Indirect inguinal hernia in children
Introduction
Introduction to pediatric inguinal hernia Indirecting of the inguinal hernia (indirectinguinal hernia) due to the failure of the peritoneal sheath during the embryonic testicular decline, can occur in the neonatal period, is a congenital disease, more common in men, the right side more than the left 2 ~ 3 times, bilateral are rare, one of the common diseases in pediatric surgery. basic knowledge The proportion of illness: 0.012% Susceptible people: young children Mode of infection: non-infectious Complications: intestinal obstruction peritonitis septic shock
Cause
Causes of indirect inguinal hernia in children
(1) Causes of the disease
1. The failure of the peritoneal sheath (Nuck tube) to be degraded is the pathological basis of inguinal hernia in children. At the 5th week of the embryo, the testis origin begins in the middle kidney, located in the 2nd to 3rd lumbar vertebrae of the retroperitoneum, and the testis at the 8th week. Formation, renal degeneration in the 12th week, after which the testis gradually decreased with the development of the embryo. At the 28th week, after the testicular band was formed, it was connected between the lower pole of the testicle and the scrotum, with the traction of the lead and the transmission of intra-abdominal pressure. The testicles also descend, passing through the inner ring of the inguinal canal, the outer ring to the scrotum, and the ventral sac protrudes from the descending peritoneum of the testicular at the inner ring, forming a sheath-like protrusion, which is normally sheathed. The distal part of the spurt surrounds the testis to form the testicular sheath. After the outer ring of the testis, the sheath is also pulled into the scrotum. When the testicle is completely lowered, the sheath is degenerated and degenerated. If the sheath is not Fully closed can form a sacral or hydrocele, and the girl's abdominal sulcus contains a round ligament, from the uterus to the labia majora. When the male testis falls, there is also a peritoneal sheath, called the Nuck tube; The round ligament descends into the labia majora through the inguinal canal, closing The boy with the situation, because of different ages, processus vaginalis there are differences in the thickness, the neonatal period is extremely thin.
2. Increased intra-abdominal pressure and weak abdominal wall muscles are the triggering factors of inguinal hernia. It has been reported that 80%-90% of neonates have not closed the peritoneal sheath during birth, and the time and mechanism of closure are not clear. The incidence of neonatal oblique hernia is not high, so the existence of sheath protrusion is only the basis of inguinal hernia. There are still other predisposing factors such as increased intra-abdominal pressure, ascites, weak muscles in the abdominal wall of premature infants, etc., which promote inguinal hernia. The appearance, sometimes in the peritoneal dialysis or lateral ventricle drainage, can cause inguinal hernia or hydrocele in children with asymptomatic disease.
(two) pathogenesis
Pediatric inguinal hernia is due to the abdominal organ entering the peritoneal sheath that is not occluded and communicating with the abdominal cavity. Therefore, the unoccluded peritoneal sheath is the hernia of the congenital inguinal hernia. The oblique sac is from the inguinal canal. Located on the outside of the inferior epigastric artery, along the inguinal canal, through the abdominal wall, in front of the spermatic cord and in close contact with the spermatic cord, the spermatic vessels are outside the vas deferens, and the spermatic vessels are often separated from the vas deferens, special attention should be paid during surgery. Adult inguinal hernia is formed after the peritoneal sheath occlusion, and the peritoneal sac is formed to form a hernia sac, so the sac and the spermatic cord are relatively loose.
The inguinal canal of children is very short, especially for newborns and babies, about 1 cm in length.
Neonatal and infant omentum is very short, rarely into the hernia sac, the most common content of the sputum is the small intestine, neonatal and infant ileocecal mesenteric fixation is not perfect, the activity is large, the cecum, the appendix can not only lick Into the right sac, and can be inserted into the left sac. With the increase of age and the development of the greater omentum, the omentum of older children can enter the sac, and the cecum or bladder of a few children constitute A portion of the wall of the capsule forms a sliding hernia.
The small neck or the outer ring is relatively small, the first hair or the small baby sputum, in the intense crying, coughing, causing a sudden increase in intra-abdominal pressure, can push more organs to expand the ankle ring and enter the sac, abdomen When the internal pressure is temporarily lowered, the ankle ring elastically retracts, and the content of the ankle can not be returned and the incarceration occurs. The intestines invaded by the inguinal hernia in the children are mostly intestines, and the symptoms and signs of intestinal obstruction appear after incarceration due to local pain. And intestinal tube colic, the child is crying more and more, the intra-abdominal pressure continues to increase, combined with local pain can reflect the abdominal wall muscle spasm, increase the incarceration, difficult to repay, compared with adults, children's sac neck and ankle ring is softer Abdominal muscles and fascia tissues are weak, the abdominal muscles are less stressed by the abdominal muscles, and the mesenteric vascular elasticity is also better. Therefore, the intestinal tube is narrowed, the necrosis is rare, and the blood circulation disorder is blocked by venous return, congestion, edema. The process of development to intestinal necrosis is relatively slow, the blood circulation of the intubated intestinal tube is blocked, the intestine can appear congestion and edema, flaky hemorrhage, intestinal fistula, and there are many exudates in the sac, and the intestine is narrowed and necrotic. The turbid exudate, bloody, scrotal swelling, accompanied by systemic symptoms, spermatic time pressure, blood flow obstruction testicular infarction can occur, the incidence of 10% to 15%.
The sputum content of female sick children can have a high incidence of uterus, ovary, fallopian tubes, ovarian incarceration and necrosis, and the broad ligament or ovarian vascular pedicle can enter the hernia sac and become part of the sliding hernia sac.
According to the degree of occlusion of the peritoneal sheath and the relationship between the hernia sac and the intestine sheath cavity, the inguinal hernia is divided into two types: testicular sputum and hernia of spermatic cord, and the entire peritoneal sheath of the testicular sputum. Insufficiency, the hernia sac consists of the intestine sheath and the spermatic sheath. The testis wrapped in the sheath can be seen in the hernia sac. The peritoneal sheath of the spermatic sac is partially occluded and the spermatic part is not covered. Closed, the sac is stopped at the spermatic cord, and the testicular intestine is not accessible, and the testis is not visible in the sac.
Prevention
Pediatric inguinal hernia prevention
1. Maintain a healthy weight and avoid over-feeding to cause obesity in infants and young children.
2. Drink plenty of water and keep the stool smooth. Children over 3 months can increase the intake of vegetable soup and broken vegetables to improve the patency of stool. If there is already dry stool, you can add probiotics such as Mommy Love to improve stool traits. .
3. During pregnancy, the mother should avoid contact with high-radiation household appliances, such as microwave ovens, induction cookers, and eat more fruits and vegetables to supplement essential vitamins, especially folic acid, which is crucial for the normal development of children.
Complication
Complications in children with inguinal hernia Complications, intestinal obstruction, peritonitis, septic shock
Can be complicated by acute mechanical intestinal obstruction, if the formation of strangulated sputum, the intestine can be necrotic, peritonitis occurs, severe cases can cause septic shock.
Symptom
Infantile inguinal hernia symptoms Common symptoms Abdominal pain Leukocytosis Pain or swell in the bowel sputum area Abdominal scrotal swelling constipation Stop exhaust testicular atrophy shock
1. The general symptoms and signs are mostly within 2 years of age. Generally, symptoms and signs appear in the months after birth. It is not uncommon in the first month after birth or even the first crying after birth. The initial manifestation is the groin. The area can be retracted. When crying or other causes cause the intra-abdominal pressure to increase, the mass can be significantly increased, quiet, supine, and the mass can be reduced or completely disappeared after sleep, generally does not hinder the activity, does not affect Children develop normally, unless there is incarceration of the contents of the sputum, there is little pain and discomfort, and older children can self-report a sense of bulging.
The main signs are reversible mass in the inguinal region, the mass of the mass is not equal, smooth and soft; the smaller the mass, mostly located in the inguinal canal or protruding from the inguinal canal to the beginning of the scrotum, is oval; the larger can protrude into the scrotum The scrotum is swollen, no matter whether the mass is located in the scrotum or the spermatic cord, the upper boundary has no obvious boundary with the inguinal canal and the inguinal inner ring. It seems that the pedicle leads to the abdominal cavity, and the contents are mostly intestinal tubes. Pushing upwards, the mass can be returned to the abdominal cavity, and the bowel sounds can sometimes be heard during the process. When the contents are returned, the outer ring can be touched to increase, relax, stimulate the infant to cry or lick the cough of the elderly. At the same time, the finger can be inserted into the outer ring to feel a sense of impact. The tip of the finger is pressed against the inner ring of the inguinal canal, and the mass can no longer bulge. After the finger is removed, the mass reappears, and the history of the inguinal mass is extended. At the time of the visit, the child who did not find the sputum was examined. If you examined the local area, you can find that the groin area of the affected side is fuller than the opposite side. If the contents of the scrotum can fall into the scrotum, the scrotum of the affected side is larger than the opposite side, and the index finger is placed at the outer ring. When sliding left and right over the spermatic cord, Compared with the contralateral and ipsilateral spermatic cord thickening, and two layers of silk frictional feeling.
In addition, physical examination should pay attention to check whether the contralateral side is also present.
2. Clinical features of infantile incar cerated indirect inguinal hernia
(1) Occurred in infants under 2 years of age, especially in the small neck of the sac, or the narrow ring of the initial ring, or small babies are more likely to occur, domestic scholars reported 524 cases of infantile inguinal hernia in infants Children accounted for 90%, including 6 newborns, 111 infants, 360 children, and only 47 preschoolers to children.
(2) Compared with adults, intestinal narrowing occurs, necrosis is rare, and it occurs later.
(3) easy to lead to testicular atrophy and necrosis, the incidence rate of 10% to 15%.
(4) After a lot of intense crying, after coughing, the crotch suddenly increases, becomes hard, can not be returned and has tenderness, and the incarcerated sputum contents are mostly intestines. After incarceration, abdominal pain, bloating, vomiting may occur. Stop the symptoms of obstruction such as exhaustion and defecation. If the patient has had a strangulation later, the scrotum may have edema, redness, increased skin temperature, tenderness, etc., and there is an increase in body temperature, increased white blood cells, imbalance of water and electrolytes, and acidity. Alkaline balance disorder, toxic shock and other systemic manifestations.
3. Clinical features of indirect inguinal hernia of premature infant
(1) High incidence rate: According to statistics, the prevalence of premature infants can be as high as 9% to 11%, while the incidence of inguinal hernia in full-term neonates is only 3.5% to 5.0%; the incidence of bilateral inguinal hernia is also higher. Generally speaking, full-term neonates are common. It is reported that about 55% of patients with low birth weight are bilateral inguinal hernia, and about 44% of premature infants have bilateral inguinal hernia, while the incidence of bilateral hernia in mature infants is only the total incidence. 8% to 10%.
(2) The incidence of hernia incarceration and complications is high: According to statistics, the incidence of incarcerated hernia in premature infants is 2 to 5 times that of older children, and the incidence of intestine infarcts in children with inguinal hernia is less than 3 months. 30%, significantly higher than the incidence of inferior incarcerated inguinal hernia testicular infarction (7% to 14%), especially inguinal hernia with cryptorchidism, the testicle is not located just outside the inner ring of the inguinal Testicular infarction is more likely to occur, and some ovaries or fallopian tubes of the baby may be caused by sac compression, or the genital organs themselves may cause ovarian ischemia and infarction.
(3) Intubation and strangulation of the intestine is the most serious complication: once the intubation of the intestine occurs, the systemic symptoms are severe, and there may be bilious vomiting, obvious abdominal distension, etc., and the organ is black or dark blue. Abdominal X-ray plain film shows signs of small bowel obstruction, the disease progresses rapidly, severe cases may have symptoms of poisoning, such as tachycardia (pulse rate > 160 times / min), white blood cell count > 15 × 109 / L, nuclear left shift, water and electrolyte And acid-base balance disorder.
4. Clinical features of female indirect inguinal hernia
(1) The incidence rate is lower than that of men: although about 30% of the girls are still not occluded after 3 to 4 months of birth, the inguinal canal through the female round ligament is much smaller than that of the male, and the incidence of female inguinal hernia is The rate is significantly lower than that of men.
Lichtenstein et al reported that 6321 cases of inguinal hernia accounted for 94% of males, while females only accounted for 6%. Domestic Tong Hexiang reported 728 cases of indirect inguinal hernia and 56 cases of females, accounting for 7.7%, while Japanese scholar Qianlong reported 1976-1984. In the Department of Pediatric Surgery of the Japanese Red Cross Medical Center, 2211 cases of inguinal hernia were treated in children, 1274 cases (57.1%) of boys and 937 cases (42.9%) of girls. The incidence rate of males was still higher than that of females, but the incidence of girls was significantly higher. According to other scholars' reporting ratios, he believes that the reasons for the low incidence of girls in previous literature and scholars may be: 1 Previous reports only include surgical cases, and if unoperated cases are counted, the incidence of girls is higher than the number of past reports; 2 girls inguinal hernia symptoms are mild, failed to attract the attention of parents, did not go to the hospital for treatment; 3 physicians lack of understanding, improper examination methods lead to missed diagnosis; 4 surgeons have a negative attitude towards girls surgery, no surgical treatment; 5 There is a possibility of self-healing; 6 patients with postoperative delays, etc., he conducted a survey of 237 infants with inguinal hernia after 1 month of birth, for a period of 1 to 9 years. Results 142 Of the boys, 133 (93.7%) had undergone surgery, and only 62 of the 95 girls (65.5%) underwent surgery. A study of 136 mothers with childhood disease found that childhood surgery Only 37 cases (accounting for 27.2%), self-healing in 92 cases (67.6%); 92 cases of self-healing in the adult and 34 cases (37%), including 23 cases of pregnancy.
(2) The ratio of incarcerated hernia is high: the female inguinal canal is narrow, so the probability of incarceration is high, and it is easy to cause incarcerated uterus, ovary, tubal strangulation and necrosis. The younger the incidence, the higher the rate is reported. Of the 267 infants with a 1-year-old inguinal hernia, 133 had ovarian intrusion.
(3) The ratio of sliding sputum is high: due to repeated incarceration, chronic inflammatory stimuli and other factors, girls tend to have adhesions and form sliding sputum. According to statistics, female sliding sputum accounts for 12.5% of inguinal hernia, male only accounts for 0.9%. The clinical features of girls with sliding sputum are: small age of onset, easy to escape from the mass, large and loose outer ring, large mass, irregular shape, common in the baby and girl sliding sputum and uterus and easy to embed When the ovary is incarcerated, the local symptoms are heavy and the systemic symptoms are light. When the intestine is incarcerated, the systemic symptoms are heavy.
(4) Because of the special anatomical structure of the inguinal region, female sick children are asymptomatic except for incarcerated fistula: most of the sick children often have no mass at the time of treatment, but there is a history of reversible mass in the groin area.
After incarceration, the mass of the affected groin area is visible. If the content is ovary, sometimes the outline can be touched. In some cases, the mass of the disease is often not obvious. Only the outer ring has a bulge, the rectum is diagnosed, and the affected side is inside. The ring is full or can touch the cord.
Examine
Examination of inguinal hernia in children
General symptoms, routine examinations are normal, but if the symptoms of systemic poisoning, there may be infectious blood, white blood cells significantly increased, and even thrombocytopenia. Can do B-ultrasound examination, clear the nature of the inguinal mass, can do light transmission test and X-ray film examination to help diagnosis and differential diagnosis.
Diagnosis
Diagnosis and differential diagnosis of indirect inguinal hernia in children
diagnosis
The typical oblique sputum has the phenomenon of repayment or the history of the recipient is not difficult to diagnose, can not be returned or partially reimbursed, first should be identified with testicular hydrocele, the main identification method for reliable light transmission test, the light transmission test is When the tumor is directly irradiated with a flashlight bulb, it can be seen that the oval tumor is all red and bright, that is, the hydrocele is formed. If the part where the bulb is in contact is red, it is negative. When the baby is diagnosed with difficulty, the anus can be diagnosed first. Try to see if there is a broken intestine in the inner ring of the inguinal region. If necessary, you can take the X-ray film of the groin of the inguinal mass. The X-ray transparent is a gas-filled capsule that can be diagnosed as sputum. The blind puncture test is contraindicated.
There is no difficulty in the diagnosis of occlusion, because the sputum suddenly can not be repaid, the child immediately shows abdominal pain, crying, local tenderness, frequent vomiting, etc., can be diagnosed, but children with advanced bloating such as pneumonia or infant diarrhea can also Sudden vomiting, constipation and other symptoms of functional intestinal obstruction, at this time due to increased abdominal pressure, the simultaneous emergence of sputum can not be repaid, but in fact there is no embedding, must be identified, such as misdiagnosed as a closed sputum and surgery, Adding unnecessary surgery and anesthesia damage to critically ill children can often lead to aggravation of the disease. On the contrary, it can be caused by severe abdominal distension and high abdominal pressure. If the diagnosis is not made, the treatment can often be delayed. In addition to systemic symptoms and symptoms of intestinal obstruction, the diagnosis of embedding sputum should also pay attention to local tenderness, hardness, impulsiveness and the time program of each symptom, in order to identify, the advanced stenosis, severe poisoning in children, local red , swollen, hot pain, sometimes need to be differentiated from inguinal lymphadenitis, detailed history and clear symptoms of intestinal obstruction are often the key to diagnosis.
Differential diagnosis
Pediatric inguinal hernia should be identified with the following diseases.
1. Hydrocele of tunica vaginalis The pathogenesis of pediatric hydrocele and congenital inguinal hernia is the same, both of which are delayed or paused in the development of the peritoneal sheath, still not occluded at birth or only Partial occlusion, caused by the communication with the abdominal cavity, the difference is that the patent is closed, the peritoneal sheath is relatively narrow. In recent years, according to its occlusion site, it is divided into two types: spermatic hydrocele and testicular hydrocele. .
(1) funicular hydrocele: the peritoneal sheath is extremely occluded on the testicle, only the spermatic cord communicates with the abdominal cavity, and the fluid accumulates in the spermatic cord above the testicle, and the mass is round or oval. Located in the inguinal canal or above the scrotum, it can move with the spermatic cord, the light transmission test is positive, the testicle can be touched, and the female hydrocele is located in the inguinal canal or the labia majora.
(2) hydrocele testis (hydrocele testis): the entire peritoneal sheath is not closed, the liquid enters the testis inherent sheath cavity through the spermatic sheath, the mass is located in the scrotum, cystic, slowly changing by hand Small, testicles were encased in the capsular sac, and the smear was positive for light transmission.
The serosal hydrocele and the testicular hydrocele can shrink or disappear after morning or rest, and increase after activity and play.
2. cryptorchidism (cryptorchidism) The testis is located in the inguinal canal or the upper part of the scrotum, is a substantial mass, but small, squeezing pain, the affected side of the scrotum development is small, emptiness, contracture, the scrotum can not touch the testicles, squeeze There is pain in the lower abdomen, because there is often a sclerosing insufficiency, so there are cryptorchidism, oblique or hydrocele fluid signs.
3. Inguinal lymphadenitis (bubo) Incarcerated or strangulated sputum should be differentiated, inguinal lymphadenitis children have no history of mass in the inguinal region, accompanied by pain in the inguinal region, fever, but no symptoms and signs of intestinal obstruction, The mass is located on the outer side of the outer ring, the boundary is clear, and the relationship with the inguinal canal is not close. The local skin has redness, temperature rise and tenderness and other inflammatory changes, while the upper boundary of the block has no obvious boundary with the inguinal canal and the inguinal inner ring. The pedicle leads to the abdominal cavity. In addition, some children with inguinal lymphadenitis can sometimes find traumatic or infectious lesions in the inguinal lymphatic drainage area. B-ultrasound is helpful for diagnosis.
4. Testicular tumor (orchioncus) is mostly a painless solid mass, the scrotum has a heavy fall feeling, can not be included in the abdominal cavity, some children have sexual precocity, serum alpha-fetoprotein determination, etc. are helpful for diagnosis.
5. Cyst of ligmentum teres uteri can also promote the occurrence of inguinal hernia, should pay attention to the identification of the two, but the identification is more difficult.
6. direct hernia (direct hernia) pediatric inguinal hernia is rare, anatomical oblique sac neck in the inferior epigastric artery into the inguinal canal, and the direct sac is directly protruding outward in the inner side of the artery, oppressed The ring mouth can prevent the drop from falling, but the straight sputum can still appear. The sacral neck is wide and rarely incarcerated. Most children with straight sac have a history of ipsilateral sacral repair, which may be when looking for a sac. Injury of the posterior wall of the inguinal canal, resulting in weak transverse fascia injury, when the abdominal pressure increases, the peritoneum and visceral protrusion, surgical treatment is mainly to repair the posterior wall of the inguinal canal, suture the transverse fascia, combined tendon to pubic ligament (Cooper ligament).
