Hernias (Children)

🧠 Introduction

• Hernias in children are common surgical presentations 👶. They occur when abdominal contents protrude through a weakness in the abdominal wall.
• In children, the majority are inguinal hernias, due to persistence of the processus vaginalis. Umbilical and epigastric hernias are also seen.
• Important because of the risk of incarceration and strangulation, which are surgical emergencies 🚨.

📍 Types of Hernias in Children

• Inguinal hernia – indirect type via processus vaginalis, commonest. More common in boys (10:1), especially premature infants. Right side > left.
• Umbilical hernia – failure of umbilical ring to close fully. Very common in infants, especially in Afro-Caribbean children. Most close spontaneously by 2–3 yrs.
• Epigastric hernia – defect in linea alba between umbilicus and sternum. Small, may be painful.
• Incisional hernia – after surgery (rare in children).

⚡ Risk Factors

• Prematurity (inguinal hernia in up to 30% of very low birthweight babies 👶).
• Connective tissue disorders (Ehlers–Danlos, Marfan).
• Raised intra-abdominal pressure (chronic cough, constipation, ascites).
• Family history of hernias.

🩺 Clinical Features

• Inguinal hernia: Intermittent swelling in groin/scrotum, often more obvious on crying/straining. Soft, reducible lump. ⚠️ Incarceration → tense, tender, irreducible, vomiting.
• Umbilical hernia: Soft swelling at umbilicus, expands with crying. Usually reducible, rarely strangulates.
• Epigastric hernia: Small midline lump, may cause localised pain/tenderness.

🔎 Diagnosis

• Primarily clinical 👀.
• Ultrasound useful if diagnosis uncertain (esp. in obese children or girls with groin swelling where an ovary may herniate).

⚖️ Differential Diagnosis of Groin Lump

• Hydrocele 💧 (transilluminates, not reducible).
• Inguinal lymphadenopathy.
• Undescended testis.
• Femoral hernia (rare in children).

🛠️ Management

• Inguinal hernia:
  • Repair indicated in all children (does not resolve spontaneously).
  • Surgery often within weeks of diagnosis; sooner if infant or premature (higher risk of incarceration).
  • If incarcerated ➝ urgent surgical referral 🚨.
• Umbilical hernia:
  • Observe until ~3 yrs, as most close spontaneously.
  • Surgery if persisting beyond 3–5 yrs, symptomatic, or very large defect (>2 cm).
• Epigastric hernia:
  • Elective repair if symptomatic or enlarging.

📊 Key Differences Table

💡 Clinical Pearls

• All paediatric inguinal hernias should be referred for surgical repair ➝ high incarceration risk.
• In girls, inguinal hernia may contain ovary – strangulation can cause loss of ovary ⚠️.
• Umbilical hernias usually harmless and self-resolving ➝ reassure parents 🤱.
• Painful, irreducible swelling with vomiting = emergency → call surgery immediately 🚨.

Cases

• Case 1 — Inguinal Hernia (Infant): A 3-month-old boy presents with an intermittent groin swelling, more prominent when crying and reducible on gentle pressure. No tenderness or systemic upset. Diagnosis: congenital inguinal hernia due to a patent processus vaginalis. Plan: Refer to paediatric surgery for elective repair (risk of incarceration is high in infants).
• Case 2 — Incarcerated Inguinal Hernia: A 2-year-old girl presents with a painful irreducible groin lump, vomiting, and abdominal distension. Lump is tender, tense, and non-reducible. Diagnosis: incarcerated inguinal hernia. Plan: Urgent surgical referral; attempt gentle reduction if early and stable, otherwise emergency hernia repair.
• Case 3 — Umbilical Hernia: A 5-year-old child with a small central swelling at the umbilicus, visible when standing or coughing, easily reducible and asymptomatic. Diagnosis: umbilical hernia. Plan: Reassure parents—most resolve spontaneously by age 4–5; surgery if persistent beyond this age or if symptomatic/large defect.
• Case 4 — Congenital Diaphragmatic Hernia (Rare): A newborn presents with respiratory distress and scaphoid abdomen. Chest X-ray shows bowel loops in the thorax with mediastinal shift. Diagnosis: congenital diaphragmatic hernia (Bochdalek). Plan: Stabilise with ventilation, avoid bag-mask ventilation, and arrange urgent neonatal surgical repair.