Pediatric Inguinal Hernias,

H y d ro c e l e s , an d U n d e s c e n d e d
Tes t i c l e s
Oliver B. Lao, MD, MPHa, Robert J. Fitzgibbons Jr, MD
b
,
Robert A. Cusick, MDc,*

KEYWORDS
! Hernia ! Adolescent hernia repair ! Hydrocele ! Undescended testicle ! Orchiopexy

KEY POINTS
! Asymptomatic inguinal hernias in children require elective repair.
! Incarcerated inguinal hernias require reduction and urgent repair, whereas strangulated
inguinal hernias require emergent repair.
! Noncommunicating hydroceles may be observed up to 24 months of life, as they may spon-
taneously resolve.
! Communicating hydroceles should be treated as inguinal hernias.
! Undescended testes that are palpable in the inguinal canal should be operated on at 6 to 12
months.
! Testicles that are not palpable should undergo ultrasonography and possibly laparoscopy
to define their location.

PEDIATRIC INGUINAL HERNIA

Introduction
Pediatric inguinal hernia repair is one of the most common procedures performed by
pediatric surgeons, and has historically been considered an “intern case”; however, it
can be one of the most difficult procedures a surgeon will perform. In experienced
hands, repair can often be performed rapidly and with a low complication rate. The
American College of Surgery, in their Maintenance of Certification program, recog-
nizes 3 distinct age groups of inguinal hernia repairs: age less than 6 months, 6 months
to 5 years, and 5 years and older. This scale reflects the increasing difficulty of this
procedure with decreasing age. Age less than 6 months increases the likelihood of

The authors have nothing to disclose.

a
Department of Pediatric Surgery, Children’s Hospital and Regional Medical Center, University
of Nebraska College of Medicine, 8200 Dodge, Omaha, NE 68114, USA; b University of
Nebraska College of Medicine & Children’s Hospital & Medical Center, 8200 Dodge Street,
Omaha, NE 68114, USA; c Department of Surgery, Children’s Hospital and Regional Medical
Center, University of Nebraska College of Medicine, 8200 Dodge, Omaha, NE 68114, USA
* Corresponding author.
E-mail address: [email protected]

Surg Clin N Am 92 (2012) 487–504

doi:10.1016/j.suc.2012.03.017 surgical.theclinics.com
0039-6109/12/$ – see front matter ! 2012 Elsevier Inc. All rights reserved.
488 Lao et al

comorbidities including prematurity, complicating the decisions on timing of surgery.

In this population a surgeon also more likely needs to perform a concomitant repair of
the floor or an orchiopexy. To maintain a low complication rate, a thorough knowledge
of the anatomy and surgical techniques of the area is crucial.
Epidemiology
Inguinal hernia repair is the most frequently performed pediatric surgical operation,
with an incidence ranging from 0.8% to 4%.1 The incidence is nearly 10 times more
common in boys than in girls, and is much more common in premature babies
(13% of babies born before 32 weeks and nearly 30% of babies weighing less than
1 kg). Inguinal hernias are much more common on the right side (75%) than on the
left (25%), primarily because of the later descent of the right testicle. Nearly one-
third of cases will present before 6 months of age, and bilaterality occurs in 15% to
20% of children.2,3 As a result of these epidemiologic findings, clinicians should be
cognizant of the possibility of a contralateral hernia in children presenting unilaterally,
and this should be discussed with the parents. Risk factors for bilateral disease
include females, babies with left-sided inguinal hernias, premature babies, young
age at presentation (<1 year), and history of an undescended testicle.
Embryology of Testicular Descent
Gonads descend from the urogenital ridge, in the upper abdomen near the developing
kidneys, to the internal ring at 3 months’ gestation. The processus vaginalis then
develops from the peritoneal lining.4 At 6 to 7 months’ gestation, descent through
the inguinal canal follows the course of the gubernaculum, likely following the genito-
femoral nerve.5 Over the next 2 months, the testes come to rest in the scrotum with
a gradual obliteration of the processus vaginalis that subsequently becomes the
tunica vaginalis.6 Incomplete obliteration of the processus vaginalis is the underlying
feature of pediatric inguinal hernias and hydroceles, and their incidence is inversely
proportional to the age of the child.1,7,8 When there is complete failure of obliteration,
the result is both an inguinal and scrotal hernia. When the distal processus is obliter-
ated but the proximal one remains patent, an inguinal hernia results. Narrowing but
incomplete closure of the proximal processus results in a communicating hydrocele.
Complete obliteration of the proximal portion but partial patency of the processus
leads to a noncommunicating hydrocele (Fig. 1). Closure of the patent processus is

Fig. 1. Configurations of hydrocele and hernia in relation to patency of the processus vag-
inalis. (A) Normal; (B) hydrocele; (C) communicating hydrocele; (D) inguinal hernia; (E)
complete inguinal hernia. (From Snyder CL. Inguinal hernias and hydroceles. In: Holcomb
GW III, Murphy JP, editors. Ashcraft’s pediatric surgery, 5th edition. Philadelphia: WB Saun-
ders; 2010. p. 670; with permission.)
 Pediatric Inguinal Hernias 489

asymmetric, with the left closing earlier than the right. This asymmetry explains the
higher prevalence of right-sided hernias, hydroceles, and undescended testicles.
In females, the round ligament represents the analogous processus vaginalis. The
canal of Nuck is an outpouching of peritoneum anterior to the round ligament, and is
the location of most inguinal hernias in females, although the floor may be weak as well.

Anatomic Considerations in Children

The inguinal canal in children is much shorter than that of an adult, with resultant over-
lapping of the internal and external rings. Passage of the testicle through the canal is at
an angle from the superior and lateral internal ring to the more medially located
external ring. Because the inguinal canal is short in infants, with the internal and
external rings overlapping, some surgeons believe that opening the external oblique
in infants is unnecessary during a pediatric hernia repair. Because most childhood
hernias are related to the processus vaginalis, the floor rarely requires repair.

Diagnosis and Examination

Inguinal hernias may be asymptomatic or symptomatic. Most inguinal hernias are
minimally symptomatic and present as intermittent bulges in the groin, scrotum, or
labia, made worse by activities that cause increased intra-abdominal pressure (crying
or straining). Other children may present with vague pain in the inguinal area. Symp-
tomatic hernias may also present with incarceration (unable to be reduced) or stran-
gulation (loss of blood supply) with a resultant bowel obstruction. Although the
swelling from the hernia may not be noticed for many years, hernias in children repre-
sent congenital defects and have been present since birth.
The examination in a child should focus on the external ring just lateral to the pubic
tubercle. Standing on one side and palpating along the contralateral inguinal canal at
the external ring is the best way to examine the canal for hernias. This maneuver,
referred to as the silk glove sign, will demonstrate thickening of the cord (representing
the hernia sac) in comparison with that on the contralateral side. Although the diag-
nostic accuracy of the silk glove sign has previously been called into question, the
use of the findings of this physical examination to support the diagnosis may be
useful.8,9 If the hernia is difficult to appreciate, provocative maneuvers should be
undertaken such as standing, straining, or the performance of an age-appropriate Val-
salva maneuver (jumping). Ultrasonography of a hernia that is difficult to palpate may
help with diagnosis as well.10,11
The examination of the child with a possible hernia should (in the male) include an
examination of the testicles and scrotum. Occluding the external ring with one hand
and palpating the testicle should prevent it from ascending into the inguinal canal.
Absence of the testicle suggests an undescended or retractile testicle (see later
discussion) and likely makes the repair more difficult. In the infant female, the ovary
is the most common structure to be palpated in a hernia, and may become incarcer-
ated. Bilateral hernias in a female should raise the concern of an abnormality with
sexual differentiation, the evaluation of which is beyond the scope of this article.
If the hernia is complicated by incarceration the child will present with pain, abdom-
inal distension, and emesis. The incidence of incarceration in the pediatric population
is reported at 5% to 15% but is much higher in infants (30%).12 After an incarcerated
hernia is diagnosed, all attempts should be made at reduction of the hernia. Appro-
priate pain medication and sedation along with the Trendelenburg position may assist
in reduction. These maneuvers are successful 70% to 85% of the time.12–14 If the
hernia is easily reduced, an elective hernia repair may be scheduled on an outpatient
basis. If it is reduced with difficulty, there are some who would advocate admitting and
490 Lao et al

repairing within 24 hours. If the hernia is not reducible (incarcerated) or there is

concern for strangulation (fever, tachycardia, leukocytosis, emesis, severe pain, pro-
longed history of bulge and erythema), immediate surgery is warranted. The caveat
that dead bowel cannot be reduced must be borne in mind.

Differential Diagnosis
The differential for groin pain is substantial. However, swelling in the groin extending
into the scrotum is a limited differential. Scrotal swelling that will not reduce is either an
incarcerated hernia that is an emergency, or a noncommunicating hydrocele that can
be managed electively. An incarcerated hernia is usually erythematous, swollen, and
exquisitely tender. The rest of the history and examination are also consistent with
a bowel obstruction: vomiting and abdominal distension. If the clinical picture is
unclear, which is more common in infants, an abdominal radiograph may show the
typical findings of a bowel obstruction (Fig. 2). In this setting, ultrasonography can
also be helpful.10,11 Other entities that may mimic a hernia include testicular torsion
and torsion of the appendix testes; however, both present with the acute onset of
pain. Torsion of the testicle should have an associated scrotal mass that is not contig-
uous with the inguinal canal. Torsion of the appendix testes often has a blue-dot sign
representing the torsed, necrotic appendix testes at the superior pole of the testicle.
Enlarged inguinal lymph nodes are also on the differential.

Treatment
Although there is some variability in technique, high dissection and high ligation of the
hernia sac at the level of the internal ring remains the gold standard for repair.15,16 As
previously mentioned, this may or may not involve opening the external oblique to
obtain adequate exposure of the internal ring. Before ligation, the sac is opened to
ensure there are no contents within the sac. The distal sac is not resected because
of concern about damage to the testicle. The distal sac is instead widely opened to
prevent a postoperative hydrocele. A transient postoperative hydrocele is common
and can be very large in neonates with large hernias. In this setting, parents should

Fig. 2. Abdominal film from an infant presenting to the emergency room with scrotal
swelling. Differential included an incarcerated hernia and a hydrocele on physical examina-
tion. The film is consistent with a bowel obstruction from an incarcerated inguinal hernia.
Note the air in the right scrotal sac.
 Pediatric Inguinal Hernias 491

be counseled preoperatively. Once the sac has been ligated and the distal sac
opened, the floor of the canal is examined. In neonates with large hernias the floor
can be quite weak. In this setting, some clinicians advocate interrupted sutures to
approximate the conjoined tendon and the shelving edge of the inguinal ligament
with interrupted sutures (Figs. 3 and 4). It should be noted that mesh is rarely used
because of the historically low recurrence rates.
In girls, the hernia sac follows the round ligament. Again, the sac is opened and then
ligated at the level of the internal ring. The internal ring is then closed with interrupted
sutures by approximating the conjoined tendon and the inguinal ligament.
Timing of Repair
The timing of inguinal hernia repair is debatable, and is dependent on age and comor-
bidities. Because most hernias are asymptomatic, the principal concern is risk of
incarceration. In older children and adolescents, in whom risk of incarceration is
low, the hernia repair can be performed electively.15 The timing of infant hernia repair
is more complicated. Compared with older children, Term infants are at increased risk
of incarceration and therefore repair should be undertaken without delay.13,17 For
older term infants who are otherwise healthy, hernia repairs can be done on an outpa-
tient basis.
Preterm infants have a higher incidence of inguinal hernias (20%–30%) as well as
rates of incarceration.18–20 For preterm infants with hernias, the timing of repair is
controversial.21–27 For those infants hospitalized for prematurity, the surgeon may
choose to monitor the baby in the neonatal intensive care unit (NICU) and delay repair
until ready for discharge.19,25–29 Alternatively, the surgeon may opt to perform the
hernia repair shortly after discharge from the NICU.19,28 In this population there is
concern about apnea after a general anesthetic, therefore these patients require
apnea and bradycardia monitors overnight.30,31 Determination of which patients
require admission is based on gestational age at birth, comorbidities, and postcon-
ceptual age (ranging from 46 to 60 weeks), and varies among hospitals. Comorbidities
associated with an increased risk of apnea include lung disease, home apnea moni-
toring, anemia, and use of supplemental oxygen, as well as use of narcotics and
muscle relaxants during the operation.30,32,33 The question of whether to repair the
hernia before discharge from the newborn nursery or to wait until the anesthetic risk
of apnea subsides does not have a clear answer in the literature.25,27,28,31,32

Fig. 3. Giant neonatal inguinal hernia in the operating room before reduction of the
hernia.
492 Lao et al

Fig. 4. After reduction of the hernia. The floor of the canal was quite weak and required
reinforcement with sutures. The patient also required an orchiopexy at the same time for
an undescended testicle diagnosed at the time of surgery.

Contralateral Groin
The question of whether to explore or repair the contralateral groin was raised by
a report in 1955 citing the rate of bilateral hernias as 100% in infants and 60% in chil-
dren.34 Other reports have similarly noted the presence of a patent processus vagina-
lis on routine exploration of the contralateral side as well as the risk of a metachronous
contralateral hernia after unilateral repair. These findings led many surgeons to recom-
mended routine, bilateral groin exploration in all children with unilateral hernias.35,36
Other surgeons have pointed to the risk of injuring the vas deferens and testes bilat-
erally, and questioned the true incidence of bilaterality as reasons for not exploring
both groins.37–40 The clinical question is whether a patent processus vaginalis always
becomes an inguinal hernia. The percentage of children with a patent processus on
the contralateral side was studied with bilateral exploration, and was found to range
from 40% to 60% with apparent decline with increasing age.7,41 The percentage of
children that develops a metachronous hernia was found to be anywhere from 10%
to 30% in a group observed following a unilateral hernia repair.41–43 An autopsy study
has suggested that adults who die without a clinical hernia will have a patent proces-
sus vaginalis 15% to 30% of the time.44 Taken together, the aggregate of these
studies points toward roughly 50% of infants having a patent processus vaginalis,
with slightly fewer (w20%–40%) children having a patent processus as they progress
to adulthood.
Another option is to perform routine laparoscopic evaluation of the contralateral
groin through the hernia sac.1,8,45–47 A recent study by Lazar and colleagues45 reported
that 30% to 40% of children with clinically relevant unilateral inguinal hernias will have
a contralateral patent processus vaginalis when studied laparoscopically. It is still
unclear as to what percentage of those patent processi, visualized laparoscopically,
will progress to clinical hernias. A meta-analysis of more than 13,000 unilateral inguinal
hernia repairs in children demonstrated a 7% rate of metachronous hernia, although
a rate of 8% to 20% has been reported elsewhere.1–3,6,37,43,48,49 In an effort to reduce
the number of negative explorations of the contralateral groin, additional patient char-
acteristics such as age, sex, side, and underlying disease process have been consid-
ered.7 Risk factors for contralateral disease are infants with left hernias, early age at
presentation, and females. Also, patients with unique underlying conditions such as
 Pediatric Inguinal Hernias 493

cystic fibrosis, ventriculoperitoneal shunts, peritoneal dialysis catheters, or connective

tissue disorders are at increased risk for contralateral hernias.50 Additional testing such
as ultrasonography should be considered in these patients.10,51
In their practice, the authors do not routinely offer contralateral exploration. Selective
contralateral exploration is offered after consultation with the parents of patients who
fall into the following categories: girls younger than 5 years with a unilateral hernia, and
premature infants. In boys with a question of bilateral disease, the authors recommend
laparoscopy through the umbilicus to evaluate the contralateral side (Fig. 5).

Laparoscopic Repair
Laparoscopic inguinal hernia repair in children was first described in females in 1997
and in males in 1999.27,43,49 Multiple techniques have been described to replicate the
open repair. Most of these techniques begin with access through the umbilicus, and
both internal rings are evaluated. Hernia repair begins with passage of a needle
through a stab incision over the internal ring. The needle is passed superficial to the
peritoneum around the internal ring, taking care to avoid cord structures. A modifica-
tion includes making a second pass of the needle to bisect the sac and to further ligate
the sac, similar to what is done with open repairs. This procedure is performed with
a permanent suture to decrease the recurrence rate (Figs. 6–8).52
Most laparoscopic series to date have documented an increased recurrence rate in
comparison with the open repair. With increasing experience, the recurrence rate has
approached that of open repair in some series.53–58 Proponents of the laparoscopic
method tout cosmesis, ease of evaluation of the contralateral side, and visualization
of the vas and vessels, perhaps making the repair less traumatic.59–61 One study found
decreased pain along with parental perception of a faster recovery and better wound
cosmesis compared with open repair. Another study found similar recovery and
outcomes but worse pain in the laparoscopic group.57,62 Subjective outcomes such
as pain and cosmesis are difficult to quantify and even more difficult to compare
between the two groups.63 Although this is a safe and effective alternative to open repair,
it cannot yet be considered the gold standard because long-term data are still lacking.

Outcomes
Overall, pediatric inguinal hernia repairs have a low complication rate. Complications
include recurrence, testicular atrophy, injury to the vas, and infection. The largest

Fig. 5. Male presenting with an umbilical hernia and a vague history of intermittent right
scrotal swelling. During the umbilical hernia repair, a 5-mm trocar was placed in the umbi-
licus and confirmed a right-sided hernia.
494 Lao et al

Fig. 6. Technique of laparoscopic repair of an inguinal hernia in a boy. A second pass has
been used to bisect the hernia sac. (Photo courtesy of Dr Matias Bruzoni.)

single-surgeon series including 6361 patients describes a 1.2% recurrence rate and
a 0.3% rate of testicular atrophy.3 The recurrence rate of 1% is mirrored in a survey
study.31 Although there is evidence of transient changes in the vascularity of the testes
immediately postoperatively, these nearly all resolve with time.64 In preterm infants the
complication rate may be higher.44,65 The long-term effects of pediatric inguinal hernia
repair have recently been reported over an average 49-year follow-up. The data
demonstrated an 8.4% reexploration for a hernia on the ipsilateral side presenting
at an average of 38.4 years postoperatively. The majority of these cases were
“new” direct hernias rather than recurrences of an indirect hernia (2.8% recurrence
rate).66

ADOLESCENT INGUINAL HERNIA

Principles of Inguinal Hernia Surgery in Adults
There is overwhelming evidence in the literature that a mesh-based inguinal hernior-
rhaphy dramatically decreases the recurrence rate in comparison with a pure tissue
repair.67 Mesh-based repairs, as a group, are usually referred to as tension-free
repairs (TFR). There are more than 70 named tissue repairs in the literature, but
most are simple modifications of operations already illustrated in this article for pedi-
atric patients.68 The classic Bassini is the prototype operation, and involves recon-
struction of the posterior wall by suturing Bassini’s famous triple layer (the
transversalis fascia, the transversus abdominis muscle, the internal oblique muscle)
to the inguinal ligament (Fig. 9).

Fig. 7. Technique of laparoscopic repair of an inguinal hernia in a girl before tying the
suture.
 Pediatric Inguinal Hernias 495

Fig. 8. Technique of laparoscopic repair of an inguinal hernia in a girl after tying the suture.
(Courtesy of Dr Matias Bruzoni.)

Tissue repairs are not be discussed further because they are only used today in
exceptional circumstances such as for infected or contaminated wounds. The tech-
nique popularized by Liechtenstein is considered the gold-standard TFR operation.69
In this procedure the groin is initially prepared in a manner similar to a tissue repair. The
external oblique is exposed through a transverse groin incision and opened through
the external ring. A large space is then created beneath the fascia of the external obli-
que using blunt dissection from the anterior superior iliac spine laterally to a point 2 cm
medial to the pubic tubercle medially. Dissection is continued from lateral to medial
along the inferior edge of the external oblique aponeurosis; the so-called shelving
edge of the inguinal ligament. The pubic tubercle is exposed and the cord structures
are elevated out of the inguinal floor. Indirect inguinal hernia sacs are dissected from

Fig. 9. The classic Bassini is the prototype operation and involves reconstruction of the
posterior wall by suturing Bassini’s famous triple layer (the transversalis fascia, the transver-
sus abdominis muscle, the internal oblique muscle) to the inguinal ligament. (From Fitzgib-
bons RJ Jr, Greenburg AG. Nyhus and Condon’s hernia. Philadelphia: Lippincott Williams &
Wilkins; 2001. p. 108; with permission.)
496 Lao et al

the cord and reduced into the preperitoneal space. High ligation is also an option, but
is not preferred in deference to the possibility of greater pain because of the incision
across the richly innervated peritoneum. An exception is the inguinal scrotal indirect
hernia because dissecting out the entire sac, as in pediatric hernias, is associated
with an increased rate of testicular complications. Division of the sac with high ligation
of the proximal sac and generous opening of the distal sac is recommended. Direct
hernias are dissected away from surrounding structures and reduced. Commonly
the musculofascial elements that make up the ring of the direct hernia are closed to
maintain reduction while the formal repair of the inguinal hernia is accomplished.
This action adds little to the ultimate strength of the repair and is more a matter of
making the prosthetic repair easier by keeping the hernia sac out of the field, espe-
cially if the procedure is being performed under local anesthesia. It is at this point
that the procedure begins to differ from a tissue repair. Instead of suturing the triple
layer to the inguinal ligament, a prosthesis, which is at least 9 by 12 cm and usually
a polypropylene mesh, is sutured to the anterior rectus sheath 2 cm medial to the
pubic tubercle. This same suture is continued laterally, securing the inferior edge of
the prosthesis to either side of the pubic tubercle and then the inguinal ligament.
The suture is tied at the internal ring and the mesh is slit laterally to accommodate
the cord structures. The tails created are tucked beneath the fascia of the external
oblique aponeurosis to the level of the anterior superior iliac spine, with the superior
tail overlapping the inferior tail. A so-called shutter-valve stitch is placed next, which
incorporates the inferior edge of the superior tail, the inferior edge of the inferior tail,
and the inguinal ligament. This stitch serves to create a new internal ring and also to
wrinkle the mesh somewhat medially, which is believed to be important in minimizing
tension when the patient is in the upright position. The mesh is then trimmed and
secured to the anterior rectus sheath and the internal oblique aponeurosis medially
and cranially (Fig. 10). The external oblique aponeurosis is closed over the repair,
reconstructing the external ring.

Fig. 10. The mesh repair technique popularized by Liechtenstein. The lower edges of the 2
tails are sutured to the inguinal ligament for creation of a new internal ring made of mesh.
(From Fitzgibbons Jr RJ, Greenburg AG. Nyhus and Condon’s Hernia. Philadelphia: Lippin-
cott Williams & Wilkins; 2001. p. 108; with permission.)
 Pediatric Inguinal Hernias 497

An alternative to a TFR is a laparoscopic herniorrhaphy. Unlike the conventional TFR

the laparoscopic operation is performed in the preperitoneal space, which may be
entered either through the abdomen after a conventional laparoscopy (transabdominal
preperitoneal or TAPP) or a totally extraperitoneal technique (TEP) using a dissecting
balloon placed between the posterior rectus sheath and the rectus muscle. A pneumo-
extraperitoneum is then produced. With either approach, a radical dissection of the
preperitoneal space is next accomplished exposing both pubic tubercles, the Cooper
ligament, the inferior epigastric vessels, and the cord structures. It is important that the
peritoneum over the internal spermatic vessels be dissected well proximally so that
a large space is created to prevent roll-up of the prosthesis when the peritoneum is
eventually closed. Next, a mesh prosthesis, usually made of polypropylene, is posi-
tioned to widely overlap both the direct and indirect spaces, that is, the myopectineal
orifice (Fig. 11). In addition to the laparoscopic operation there are several conven-
tional operations, such as popularized by Kugel,70 that take advantage of the preper-
itoneal space.

Mesh Repair or High Ligation for Adolescents

The critical question is, when should the principles of adult inguinal hernia surgery be
applied to the pediatric population? In other words, when is a child an adult? Clearly
there is no high-level evidence in the literature to answer this question. However, most
surgical textbooks are consistent in a recommendation that prosthetic material is not

Fig. 11. Laparoscopic repair. The mesh prosthesis usually is positioned to widely overlap both
the direct and indirect spaces (ie, the myopectineal orifice). (A) Medial mesh fixation over
a left-sided inguinal hernia defect. (B) Lateral mesh fixation over a left-sided inguinal hernia
defect, taking care to place the endotack above the iliopubic tract. (C) Final orientation of the
mesh covering all left-sided myopectineal orifices. (From Kim B, Duh QY. Laparoscopic inguinal
hernia repair. In: Evans SR, editor. Surgical pitfalls—prevention and management. Philadel-
phia: Elsevier; 2009. p. 515–21; with permission.)
498 Lao et al

appropriate in patients younger than 15 years, because of continuing growth consid-

erations. There is another unsettled controversy pertinent to this consideration, which
is whether mesh in contact with the cord structures might result in vasal obstruction in
a small subset of patients because of an exasperated fibroplastic inflammatory
response caused by mesh.71 Scattered case reports of apparent infertility caused
by mesh have surfaced, but alternative explanations for the vasal obstruction have
been proposed.72 Most adult inguinal hernia surgeons will recommend the use of
a prosthesis for any patient aged 20 years or older, with appropriate counseling for
patients potentially intending to have children. This counseling is particularly important
in patients with bilateral operations. For adolescents aged 15 to 19 years this question
remains unsettled, with almost no objective scientific evidence to address the
question.

PEDIATRIC HYDROCELE

A hydrocele is a collection of fluid in the tunica vaginalis around the testicle. If there is
no connection to the abdominal cavity through a patent processus vaginalis, it is
called a noncommunicating hydrocele. If there is a patent processus vaginalis, this
is termed a communicating hydrocele. A communicating hydrocele is essentially
a hernia. Hydroceles, like hernias, are more common on the right side.
Distinguishing between a communicating and noncommunicating hydrocele is
important because they are managed very differently. Hydroceles usually can be
differentiated by history and physical examination. A communicating hydrocele will
fluctuate throughout the day in size, especially when in the dependent position
(standing). A noncommunicating hydrocele will not fluctuate in size but may gradually
change in size over weeks. On physical examination a communicating hydrocele can
be compressed into the abdomen. A noncommunicating hydrocele will not compress.
The differential of scrotal swelling also includes a hernia (incarcerated hernia) or
a varicocele.
Treatment for a communicating hydrocele is essentially the same as for a hernia:
operative repair once the diagnosis has been confirmed.15,19 Noncommunicating
hydroceles are extremely common at birth and should be considered a normal part
of development. Most will resolve spontaneously. If they persist after a period of
time (12 to 24 months), they should be repaired.73 When hydroceles are present at
birth, they do not increase the likelihood of a subsequent hernia.74 However, if the
hydrocele develops after birth there is a higher likelihood, by definition, that the patent
processus vaginalis will not close.74 Repair of a hydrocele involves an inguinal
approach to make sure there is not a patent processus vaginalis (a hernia). A high liga-
tion of the processus is performed (Fig. 12). Once this has been completed, the distal
hydrocele is widely opened to prevent recurrence. The hydrocele sac is not
completely removed to avoid injury to the testicle.

UNDESCENDED TESTICLE

The incidence of cryptorchidism is between 1% and 3%. Prematurity is a risk factor

because of testicular descent during the seventh month of gestation.75 Descent of
the testicle is limited by the vasculature rather than the vas deferens. An undescended
testicle is at increased risk for malignancy and will be unable to properly produce
sperm.76 The testicle requires a cooler environment, such as in the scrotum, to
produce sperm.
Although the risk of malignancy is increased in the undescended testicle, it is still
relatively rare. Multiple studies suggest a relative risk of 4.0 to 5.7 for testicular cancer
 Pediatric Inguinal Hernias 499

Fig. 12. High ligation of a processus vaginalis in a boy presenting with a communicating
hydrocele.

in the undescended testicle. This risk also seems to be higher if the testicle is in the
abdominal location rather than in the inguinal location. The contralateral side is
thought by some to also be at increased risk for malignancy, while others suggest
the rate is similar to that in the general population.77 Orchiopexy does not completely
negate the increased risk of malignancy.78,79 However, performance of orchiopexy at
an earlier age has been associated with a decreased relative risk of cancer.77 Another
potential advantage of orchiopexy is improved surveillance and earlier detection.
Diagnosis
An undescended testicle is often detected at birth on routine examination. An empty
hemiscrotum at birth represents either in utero torsion of the testicle or an unde-
scended testicle. On physical examination, with the aid of lubricating jelly, an examiner
stands on the contralateral side and slides his or her fingers from the anterior superior
iliac spine down to the pubic tubercle. The testicle within the canal can be felt with this
maneuver, even in a toddler. The size of the testicle should be documented because
undescended testicles are generally smaller than the contralateral gonad.
If the testicle can be easily pulled into the scrotum, it is a retractile testicle and needs
no additional therapy. If the testicle is palpable but will not descend, it will require
orchiopexy. If the testicle is nonpalpable, ultrasonography can be used to identify
the testicle. If an ultrasonogram does not identify a testicle, this may indicate that
the testicle is intra-abdominal or not present (from in utero testicular torsion). In this
setting some advocate the use of magnetic resonance imaging.80,81 The authors
prefer proceeding to laparoscopy to differentiate an intra-abdominal testicle and in
utero testicular torsion.
Treatment
Orchiopexy is performed in the setting of an undescended testicle, and may be per-
formed in either the open or laparoscopic fashion.80,82,83 Timing of orchiopexy is
controversial, but most surgeons recommend performing this procedure at 6 to 12
months of age.83 Waiting 6 months, especially in premature infants, may allow
a partially descended testicle to completely descend. Historically, orchiopexy was per-
formed in older boys. There is increasing evidence from testicular biopsies that waiting
could affect fertility. Cortes and colleagues81 demonstrated complete loss of germ
cells on biopsy as early as 18 months of age. Others have demonstrated progressive
500 Lao et al

loss of not only germ cells but also Leydig cells, and this is more severe in nonpalpable
testes.84 For these reasons the authors prefer to operate before 1 year of age.
In the setting of a palpable testicle, a 1-stage orchiopexy is performed. An inguinal
incision is made, slightly larger than a hernia incision, to allow access to the external
and internal rings. The external oblique is approached with care because the testicle
may reside in a hernia sac that exits the external ring and sits in an ectopic position in
the thigh or over the external oblique. Once the external oblique is identified and
opened, the hernia sac is mobilized with sharp and blunt dissection from the guber-
naculum. The hernia sac is then opened opposite the vas and the vessels (in a minority
of cases no hernia sac is identified). The hernia sac is peeled off the cord structures
and ligated at the level of the internal ring.82,83,85 The process of mobilizing the hernia
sac and dividing the retroperitoneal attachments to the hernia sac gives the testicle
length to reach the scrotum in most cases. An incision is then made in the scrotum,
and a pouch is created for the testicle. The testicle is then passed into the scrotum
and secured to the median raphe using nonabsorbable sutures.

Nonpalpable Testis
When the testicle is nonpalpable and not identified on the ultrasonogram, laparo-
scopic exploration is performed.82,85 Laparoscopy can distinguish an in utero torsion
or an intra-abdominal testicle. Laparoscopy is diagnostic of an in utero torsion if there
is a blind-ending vas deferens and spermatic vessels at the level of the internal ring.80
These remnants can be left because their malignant potential is very low.77 If the tes-
ticle is found to be intra-abdominal on laparoscopic exploration, the first stage of
a Fowler-Stephens orchiopexy can be performed. With this procedure the testicular
vessels are divided 2 to 3 cm from the testicle laparoscopically during the first oper-
ation. The testicle then survives on the peritoneum and the vessel to the vas. In 3 to
6 months the child is returned to the operating room for an open or a laparoscopic
orchiopexy. Others report similar results with a 1-stage Fowler-Stevens.86

Outcomes
In terms of testicular salvage, outcomes are excellent for orchiopexy overall. Series
report testicular salvage as high as 90% even when using the Fowler-Stevens
approach of dividing the testicular vessels, documented by preservation of testicular
size on physical examination during long-term follow-up. Fertility for males with unilat-
eral undescended testicles is nearly normal, whereas it drops to 65% with bilateral
disease.87 Studies also demonstrate decreased sperm counts and abnormal hormone
levels compared with controls, especially in patients with bilateral disease.

REFERENCES

1. Manoharan S, Samarakkody U, Kulkarni M, et al. Evidence-based change of

practice in the management of unilateral inguinal hernia. J Pediatr Surg 2005;
40(7):1163–6.
2. Brandt ML. Pediatric hernias. Surg Clin North Am 2008;88(1):27–43, vii–viii.
3. Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal
hernias: a 35-year review. J Pediatr Surg 2006;41(5):980–6.
4. Shrock P. The processus vaginalis and gubernaculum. Their raison d’etre rede-
fined. Surg Clin North Am 1971;51(6):1263–8.
5. Davenport M. ABC of general paediatric surgery. Inguinal hernia, hydrocele, and
the undescended testis. BMJ 1996;312(7030):564–7.
 Pediatric Inguinal Hernias 501

6. Toki A, Watanabe Y, Tani M, et al. Adopt a wait-and-see attitude for patent proc-
essus vaginalis in neonates. J Pediatr Surg 2003;38(9):1371–3.
7. Rowe MI, Copelson LW, Clatworthy HW. The patent processus vaginalis and the
inguinal hernia. J Pediatr Surg 1969;4(1):102–7.
8. Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopic evaluation of the pedi-
atric inguinal hernia—a meta-analysis. J Pediatr Surg 1998;33(6):874–9.
9. Luo CC, Chao HC. Prevention of unnecessary contralateral exploration using the
silk glove sign (SGS) in pediatric patients with unilateral inguinal hernia. Eur J
Pediatr 2007;166(7):667–9.
10. Chen KC, Chu CC, Chou TY, et al. Ultrasonography for inguinal hernias in boys.
J Pediatr Surg 1998;33(12):1784–7.
11. Erez I, Rathause V, Vacian I, et al. Preoperative ultrasound and intraoperative
findings of inguinal hernias in children: a prospective study of 642 children. J
Pediatr Surg 2002;37(6):865–8.
12. Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J
Surg 1989;13(5):506–15.
13. Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to
elective repair. J Pediatr Surg 1993;28(4):582–3.
14. Goldman RD, Balasubramanian S, Wales P, et al. Pediatric surgeons and pedi-
atric emergency physicians’ attitudes towards analgesia and sedation for incar-
cerated inguinal hernia reduction. J Pain 2005;6(10):650–5.
15. Potts WJ, Riker WL, Lewis JE. The treatment of inguinal hernia in infants and chil-
dren. Ann Surg 1950;132(3):566–76.
16. Levitt MA, Ferraraccio D, Arbesman MC, et al. Variability of inguinal hernia
surgical technique: a survey of North American pediatric surgeons. J Pediatr
Surg 2002;37(5):745–51.
17. Chen LE, Zamakhshary M, Foglia RP, et al. Impact of wait time on outcome for
inguinal hernia repair in infants. Pediatr Surg Int 2009;25(3):223–7.
18. Harper RG, Garcia A, Sia C. Inguinal hernia: a common problem of premature
infants weighing 1,000 grams or less at birth. Pediatrics 1975;56(1):112–5.
19. Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early
infancy: clinical considerations. J Pediatr Surg 1984;19(6):832–7.
20. Puri P, Guiney EJ, O’Donnell B. Inguinal hernia in infants: the fate of the testis
following incarceration. J Pediatr Surg 1984;19(1):44–6.
21. Gonzalez Santacruz M, Mira Navarro J, Encinas Goenechea A, et al. Low preva-
lence of complications of delayed herniotomy in the extremely premature infant.
Acta Paediatr 2004;93(1):94–8.
22. Krieger NR, Shochat SJ, McGowan V, et al. Early hernia repair in the premature
infant: long-term follow-up. J Pediatr Surg 1994;29(8):978–81 [discussion:
981–2].
23. Melone JH, Schwartz MZ, Tyson KR, et al. Outpatient inguinal herniorrhaphy in
premature infants: is it safe? J Pediatr Surg 1992;27(2):203–7 [discussion:
207–8].
24. Misra D, Hewitt G, Potts SR, et al. Inguinal herniotomy in young infants, with
emphasis on premature neonates. J Pediatr Surg 1994;29(11):1496–8.
25. Misra D. Inguinal hernias in premature babies: wait or operate? Acta Paediatr
2001;90(4):370–1.
26. Rajput A, Gauderer MW, Hack M. Inguinal hernias in very low birth weight infants:
incidence and timing of repair. J Pediatr Surg 1992;27(10):1322–4.
27. Uemura S, Woodward AA, Amerena R, et al. Early repair of inguinal hernia in
premature babies. Pediatr Surg Int 1999;15(1):36–9.
502 Lao et al

28. Wiener ES, Touloukian RJ, Rodgers BM, et al. Hernia survey of the Section on
Surgery of the American Academy of Pediatrics. J Pediatr Surg 1996;31(8):
1166–9.
29. DeCou JM, Gauderer MW. Inguinal hernia in infants with very low birth weight.
Semin Pediatr Surg 2000;9(2):84–7.
30. Warner LO, Teitelbaum DH, Caniano DA, et al. Inguinal herniorrhaphy in young
infants: perianesthetic complications and associated preanesthetic risk factors.
J Clin Anesth 1992;4(6):455–61.
31. Antonoff MB, Kreykes NS, Saltzman DA, et al. American Academy of Pediatrics
Section on Surgery hernia survey revisited. J Pediatr Surg 2005;40(6):1009–14.
32. Walther-Larsen S, Rasmussen LS. The former preterm infant and risk of post-
operative apnoea: recommendations for management. Acta Anaesthesiol Scand
2006;50(7):888–93.
33. Allen GS, Cox CS Jr, White N, et al. Postoperative respiratory complications in ex-
premature infants after inguinal herniorrhaphy. J Pediatr Surg 1998;33(7):1095–8.
34. Rothenburg R, Barnett T. Bilateral herniotomy in infants and children. Surgery
1955;37:947–50.
35. Zona JZ. The incidence of positive contralateral inguinal exploration among
preschool children—a retrospective and prospective study. J Pediatr Surg
1996;31(5):656–60.
36. Rowe MI, Clatworthy HW Jr. The other side of the pediatric inguinal hernia. Surg
Clin North Am 1971;51(6):1371–6.
37. Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia following unilat-
eral repair in a pediatric hospital. J Pediatr Surg 1989;24(10):963–5.
38. Janik JS, Shandling B. The vulnerability of the vas deferens (II): the case against
routine bilateral inguinal exploration. J Pediatr Surg 1982;17(5):585–8.
39. McGregor DB, Halverson K, McVay CB. The unilateral pediatric inguinal hernia:
should the contralateral side by explored? J Pediatr Surg 1980;15(3):313–7.
40. Surana R, Puri P. Is contralateral exploration necessary in infants with unilateral
inguinal hernia? J Pediatr Surg 1993;28(8):1026–7.
41. Sparkman RS. Bilateral exploration in inguinal hernia in juvenile patients. Review
and appraisal. Surgery 1962;51:393–406.
42. Kiesewetter WB, Parenzan L. When should hernia in the infant be treated bilater-
ally? J Am Med Assoc 1959;171:287–90.
43. Tackett LD, Breuer CK, Luks Fl, et al. Incidence of contralateral inguinal hernia:
a prospective analysis. J Pediatr Surg 1999;34(5):684–7 [discussion: 687–8].
44. Rathauser F. Historical overview of the bilateral approach to pediatric inguinal
hernias. Am J Surg 1985;150(5):527–32.
45. Lazar DA, Lee TC, Almulhim SI, et al. Transinguinal laparoscopic exploration for
identification of contralateral inguinal hernias in pediatric patients. J Pediatr Surg
2011;46(12):2349–52.
46. Wulkan ML, Wiener ES, VanBalen N, et al. Laparoscopy through the open ipsilat-
eral sac to evaluate presence of contralateral hernia. J Pediatr Surg 1996;31(8):
1174–6 [discussion: 1176–7].
47. Holcomb GW 3rd, Brock JW 3rd, Morgan WM 3rd. Laparoscopic evaluation for
a contralateral patent processus vaginalis. J Pediatr Surg 1994;29(8):970–3
[discussion: 974].
48. Rowe MI, Marchildon MB. Inguinal hernia and hydrocele in infants and children.
Surg Clin North Am 1981;61(5):1137–45.
49. Miltenburg DM, Nuchtern JG, Jaksic T, et al. Meta-analysis of the risk of meta-
chronous hernia in infants and children. Am J Surg 1997;174(6):741–4.
 Pediatric Inguinal Hernias 503

50. Sozubir S, Ekingen G, Senel U, et al. A continuous debate on contralateral proc-

essus vaginalis: evaluation technique and approach to patency. Hernia 2006;
10(1):74–8.
51. Hata S, Takahashi Y, Nakamura T, et al. Preoperative sonographic evaluation is
a useful method of detecting contralateral patent processus vaginalis in pediatric
patients with unilateral inguinal hernia. J Pediatr Surg 2004;39(9):1396–9.
52. Kastenberg Z, Bruzoni M, Dutta S. A modification of the laparoscopic transcuta-
neous inguinal hernia repair to achieve transfixation ligature of the hernia sac.
J Pediatr Surg 2011;46(8):1658–64.
53. Parelkar SV, Oak S, Gupta R, et al. Laparoscopic inguinal hernia repair in the
pediatric age group—experience with 437 children. J Pediatr Surg 2010;45(4):
789–92.
54. Montupet P, Esposito C. Fifteen years experience in laparoscopic inguinal hernia
repair in pediatric patients. Results and considerations on a debated procedure.
Surg Endosc 2011;25(2):450–3.
55. Sneider EB, Jones S, Danielson PD. Refinements in selection criteria for pediatric
laparoscopic inguinal hernia repair. J Laparoendosc Adv Surg Tech A 2009;
19(2):237–40.
56. Becmeur F, Phillipe P, Lemandat-Schultz A, et al. A continuous series of 96 lapa-
roscopic inguinal hernia repairs in children by a new technique. Surg Endosc
2004;18(12):1738–41.
57. Chan KL, Hui WC, Tam PK. Prospective randomized single-center, single-blind
comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surg En-
dosc 2005;19(7):927–32.
58. Spurbeck WW, Prasad R, Lobe TE. Two-year experience with minimally invasive
herniorrhaphy in children. Surg Endosc 2005;19(4):551–3.
59. Schier F. Laparoscopic inguinal hernia repair—a prospective personal series of
542 children. J Pediatr Surg 2006;41(6):1081–4.
60. Ozgediz D, Roayaie K, Lee H, et al. Subcutaneous endoscopically assisted liga-
tion (SEAL) of the internal ring for repair of inguinal hernias in children: report of
a new technique and early results. Surg Endosc 2007;21(8):1327–31.
61. Dutta S, Albanese C. Transcutaneous laparoscopic hernia repair in children:
a prospective review of 275 hernia repairs with minimum 2-year follow-up. Surg
Endosc 2009;23(1):103–7.
62. Koivusalo AI, Korpela R, Wirtavuori K, et al. A single-blinded, randomized
comparison of laparoscopic versus open hernia repair in children. Pediatrics
2009;123(1):332–7.
63. Saranga Bharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic
versus open surgery. JSLS 2008;12(3):277–81.
64. Palabiyik FB, Cimilli T, Kayhan A, et al. Do the manipulations in pediatric inguinal
hernia operations affect the vascularization of testes? J Pediatr Surg 2009;44(4):
788–90.
65. Phelps S, Agrawal M. Morbidity after neonatal inguinal herniotomy. J Pediatr Surg
1997;32(3):445–7.
66. Zendejas B, Zarroug AE, Erben YM, et al. Impact of childhood inguinal hernia
repair in adulthood: 50 years of follow-up. J Am Coll Surg 2010;211(6):762–8.
67. Repair of groin hernia with synthetic mesh: meta-analysis of randomized
controlled trials. Ann Surg 2002;235(3):322–32.
68. Amid PK. Groin hernia repair: open techniques. World J Surg 2005;29(8):1046–51.
69. Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and prin-
ciples. Hernia 2004;8(1):1–7.
504 Lao et al

70. Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless,

inguinal herniorrhaphy. Am J Surg 1999;178(4):298–302.
71. Fitzgibbons RJ Jr. Can we be sure polypropylene mesh causes infertility? Ann
Surg 2005;241(4):559–61.
72. Shin D, Lipshultz LI, Goldstein M, et al. Herniorrhaphy with polypropylene mesh
causing inguinal vasal obstruction: a preventable cause of obstructive azoo-
spermia. Ann Surg 2005;241(4):553–8.
73. Koski ME, Makari JH, Adams MC, et al. Infant communicating hydroceles—do
they need immediate repair or might some clinically resolve? J Pediatr Surg
2010;45(3):590–3.
74. Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr
Ann 2001;30(12):729–35.
75. Cortes D. Cryptorchidism—aspects of pathogenesis, histology and treatment.
Scand J Urol Nephrol Suppl 1998;196:1–54.
76. Lee PA. Fertility after cryptorchidism: epidemiology and other outcome studies.
Urology 2005;66(2):427–31.
77. Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from
fiction. J Urol 2009;181(2):452–61.
78. Swerdlow AJ, Higgins CD, Pike MC. Risk of testicular cancer in cohort of boys
with cryptorchidism. BMJ 1997;314(7093):1507–11.
79. Prener A, Engholm G, Jensen OM. Genital anomalies and risk for testicular
cancer in Danish men. Epidemiology 1996;7(1):14–9.
80. Jordan GH. Laparoscopic management of the undescended testicle. Urol Clin
North Am 2001;28(1):23–9, vii–viii.
81. Cortes D, Thorup JM, Visfeldt J. Cryptorchidism: aspects of fertility and
neoplasms. A study including data of 1,335 consecutive boys who underwent
testicular biopsy simultaneously with surgery for cryptorchidism. Horm Res
2001;55(1):21–7.
82. Escarcega-Fujigaki P, Rezk GH, Huerta-Murrieta E, et al. Orchiopexy-laparos-
copy or traditional surgical technique in patients with an undescended palpable
testicle. J Laparoendosc Adv Surg Tech A 2011;21(2):185–7.
83. Hutson JM, Clarke MC. Current management of the undescended testicle. Semin
Pediatr Surg 2007;16(1):64–70.
84. Tasian GE, Hittelman AB, Kim GE, et al. Age at orchiopexy and testis palpability
predict germ and Leydig cell loss: clinical predictors of adverse histological
features of cryptorchidism. J Urol 2009;182(2):704–9.
85. Peters CA. Laparoscopy in pediatric urology. Curr Opin Urol 2004;14(2):67–73.
86. Elyas R, Guerra LA, Pike J, et al. Is staging beneficial for Fowler-Stephens orchi-
opexy? A systematic review. J Urol 2010;183(5):2012–8.
87. Lee PA, Coughlin MT. Fertility after bilateral cryptorchidism. Evaluation by pater-
nity, hormone, and semen data. Horm Res 2001;55(1):28–32.