Inguinal hernia in kids is very common surgical problem and develops in 2-3% of all kids before the age of 15 years. Once diagnosed, hernia in a child always requires surgery. If not operated then there can be a high risk of hernia getting stuck (incarceration/ strangulation) and this risk is more in younger kids.

Surgery for hernia in kids is called Herniotomy and can be done by Conventional open or laparoscopic technique. For a one sided hernia in a child we prefer open technique as Laparoscopic technique even for such a minor surgery involves more anesthesia and 3 cuts to put instruments into belly for hernia repair.

We recommend laparoscopic hernia repair in children only in special cases such as:

• Both sided hernia repair
• Previously failed hernia repair
• Concurrently with other laparoscopic surgeries
• In girls where some ovary or other internal disorder may be suspected.

Brief description

Herniotomy by conventional open technique is a short (20 minutes), minimally invasive daycare surgery which involves only 1.5cm-2cm cut which is then closed with stitches inside the skin. The children are admitted on morning of surgery and discharged in evening and they can play around the same day.

Who should do hernia repair in children?

Tissues and organs in children are very delicate and hence hernia repair in children should be done only by surgeons who are trained in handling such delicate tissues. Such hernia specialist surgeons are a Pediatric Urologist or a Pediatric Surgeon. Further, since hernia in children is a birth defect, pediatric urologists/ surgeons are able to understand the anatomy better and do a best hernia repair in a child. Cuts given for hernia repair are also smaller when a pediatric urologist or surgeon is doing the surgery. They are also able to give proper dosages of medicines and take care of pre-operative and postoperative care better than adult surgeons.

How is Conventional Open Hernia repair (Herniotomy) done in children?

Surgery for hydrocele and hernia in children is performed via inguinal or groin skin crease incision. Inguinal herniotomy is a simple and a precise surgery which can be performed in 15-20 minutes by a well-trained child hernia specialist. We prefer to give caudal epidural analgesia along with sedation for hernia repair in children. The child is placed in a supine position on the table and operative area is cleaned with an antiseptic solution such as betadine. Surgeon stands on the side of hydrocele/ hernia. Lower inguinal skin crease incision is marked and an incision is made through the skin with knife and deepened with cautery through layers till inguinal canal is opened.  Small retractors help in exposure to visualise the cremaster muscle which covers the spermatic cord. Cremaster fascia is gently separated to reveal the glistening white processus or hernia sac and Sac is splayed on the index finger of the left hand and tissues are teased off gradually layer by layer with a delicate forceps. This way the spermatic cord with vessels and vas deferens are separated from the sac. It is vital not to handle vas during this maneuver as it can get injured very easily. Once the sac is totally dissected clear of the cord, the sac is divided and dissected till internal ring. An inspection and palpation is done to confirm that the sac is empty; and sac is twisted for 2-3 turns. This allows narrowing of the neck of sac and also provides a slightly tougher tissue for placing a transfixation suture. A transfixation suture is passed with a delayed absorbable suture such as monocryl or vicryl to close the sac at level of internal ring. The distal sac towards testis is laid open with a bipolar diathermy for a short distance to decrease the incidence of post-operative hydrocele. Hemostasis is ensured and the cord and testis are reposited back to the scrotum by a gentle pull on the scrotal tissues. This is again an important step otherwise the testis can get trapped in the healing process and result in an iatrogenic ascended testis.

Tissues are closed in layers with absorbable sutures and skin is closed in a subcuticular fashion. A small gauze dressing or skin strips are placed at the end of the procedure.

About the Author:

Dr A.K.Singal is a renowned Pediatric Surgeon and Pediatric Urologist. He has trained at top most indian and US medical universities. He is also an expert in hernia surgery for children (child hernia specialist) and does more than 80-90 such hernia surgeries every year in small children. Right from newborn age to 15 years. Very skilled in laparoscopic hernia repair and other major laparoscopic urological surgeries in children, Dr Singal reserves laparoscopic technique only for bilateral hernia and failed hernia repairs.

He is available for consultation at Fortis Hospital in Mulund, Mumbai and Vashi, Navi Mumbai; Jupiter Hospital in Thane and MGM Hospital in Vashi. He also his own centre at MITR Hospital in Kharghar Navi Mumbai