risk of an emergency.
In communicating hydroceles that are not so large, the timing for surgery can be more of a grey area. Very large hydroceles should be repaired soon after diagnosis, but small hydroceles may sometimes still close for periods of as long as the first 18 to 24 months. Parents should have a good and open discussion with their surgeons about their child’s individual case.
Unfortunately, if an incarceration or strangulation happens, the child will need an urgent reduction at the emergency room and possible surgery.
Does the child need to be admitted? What type of anesthetic is needed?
In many parts of the world, a herniotomy is either done as a “day procedure” or an “overnight” procedure.
A day procedure means that the child, especially one who is otherwise healthy, goes home on the same day. An overnight procedure means the child is admitted overnight and goes home the next day, usually because they need some observation for different reasons.
Your anesthesiologist will talk to you and your child about the best options for anesthetic. This depends on their age, their overall health, what the surgeon needs to do, and how long the child should be monitored after surgery.
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Children typically need a general anesthetic, so that they will not move during the operation.
In general, this anesthetic is very safe. Please don’t be afraid to ask your anesthesiologist about specific concerns you may have for your child.
What happens during surgery?
A small cut is made in the groin.
This allows the surgeon to identify the connection that causes the hernia or hydrocele, called the “patent processus vaginalis” (or canal of Nuck in females).​​​
After making sure that all bowel or organs are safe and in their proper place, the surgeon ties off this connection, then closes all the skin layers.
These days, the sutures for closing skin are normally absorbable. They do not need removing in the clinic as the sutures will melt into the skin.
A sterile dressing or surgical glue are typically placed after closing the wound.
Do kids also need a hernia mesh?
Many adults who undergo hernia repair also undergo placement of a mesh. This is a synthetic material used to reinforce a hernia repair.
The mesh helps to address weakness of the muscles that support the abdomen, and is important in preventing a recurrence of the hernia in adults.
However, children and teens typically do not need a mesh. For most children, closing of the processus vaginalis is enough. When operating on children, surgeons are usually concerned that the mesh can react with local tissues in the area, and cause complications like infertility, chronic pain, and contracture.
Thus we tend to avoid placement of meshes in children and in most adolescents.
Can laparoscopy or robotics be used for repair?
Laparoscopy and robotics can definitely be used for hernia repair in children and adolescents. They are particularly useful in cases where the hernia or hydrocele is in both sides, or if the patient has had previous hernia repair or needs a “redo” surgery.
Talk to your surgeon about your options for minimally invasive surgery. In general, what is important is the expertise or comfort of the surgeon in doing surgery, as well as the specific needs of the patient.
What are the risks?
The procedure is relatively safe. However complications are not 0%. They can include
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Infection
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Wound breakdown because of infection
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Bruising
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Bleeding and hematoma
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Damage to surrounding structures, including the bladder
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Recurrence of the hernia and need for additional surgery
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Reactions to anesthesia
Bruising of the area, and swelling of the groin (or the scrotum or labia) for up to many weeks is a normal part of healing.
Red flags for return to the emergency room usually include
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Fever
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Vomiting, inability to eat, signs of dehydration
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Massive or quick bleeding from the wound
How do I take care of my child after a herniotomy?
Every surgeon chooses a different dressing and different types of aftercare after herniotomy. The dressing can range from waterproof dressings, surgical glue that dries down like a plastic covering, and gauze with medical tape. What is important is that you discuss the aftercare with your surgeon.
In general, we avoid getting the wound directly wet with running water for the first week of surgery, and it helps to have some covering on the wound. Still, we encourage sponge baths or showers early on, since keeping clean is important to avoid infection.
Make sure to check the wound daily for discharge or signs of infection.
Swelling is normal. In the first two days, a cold compress to the scrotum may help reduce the swelling.
In general, there is no restriction on what to eat.
If a child is able to avoid heavy exercise, or activities that put pressure on the groin, then all the better. This means we generally ask our patients to avoid biking, swimming, jogging, or other heavy exercise. They are allowed to go about usual activities like going to school, sitting up straight, or walking short distances.
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Follow-up with your surgeon focuses on checking how the wound is healing, as well as watching out for return or recurrence of the hernia.
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The information in this infographic is for general information purposes only.
We encourage you to seek an individualized consult for the most appropriate management. You may book an appointment with us or with your preferred pediatric urologist or pediatric surgeon.
Please feel free to send us a message for questions on pediatric urologic health!
