49 Umbilical and Other
Abdominal Wall Hernias
JOSEPH A. SUJKA and GEORGE W. HOLCOMB III
Umbilical Hernia
Umbilical hernia is a common disorder in children and is
frequently evaluated and treated by pediatric and general
surgeons. Unlike other hernias of childhood, a fascial defect
is present at birth but may resolve without the need for an
operation. An understanding of the embryology, anatomy,
incidence, natural history, and complications is important
to any surgeon managing umbilical hernias in children.
ANATOMY
After birth, closure of the umbilical ring is the result of
complex interactions with the lateral body wall folding in
a medial direction, fusion of the rectus abdominis muscles
into the linea alba, and umbilical orifice contraction that
is aided by elastic fibers from the obliterated umbilical
arteries. Fibrous proliferation of the surrounding lateral
connective tissue plates and mechanical stress from rec-
tus muscle tension also may help with natural closure.
Failure of these closure processes results in an umbilical
hernia. The hernia sac is peritoneum and is usually very
adherent to the dermis of the umbilical skin. The diam-
eter of the actual fascial defect can range from several
millimeters to 5 cm or more. The extent of skin protru-
sion is not always indicative of the size of the fascia defect.
Frequently, small defects can result in alarmingly large
proboscis-like protrusions (Fig. 49.1). Thus, it is impor-
tant to palpate the actual fascial defect by reducing the
hernia to assess whether operative or nonoperative treat-
ment is appropriate.
INCIDENCE
The incidence of umbilical hernia in the general population
varies with age, race, gestational age, and coexisting disor-
ders. In the United States, umbilical hernias are present in
15–25% of newborns or approximately 800,000 children
annually.1,2 Historical studies suggest a higher incidence
of umbilical hernia in the African-American population,
with an incidence from birth to 1 year of age ranging from
25–58%, whereas Caucasian children in the same age
group have an incidence of 2–20%.3,4 Premature and low
birth weight infants have a higher incidence than full-term
infants.5 Infants with other conditions, such as Beckwith–
Wiedemann syndrome, Hurler syndrome, various trisomy
conditions (trisomies 13, 18, and 21), and congenital hypo-
thyroidism, also have an increased incidence, as do children
requiring peritoneal dialysis.6,7
780
TREATMENT
For many years, it has been known that umbilical hernias
will close spontaneously. It is very safe to observe the hernia
until ages 4–5 years to allow closure to occur. Pressure dress-
ings and other devices to keep the hernia reduced are not
suggested and do not enhance the closure process. Instead
they may result in skin irritation and breakdown. A number
of studies have demonstrated spontaneous resolution rates of
>90% of hernias by 1 year of age.8–14 One study found that
50% of hernias still present at age 4–5 years will close by age
11 years.11 Another study suggests that hernias with fascial
defects greater than 1.5 cm are unlikely to close by age 6
years, whereas other series conclude that even large defects
may spontaneously resolve without an operation.10,15,16
The primary danger associated with observation is the possi-
bility of incarceration or strangulation. Studies have shown
these complications to be quite rare, with an incidence less
than 1%.12,17,18 Patients with small fascial defects (0.5–1.5
cm in diameter) appear more prone to incarceration.18
Operative closure of an umbilical hernia is generally
straightforward and usually can be completed as an out-
patient procedure. A small transverse infraumbilical inci-
sion is made, usually placed in the redundant skin, which
is inverted at the conclusion of the procedure, thereby hid-
ing the incision. The hernia sac is identified and dissected
free from the dermis underlying the umbilical cicatrix. The
authors’ preference is excision of the sac to the fascial edges,
although other surgeons prefer a more limited excision of
the sac or inversion of the sac through the fascial opening.
Interrupted sutures with 0 or 2-0 nonabsorbable or long-
lasting absorbable sutures are placed and tied, closing the
Fig. 49.1 This 5-year-old child has a large proboscis-like umbilical
­hernia.

fascial defect in a transverse direction. Using 3-0 absorbable
suture, the dermis of the umbilicus is tacked in two places to
the fascial closure. Inversion of the umbilical skin may be
impaired in the setting of a fascial remnant of the umbili-
cal stalk or a thickened dermis. To improve skin inversion,
radial partial-thickness incisions on the undersurface of the
umbilicus in the fascia and dermis can be performed.19
A
B C
D tric hernia should not be confused with diastasis recti, which
E xiphoid, and almost always resolves by 10 years of age.
F
Fig. 49.2 The technique for operative repair for an umbilical hernia.
(A) An infraumbilical skin crease incision is made. (B) The hernia sac
is opened, leaving a portion of the sac attached to the umbilical skin
for ease of subsequent umbilicoplasty. (C) The umbilical sac has been
completely divided and excised to strong fascia. (D) The fascial defect
is closed in a transverse fashion with interrupted, simple nonabsorb-
able sutures. (E) The remaining umbilical sac, which is attached to the
umbilical skin, is secured to the fascia with interrupted, absorbable
sutures. (F) The skin incision is closed with a subcuticular suture.
A B
Fig. 49.3 The steps depicted in the operative diagram in Figure 49.2 are shown. (A) An infraumbilical incision is made. (B) The umbilical hernia sac has
been encircled with a hemostat. (C) The umbilical hernia sac is excised, and transverse closure of the fascial defect is accomplished with interrupted
long-lasting absorbable sutures. (D) The umbilicus has been tacked to the fascial closure, and the skin is approximated with a subcuticular closure.
49 • Umbilical and Other Abdominal Wall Hernias 781
The skin incision is closed with an absorbable subcu-
ticular suture, and a dressing is applied. The most com-
mon method of repair is shown in Figures 49.2 and 49.3.
Many surgeons use a pressure dressing to help prevent the
development of a hematoma and keep the umbilical skin
inverted, but it is not clear if this type of dressing is neces-
sary.20 Methods used commonly in the adult, such as pros-
thetic placement, are almost never needed in the child.
Excision of the redundant skin is usually not needed
because the umbilicus tends to return to a normal appearance
after the hernia is repaired. This can take up to 12 months
to occur, and the family should be reassured appropriately.
If the umbilicus fails to return to an acceptable appearance
after 1–2 years, there are a number of techniques described
to restore it to a more normal configuration.21–23
Complications of umbilical hernia repair are infrequent
and include seroma or hematoma formation. These are
usually self-limited and resolve spontaneously. Wound
infections generally can be managed with local care and
antibiotics, whereas a recurrent hernia, occurring in less
than 1%, requires reoperation.18
Epigastric Hernia
Hernias of the abdominal wall through the midline linea
alba, also termed epigastric hernias, are common, with an
incidence up to 5%.24 Half of these patients are symptom-
atic on presentation. These hernias present as either a small
painless mass, which becomes painful with activity, or a
small painful incarcerated mass. Typical contents are pre-
peritoneal fat, with a location between the umbilicus and
xiphoid process (Fig. 49.4). These hernias can be multiple
and can be found along with an umbilical hernia. An epigas-
is generalized weakness in the linea alba from umbilicus to
Epigastric hernias do not resolve and should be repaired.
A small midline incision over the hernia is generally used,
with suture repair of the defect after the contents (pre-
peritoneal fat) are reduced or excised. The site of the her-
nia always should be marked before general anesthesia
is induced because the defect may be difficult to find after
muscle relaxation. Recurrence is not common.
Spigelian Hernia
Spigelian hernias are quite rare in children and can be dif-
ficult to detect and diagnose. The actual defect occurs at the
C D
782 Holcomb and Ashcraft’s Pediatric Surgery
Fig. 49.4 At the time of epigastric hernia repair, this operative pho-
tograph shows herniation of properitoneal fat through a small fascial
defect in the linea alba.
intersection of the linea semicircularis, linea semilunaris,
and the lateral border of the rectus abdominis muscle. It
usually involves absence or attenuation of the transver-
sus abdominis and internal oblique muscles. These hernias
occur more frequently in girls and occur equally on both
sides of the abdomen.25,26 The hernia defects range in size
from 1–3 cm.27 Pain in the area with a feeling of fullness or
an actual mass are the most common symptoms. They are
occasionally associated with skeletal abnormalities28 and
also may be associated with ipsilateral cryptorchidism.29
Ultrasonography may aid in the diagnosis. In select cases,
computed tomography may be needed.
Repair consists of a transverse incision over the defect
with excision of the hernia sac and closure of the defect. Fre-
quently, the sac is found below the external oblique muscle
and may require mesh if the defect is large. A tension-free
closure is important to prevent recurrence in this area that
has a high level of muscle tension.
Lumbar Hernia
Lumbar hernias typically present by 2 years of age as a vis-
ible bulge in the area bordered by the 12th rib, sacrospinalis
muscle, and internal oblique muscle.30 Occasionally, they
extend inferiorly to the iliac crest. These hernias tend to
develop at the site of penetration of the intercostal nerves
and vessels, or of the ilioinguinal, iliohypogastric, and lum-
bar nerves. The bulge is usually due to herniated preperito-
neal fat. Physical findings include a soft mass that is easily
reducible. Although frequently asymptomatic, repair is
advisable because the defect never resolves spontaneously
and incarceration is possible.
Repair sometimes requires prosthetic reinforcement of
the fascia or muscle closure because the tissue available for
repair is usually thin and weak. Using absorbable biosyn-
thetic mesh that will not cause scoliosis later is preferred in
the growing child. Recurrence is not uncommon, but sev-
eral operations may be needed. Bilateral lumbar hernias
can be corrected with either staged or simultaneous clo-
sures, depending on the surgeon’s and family’s preferences.
References
1. Arias E. United States Life Tables, 2011. Natl Vital Stat Rep Cent Dis
Control Prev Natl Cent Health Stat Natl Vital Stat Syst. 2015;64:1–63.
2. Keshtgar AS, Griffiths M. Incarceration of umbilical hernia in chil-
dren: is the trend increasing? Eur J Pediatr Surg. 2003;13:40–43.
3. Crump EP, Umbilical hernia I. Occurrence of the infantile type in
Negro infants and children. J Pediatr. 1952;40:214–223.
4. Evans AG. The comparative incidence of umbilical hernias in colored
and white infants. J Natl Med Assoc. 1941;33:158–160.
5. Vohr BR, Rosenfield AG, Oh W. Umbilical hernia in the low-birth-
weight infant (less than 1,500 gm). J Pediatr. 1977;90:807–808.
6. Smith DW, Jones KL. Abdominal wall. In: Jones KL, ed. Smith’s Rec-
ognizable Patterns of Human Malformation. 4th ed. Philadelphia: Saun-
ders; 1988:778.
7. Tank ES, Hatch DA. Hernias complicating chronic ambulatory perito-
neal dialysis in children. J Pediatr Surg. 1986;21:41–42.
8. Woods GE. Some observations on umbilical hernia in infants. Arch Dis
Child. 1953;28:450–462.
9. Heifetz CJ, Bilsel ZT, Gaus WW. Observations on the disappearance
of umbilical hernias of infancy and childhood. Surg Gynecol Obstet.
1963;116:469–473.
10. Walker SH. The natural history of umbilical hernia. A six-year fol-
low up of 314 Negro children with this defect. Clin Pediatr (Phila).
1967;6:29–32.
11. Hall DE, Roberts KB, Charney E. Umbilical hernia: what happens after
age 5 years? J Pediatr. 1981;98:415–417.
12. Sibley WL, Lynn HB, Harris LE. A twenty-five year study of infantile
umbilical hernia. Surgery. 1964;55:462–468.
13. Mack NK. The incidence of umbilical herniae in Africans. East Afr Med
J. 1945;22:369–371.
14. Haworth JC. Adhesive strapping for umbilical hernia in infants; clini-
cal trial. Br Med J. 1956;2:1286–1287.
15. Blumberg NA. Infantile umbilical hernia. Surg Gynecol Obstet.
1980;150:187–192.
16. Halpern LJ. Spontaneous healing of umbilical hernias. JAMA.
1962;182:851–852.
17. Zendejas B, Kuchena A, Onkendi EO, et al. Fifty-three-year experi-
ence with pediatric umbilical hernia repairs. J Pediatr Surg. 2011;46:
2151–2156.
18. Lassaletta L, Fonkalsrud EW, Tovar JA. The management of umbi-
licial hernias in infancy and childhood. J Pediatr Surg. 1975;10:
405–409.
19. Cordes EJ, LaPlant M, Saltzman DA. Radial umbilical dermatofacioly-
sis to invert the skin following umbilical herniorrhaphy. J Pediatr Surg.
2018;53(6):1250–1251.
20. Merei JM. Umbilical hernia repair in children: is pressure dressing nec-
essary. Pediatr Surg Int. 2006;22:446–448.
21. Jamra FA. Reconstruction of the umbilicus by a double V--Y proce-
dure. Plast Reconstr Surg. 1979;64:106–107.
22. Reyna TM, Hollis HW, Smith SB. Surgical management of proboscoid
herniae. J Pediatr Surg. 1987;22:911–912.
23. Koshy CE, Taams KO. Umbilicoplasty. Plast Reconstr Surg.
1999;104:1203–1204.
24. Coats RD, Helikson MA, Burd RS. Presentation and management of
epigastric hernias in children. J Pediatr Surg. 2000;35:1754–1756.
25. Spangen L. Spigelian hernia. Surg Clin North Am. 1984;64:351–366.
26. Losanoff JE, Richman BW, Jones JW. Spigelian hernia in a child: case
report and review of the literature. Hernia. 2002;6:191–193.
27. Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surg Clin North
Am. 2013;93:1255–1267.
28. Aksu B, Temizöz O, Inan M, et al. Bilateral spigelian hernia concomi-
tant with multiple skeletal anomalies and fibular aplasia in a child.
Eur J Pediatr Surg. 2008;18:205–208.
29. Balsara ZR, Martin AE, Wiener JS. Congenital spigelian hernia and
ipsilateral cryptorchidism: raising awareness among urologists.
Urology. 2014;83:457–459.
30. Rattan KN, Agarwal A, Dhiman A. Congenital lumbar her-
nia: a 15-year experience at a single tertiary centre. Int J Pediatr.
2016;2016:7162475.
SECTION V
Inguinal Region and
Scrotum

783
 50 Inguinal Hernia
CHARLES L. SNYDER, MARIA ESCOLINO, and CIRO ESPOSITO
Inguinal hernias have been documented since the dawn of
recorded history. The term “hernia” comes from the Greek
hernios, meaning offshoot or bud. Because an inguinal her-
nia is present in many different species of animals, particu-
larly primates, prehistoric humans likely suffered from this
condition as well.
The Egyptian Ebers papyrus from 1550 bc describes
the diagnosis and treatment of an inguinal hernia.1 Also,
mummies (e.g., Ramses V, 1157 bc) from ancient Egypt
have been found to have inguinal hernias.2 Hernias were
mentioned in the Hippocratic Corpus in ancient Greece.2
During the Roman Empire, Celsus (c. 25 bc to c. 50 ad)
described hernia reduction and treatment (ligation, spar-
ing the testis) in de Re Medica.2 Galen (b. 129 ad) later
described the processus vaginalis and defined hernias as a
rupture of the peritoneum.3 He advised ligation of the sac
and cord with sacrifice of the testicle. Galen’s recommenda-
tions were followed for centuries. Arabic surgeons (Albuca-
sis, 1114–1187) recommended treating an inguinal hernia
by cauterization, and this technique was adopted by some
Western surgeons during the Middle Ages.2 Ambrose Paré
(1510–1590) recommended conservative treatment but
also described ligation of inguinal hernias in childhood and
advocated against removal of the testis.1
The advent of anesthesia and antisepsis in the mid-1800s
paved the way for refinements in the treatment of inguinal
hernias. Bassini described internal inguinal ring tightening
and reinforcement of the posterior canal in 1887.4 His recur-
rence and infection rates after over 200 repairs were approxi-
mately 5%. Gross reported a 0.45% recurrence rate in a large
series of hernia repairs in 3874 children in 1953.5 The first
laparoscopic hernia repair was reported by Ger in 1982.2
Incidence and Epidemiology
The overall lifetime incidence of an inguinal hernia is esti-
mated to be approximately 5% for males. Inguinal hernias
in males are 5–10 times more common than in females.
The age at presentation of an inguinal hernia also varies by
gender. A database review of nearly 80,000 children from
Taiwan found the peak incidence of an inguinal hernia in
males to be under 1 year of age and 4.7 years in females.6 In
that study, hernias were much more common under 1 year
of age, with a decreasing incidence thereafter. Incarcera-
tion was found to be equally common in males and females.
Hernias are about twice as common on the right7,8 and
are bilateral in about 10% of patients.6,7 Bilateral hernias
are nearly twice as common in girls.6 A Swedish population-
based study found that there was a twofold increase in
the odds of developing an inguinal hernia when a sibling
was found to have an inguinal hernia.9 A family history
784
of inguinal hernia is found in 10–25% of children with an
inguinal hernia.10–12 There is an increased incidence in
twins, more frequently in male twins.13
Embryology
The abdominal cavity is lined by the parietal peritoneum,
and an outpouching in front of the testis and gubernaculum
in boys, known as the processus vaginalis, is first seen during
the 2nd or 3rd month of gestation.14 Germ cells are found
in the urogenital ridge by the 6th week of gestation. By the
7th week, the testes have begun to differentiate.15 Testicular
descent occurs in two stages: the first is an abdominal phase
(8–15 weeks gestation) with swelling and strengthening of
the distal gubernaculum under the influence of insulin-like
hormone 3 (Insl3).16 The swelling causes the gubernaculum
to maintain a fixed length in males. At the same time, fetal
testosterone causes regression of the cranial suspensory liga-
ment. The testis is thus anchored to the internal ring while
the abdominal cavity increases in size. By 25–35 weeks
(inguinoscrotal phase), the gubernaculum extends down
to the base of the scrotum. Androgenic hormones lead to
release of neurotrophins that regulate the sensory branches
of the genitofemoral nerve. Calcitonin gene-related peptide
(CGRP) release provides a local chemotactic gradient to guide
the gubernaculum.16 The testis then passes through the
inguinal canal and eventually reaches the base of the scro-
tum. The female anlage of the processus vaginalis is the canal
of Nuck, a structure that leads to the labia majora. This also
closes by about 7 months of fetal life, and ovarian descent is
arrested in the pelvis.
Once testicular descent is complete, obliteration of the
patent processus vaginalis (PPV) usually occurs. Initial
closure of the internal inguinal ring is followed by oblitera-
tion of the part of the processus vaginalis superior to the
testis. The residual space between the cranial and caudal
portions (funicular process) is normally the last to obliter-
ate.14 Failure of obliteration results in an indirect inguinal
hernia or hydrocele (Fig. 50.1). Factors driving PPV clo-
sure are incompletely understood. Disorders with increased
abdominal pressure/fluid (e.g., ascites, chronic cough) are
associated with an increased incidence of indirect inguinal
hernias as well as bilaterality. Prematurity results in deliv-
ery prior to completion of normal descent and obliteration,
and is associated with an increased incidence of inguinal
hernia ranging from 10–30%, depending on the degree of
prematurity.
The layers of the abdominal wall contribute to the layers
of the testis and spermatic cord as the gonad descends. The
internal spermatic fascia is a continuation of the transver-
salis fascia, the cremaster muscle derives from the internal

Peritoneal
cavity
Process
vaginalis
Normal Hydrocele
Fig. 50.1 From left, configurations of hydrocele and hernia in relation to patency of the processus vaginalis.
Box 50.1 Conditions Associated With
Inguinal Hernia
Prematurity
Family history
Cystic fibrosis and meconium peritonitis
Hydrocephalus (ventriculoperitoneal shunt)
Peritoneal dialysis
Ascites
Genitourinary abnormalities
Connective tissue disorders
Mucopolysaccharidoses
Glycogen storage diseases
Abdominal wall defects
Chronic lung disease
oblique, and the external spermatic fascia originates from
the external oblique aponeurosis. The processus vaginalis
envelops the testis as the visceral and parietal layers of the
tunica vaginalis.17
Associations and Risk Factors
Many conditions are associated with an inguinal hernia
(Box 50.1). The most common association is prematu-
rity due to interruption of the normal process of testicular
descent as well as comorbidities (e.g., chronic lung disease)
in this population.
Cystic fibrosis (CF) carries an increased incidence (15%)
of inguinal hernia.18 An increased risk of inguinal hernia
in unaffected fathers and siblings of these children suggests
genetic factors may be involved in addition to the mechanical
effects of chronic lung disease and increased intra-abdominal
pressure. The well-recognized vasal abnormalities in chil-
dren with CF support an embryologic component.19–21 Along
with many of the other conditions in Box 50.1, CF is also a
risk factor for bilaterality and recurrence.22
Occasionally, a small or absent vas is found during ingui-
nal hernia repair in males. Renal ultrasound (US) should
be electively obtained to evaluate for associated ipsilateral
renal agenesis.23,24 Abnormalities of the vas should also
prompt an evaluation for CF (Fig. 50.2). Congenital absence
50 • Inguinal Hernia 785
Communicating Inguinal hernia Complete
hydrocele inguinal hernia
(bilateral or unilateral) of the vas is a heterogeneous disor-
der, largely due to mutations in the CF gene.21 Differing
genotypes are noted with congenital absence of the vas as
an isolated entity versus congenital absence of the vas in
association with renal anomalies.20
Ventriculoperitoneal shunts (VPSs) for hydrocephalus
are associated with an increased incidence of inguinal her-
nia (15–25%)25,26 and higher rates of bilaterality, incar-
ceration, and recurrence. Inguinal hernias are more likely
to develop in neonates than in older children who undergo
VPS and are more common in boys than girls. The aver-
age time from placement of a VPS to inguinal hernia repair
is around 5–12 months.26,27 Other conditions in which
excess intra-abdominal fluid is present (peritoneal dialysis,
ascites, hydrops) have similar associations.
Classification
The term inguinal hernia includes indirect inguinal her-
nias, direct hernias, and femoral hernias. Indirect inguinal
hernias, lateral to the inferior epigastric vessels, are by far
the most common in children. Even in young adults (16–18
years of age), direct inguinal hernias are uncommon. Fem-
oral hernias (inferior to the inguinal ligament) (Fig. 50.3)
account for less than 1% of pediatric inguinal hernias.7,28,29
Sliding hernias are those in which viscera (bowel, blad-
der, reproductive structures) compose part of the hernia
sac (Fig. 50.4). Pantaloon (the term is derived from baggy
trousers gathered at the ankles) hernias consist of direct
and indirect inguinal hernias and are more common in
neonates.7,30 Eponymous inguinal hernias include Amy-
and (appendix in the hernia sac) (Fig. 50.5), Littre (Meckel
diverticulum in the sac), and Richter (ischemic antimesen-
teric bowel border in the hernia) hernias.1,31,32
Clinical Findings
The diagnosis of an inguinal hernia is clinical and rests on the
history and physical examination. The usual presentation of a
hernia in a child is an asymptomatic, intermittent, unilateral
inguinal bulge (Fig. 50.6). On occasion, an infant or young child
786 Holcomb and Ashcraft’s Pediatric Surgery

A B

Fig. 50.2 This child with cystic fibrosis is undergoing diagnostic laparoscopy. Note the vas deferens (arrows) is atrophic on both sides. (A) Left, (B) Right.
This is commonly seen in boys with cystic fibrosis.

Fig. 50.3 This 15-year-old patient presented with a left inguino-femoral

bulge that was suspicious for a left femoral hernia. The left femoral
hernia was confirmed with diagnostic laparoscopy. She underwent a
McVay repair and recovered uneventfully. Note the internal inguinal
ring is closed (arrow).

can present with bilateral inguinal hernias (Fig. 50.7). Activi-

ties that increase intra-abdominal pressure (crying, coughing,
straining, etc.) can elicit the hernia. Most are found by the par-
ents or the pediatrician on routine physical examination.
Because the inguinal bulging is intermittent, it is com-
mon to have a normal examination and a suggestive his-
tory. Cell phone picture documentation by the parents has
become commonplace. A convincing history is acceptable
as an indication for operation, particularly when diagnostic
laparoscopy in questionable cases enables definitive diag-
nosis and repair.
Pertinent elements of the history include prior pre-
maturity, family history, prior genitourinary anomalies
Fig. 50.4 This 6-month-old girl presented with a left inguinal bulge.
The hernia contents could not be reduced, and an incarcerated left
ovary was suspected. She underwent open repair the following day,
and the incarcerated ovary (asterisk) was visualized upon opening the
inguinal hernia sac. The ovary was reduced, and high ligation of the
inguinal hernia was performed. She recovered uneventfully.
(undescended testis, hypospadias, hydrocele), and the
presence or absence of the associated factors (see Box
50.1). The differential diagnosis includes retractile testis,
lymphadenopathy, hydrocele, varicocele, and prepuber-
tal fat.

A frequent referral is a child with inguinal pain, no history
of bulging or swelling, and a normal physical examination.
Other sources such as musculoskeletal strain, gastrointes-
tinal, or genitourinary causes should be excluded before
operative intervention. Diagnostic laparoscopy is useful in
those with equivocal examinations or persistent symptoms
and no other apparent cause.
The most common examination finding is a reducible
inguinal or scrotal bulge, more prominent during Valsalva
maneuvers. Having the child raise the head while supine, or
“blowing up a balloon” with a thumb in the mouth, may be
Fig. 50.5 This infant was undergoing open repair of a large right ingui-
nal hernia. Upon mobilization of the hernia sac, the appendix could
be seen through the wall of the sac. The eponym for this finding is an
Amyand hernia.
A B
Fig. 50.7 This infant with bilateral inguinal hernias was placed on the operating room table. The large bilateral inguinal hernias are seen on the left (A).
Prior to prep and drape, the hernias were reduced (B).
50 • Inguinal Hernia 787
helpful in small children. Standing the child upright also may
help demonstrate the hernia. The “silk glove sign’” (feeling
the thickened peritoneum of the patent processus as the cord
is palpated) is examiner-dependent but can have more than
90% sensitivity in experienced hands.33 In girls, a hard mass
may sometimes be felt if the ovary protrudes into the sac.
Radiologic assessment is not usually necessary or help-
ful. US can be used to identify a PPV indirectly via widening
of the internal inguinal ring (more than 4–5 mm is posi-
tive), but the technique is highly operator dependent and
not widely used in children. In a few reports, US has been
used to identify a contralateral PPV.34–36
Fig. 50.6 This infant presented in typical fashion with an intermittent,
unilateral inguinal (right) bulge that was reducible.
788 Holcomb and Ashcraft’s Pediatric Surgery
HYDROCELE
The presence of fluid in the scrotum or inguinal canal in
boys or in the inguinal/labial area in girls is indicative of a
hydrocele (Fig. 50.8). These are commonly seen in infancy,
with a secondary peak in adolescent boys.
Hydroceles in infants are usually managed expectantly
in the absence of evidence of communication indicat-
ing a PPV (Fig. 50.9). Factors indicating communication
include development of a new hydrocele after birth, wax-
ing and waning in the size of the fluid collection, and fail-
ure to resolve by 1–2 years of age. Most surgeons observe
noncommunicating hydroceles until the child reaches 1–2
years of age.
Communicating hydroceles in infants are treated as a
hernia and repaired electively after diagnosis by some sur-
geons,37 whereas others advocate observation and expect-
ant management.38,39 Surveys of North American pediatric
surgeons in 1996 and 2003 found that observation for
communicating hydroceles was preferred by only one-
third in 1996 and 54% in 2005.40,41 A 2017 survey in the
United Kingdom noted that most (61%) pediatric surgeons
and urologists did not distinguish between communicat-
ing and noncommunicating hydroceles, and most deferred
repair until 2–3 years of age.42 Resolution of apparently
communicating, asymptomatic hydroceles is reported in
60–90% of cases.38,39
Hydrocele of the cord is due to obliteration of the proxi-
mal and distal processus, with retention of a fluid-filled
sac along the spermatic cord. On examination, a smooth
sausage-link mobile mass is palpable in the inguinal canal.
Fig. 50.8 This 5-year-old child presented with a large left communicat-
ing hydrocele and underwent left inguinal hernia repair and hydroce-
lectomy.
It can sometimes be difficult to distinguish cord hydroceles
from an incarcerated inguinal hernia, particularly in an
irritable baby who has undergone attempted reduction by
other examiners. US may be helpful in this situation. As
with communicating hydroceles in infants, management of
cord hydroceles is controversial, with some favoring opera-
tion and others observation.37,41–43 Giant hydroceles (there
is no objective definition) are considered an indication for
operation by some surgeons, even without evidence of
communication.
Abdominoscrotal hydrocele is an unusual entity. These
are large scrotal masses with inguinoscrotal and abdominal
components in a dumbbell configuration. The diagnosis is
suggested by the “springing back ball” sign: cross-fluctuation
in which compression of the scrotal component causes pro-
trusion of the abdominal component and vice versa. Lapa-
roscopy can be confirmatory.44 Treatment ranges from
aspiration/observation to inguinal exploration to a com-
bined inguinoscrotal and laparoscopic approach.45–47
Most adolescent hydroceles are noncommunicating.48
A history and physical examination can reasonably reli-
ably exclude communication.49 If no clear cause is identi-
fied, US can be performed. A transscrotal hydrocelectomy is
appropriate in adolescents in the absence of signs of a PPV
or tumor.50
INCARCERATION
The incidence of incarceration in an inguinal hernia is vari-
able and age-dependent (peaking in the first year of life),
and ranges from 3–16%.51,52 Most studies show a relatively
equal gender distribution in proportion to the gender dis-
tribution of hernias in general.6,8 Prematurity, although
a risk factor for the presence of a hernia, may or may not
be associated with an increased risk of incarceration.6,51,53
Increasing the wait time for elective hernia repair in infancy
increases the risk of incarceration.54,55 Many series of incar-
cerated hernias note a prior history of an unrepaired ingui-
nal hernia, some even with a history of incarceration.51,54,56
In some patients, incarceration may be the presenting
sign of the inguinal hernia. As previously mentioned, it can
Fig. 50.9 This infant presented with a right hydrocele that was noted
at birth and was slowly resolving. The hydrocele was observed and
resolved by 1 year of age.

be difficult to distinguish a hydrocele of the cord from an
incarcerated hernia. A happy infant with no tenderness
suggests the former diagnosis, but if several examiners have
vigorously attempted to reduce the hydrocele, the distinc-
tion can be difficult and US may be helpful. If a torsed tes-
ticle is in the differential, US is indicated as well. Symptoms
of incarceration frequently manifest as a fussy or inconsol-
able infant with intermittent abdominal pain and vomit-
ing. Older, verbal patients will complain of severe pain and
tenderness. A tender and sometimes erythematous irre-
ducible mass is noted in the groin (Fig. 50.10). Abdominal
Fig. 50.10 This infant presented with a painful, tender right inguinal
mass that could not be reduced. He was taken to the operating room
emergently and found to have ischemia/infarction of a knuckle of small
bowel. Through the inguinal incision, a short-segment bowel resection
was performed with primary anastomosis. He recovered uneventfully.
A B
Fig. 50.11 These two infants underwent emergent laparoscopic repairs for incarcerated right inguinal hernias. On the left (A) the bowel could be
reduced and a laparoscopic hernia repair was performed. On the right (B) the bowel was able to be reduced, but a short segment of it was infarcted. The
bowel was exteriorized by enlarging the umbilical incision, and an extracorporeal bowel resection was performed. Both infants recovered uneventfully.
50 • Inguinal Hernia 789
distention, bowel obstruction, and bloody stools are late
signs. Peritoneal signs suggest strangulated intestine. Gas-
filled bowel loops may be seen in the scrotum on plain films.
It is sometimes stated that gangrenous or ischemic
bowel cannot be reduced, but exceptions make this a
dangerous rule to rely on.57 The presence of peritonitis,
hemodynamic instability, or septic shock is an absolute
contraindication to attempted reduction. Symptoms of
bowel obstruction are a relative contraindication. Moni-
tored conscious sedation is used after intravenous access
and rehydration. Firm and continuous pressure is applied
around the incarceration. Successful reduction is usually
confirmed by a sudden “pop” of the contents back into the
peritoneal cavity. Questionable or incomplete reductions
should be explored. Reduction en mass, in which the her-
nia contents are reduced into the peritoneal cavity but the
bowel remains incarcerated internally in the hernia sac, is
a very rare occurrence, but the surgeon should be aware
of this possibility.
After reduction of an incarcerated hernia, a delay of
24–48 hours to allow resolution of the edema prior to open
repair has historically been recommended. Delay is less
important if the laparoscopic approach is planned. Reliabil-
ity of the family as well as the clinical history (very difficult
reduction) and geographic considerations may dictate the
need for admission and observation before definitive repair.
It is estimated that 70–95% of incarcerated hernias can be
successfully reduced.51,58 In one report of 743 incarcerated
hernias, only 8% required an emergency operation and 2
children required bowel resection.8
An urgent operation is necessary if reduction of the her-
nia contents is unsuccessful or incomplete. We prefer the
laparoscopic approach for incarcerated hernias (Fig. 50.11),
and there is evidence that the laparoscopic approach is asso-
ciated with fewer complications.59–63 Using laparoscopic
traction and manual external pressure, it is usually possible
to reduce the hernia contents. The intestine or appendix
can be exteriorized through the umbilicus for examination
or to perform a bowel resection or appendectomy in the rare
event resection is needed.64,65
On occasion, the hernia may spontaneously reduce with
induction of general anesthesia. If laparoscopy is planned,
it should proceed. Once the hernia contents are reduced,
the repair is as described elsewhere in this chapter. In an
790 Holcomb and Ashcraft’s Pediatric Surgery
open repair, bloody fluid or enteric contents from the open
sac mandate additional investigation. A laparoscope can
be inserted through the sac or via the umbilicus to evalu-
ate for intestinal injury. Alternatively, a separate inci-
sion or La Roque maneuver (incision in the transversalis
through the same inguinal skin incision, above the inter-
nal inguinal ring) will allow inspection of the peritoneal
contents.
With an open repair, if the bowel is still incarcerated after
anesthesia has been induced, the sac is opened and viable
bowel is reduced, after which a standard repair (high liga-
tion) is done. The hernia sac is often quite edematous and
friable, and repair of the hernia can be quite difficult. It may
be necessary to open the internal inguinal ring laterally in
order to reduce the bowel. A sliding hernia is more frequent
in incarcerated hernias, particularly in girls.61 Ischemic
intestine can be resected via the inguinal incision and an
anastomosis performed (see Fig. 50.10), or a laparoscopic
or open abdominal approach can be utilized as well (see Fig.
50.11). Even with incarceration, intestinal injury requiring
resection is rare (1–2%).8,60
Postoperative complications are significantly increased
in incarcerated hernias compared with elective rep­
airs.51,56,66,67 The risk of recurrence is significantly
increased in the presence of incarceration.7,22,65 Wound
infections are increased,51 as are inadvertent injuries to the
vas deferens and other organs.56
The parents of a boy with an incarcerated hernia should
be counseled preoperatively about the possibility of testicu-
lar loss or injury because of the incarceration impinging on
the blood supply to this end organ (Fig. 50.12). The testis on
the incarcerated side in males is often edematous and some-
what cyanotic. Even a threatened, ischemic testis should be
preserved unless it is clearly necrotic. The incidence of tes-
ticular atrophy is 2–3%.58,63,67,68
In girls who have an incarcerated hernia, the ovary
and/or fallopian tube are more commonly involved than
is intestine (see Fig. 50.4).61 If the ovary is incarcerated
on examination in an otherwise asymptomatic infant, its
blood supply is usually unaffected. However, most pediatric
Fig. 50.12 This infant presented with an incarcerated left inguinal
hernia and underwent an emergent operation. The bowel could be
reduced and was viable. However, the left testis was infarcted due to
the pressure from the incarcerated left inguinal hernia.
surgeons will promptly (but not emergently) repair the
hernia in a girl with an asymptomatic, nontender ovarian
incarceration.41,69,70 The ovary is more likely to be compro-
mised from torsion, as opposed to compression of the vessels
with incarceration.61,71–73
TIMING OF REPAIR
The presence of an inguinal hernia is an indication for
elective repair. It is not necessary to restrict an asymptom-
atic child’s activities preoperatively. Prompt repair may
decrease incarceration, particularly in the very young. A
Canadian study found that children under 1 year of age had
twice the risk of incarceration when repair was performed
more than 2 weeks after diagnosis.54
Inguinal hernias are common in the neonatal intensive
care unit (NICU), but the timing of repair is widely variable
among surgeons and between institutions and is contro-
versial in premature infants.74 Repair of an inguinal her-
nia shortly prior to neonatal discharge (“early”) can be
more technically demanding, has higher recurrence and
complication rates, may prolong mechanical ventilation
and length of stay in the NICU, and is associated with an
increased risk of apnea and bradycardia.66,75
In contrast, “late” repair (after 55 weeks postconceptual
age) carries an increased risk of incarceration (10–30%),
more frequent emergency department and clinic visits
and readmissions, and potential failure of the family to
follow-up.55,74,75 Concerns about the long-term neurode-
velopmental risks of anesthesia in premature infants,76 if
substantiated, would favor the late approach. In a recent
database survey, approximately 40% of premature infants
underwent early repair, but variability between hospitals
was significant.55
Operative Technique
OPEN REPAIR
The open repair of an indirect inguinal hernia (OHR) in
children centers on high (internal inguinal ring) ligation of
the hernia sac. A transverse inguinal crease incision is used.
The inguinal canal is more lateral than one might expect,
a finding made apparent with laparoscopic hernia repairs.
The Scarpa fascia is opened, and the external oblique apo-
neurosis identified. This aponeurosis is opened along the
direction of its fibers. Care is taken to identify and preserve
the ilioinguinal nerve, which supplies cutaneous sensation
to the skin of the anterior thigh. The anteromedial hernia
sac is carefully separated from the cord structures in boys
(Fig. 50.13). In girls, it is simply mobilized up to the internal
inguinal ring. The sac may extend down into the scrotum
in boys. It is clamped after ensuring the absence of the vas
and testicular vessels, divided, and followed proximally to
the internal inguinal ring, where it is doubly ligated with
absorbable suture. The distal sac should be widely opened
but need not be removed. If a hydrocele is present, it is evac-
uated, but excision of the hydrocele sac is not necessary.
Large or thick sacs may be everted behind the cord (Bottle
procedure).77 In the case of a blind-ending sac, the entire
sac can be resected after high ligation. Formal repair of the
 50 • Inguinal Hernia 791

A B C

Fig. 50.13 These operative photographs depict the salient features with an open inguinal repair. The hernia sac has been separated from the adjacent
spermatic cord (A). The testicular vessels are marked with the solid arrow and the vas deferens is marked with the dotted arrow. In (B), high ligation
of the hernia sac has been performed using a 2-0 Vicryl suture followed by a 2-0 Vicryl suture ligature placed distal to the tie. The excess sac was then
amputated. On the right (C) the 2-cm left inguinal incision has been closed.

Hernia sac
Transverse
inguinal
incision
A B Vas deferens C
Vessels of the cord

Fig. 50.14 (A) After a right inguinal incision in an infant boy, the sac has been separated from the vas and vessels by grasping the sac and teasing
the cord structures away. The hernia sac, located anteromedial to the cord, has been carefully separated from the vas and vessels (vessel loop) and is
clamped in preparation for division of the sac. (B) In preparation for diagnostic laparoscopy to evaluate the contralateral internal ring, the sac is opened.
A vessel loop is around the cord structures. (C) A cannula has been introduced into the opened hernia sac, and the sac has been tied (solid arrow) to
keep the abdomen insufflated. The cord structures (dotted arrow) are retracted with the vessel loop.

A B

Fig. 50.15 Laparoscopic evaluation of the contralateral inguinal region is used by many pediatric surgeons. (A) A view of the left internal ring shows
the inverted V of the laterally located gonadal vessels and the medial vas. At the apex of the V, the left internal inguinal ring is completely closed. (B) A
right-patent process vaginalis is seen in a 7-year-old patient with a known left inguinal hernia.

floor is rarely necessary in children. If a sliding hernia is
present, inversion ligation after placing a proximal purse-
string suture is relatively straightforward.
Historically, contralateral open inguinal exploration
was common for unilateral inguinal hernias, particularly
in younger infants and children.78 Over the past 20 years,
there have been reports describing the use of laparoscopy
to evaluate the contralateral inguinal ring at the time of
open inguinal hernia repair.79,80 A small 70-degree scope
can be inserted through a 2-mm port placed through the
ipsilateral hernia sac (after insufflation) to look for a con-
tralateral PPV (Figs. 50.14–50.16). There is a small, but
definite (1–2%), incidence of developing a contralateral
hernia even after a negative evaluation (Fig. 50.17).81,82
The indications (or lack thereof) for contralateral evalua-
tion are controversial, but with the increasing use of tran-
sumbilical laparoscopic repair, this may be fast becoming
a moot point. More recent studies and meta-analyses tend
toward the opinion that contralateral evaluation may
not be necessary (overtreatment).83–85 At the same time,
792 Holcomb and Ashcraft’s Pediatric Surgery

A B C

Fig. 50.16 (A) In a small percentage of cases, a veil of peritoneum will cover the contralateral internal ring and obscure the laparoscopic findings such
that the surgeon is not completely certain whether a contralateral patent processus vaginalis (CPPV) is present. In this situation, a technique has been
reported to retract the veil of tissue. (B) A silver probe is introduced in the contralateral lower abdomen/flank and used to retract the veil medially so
that the 70-degree telescope can then look down the possible CPPV. (C) In this patient, a significant CPPV was visualized once the veil of peritoneum
was retracted medially. (Adapted from Geiger JD. Selective laparoscopic probing for a contralateral patent processus vaginalis reduces the need for a contra-
lateral exploration in inconclusive cases. J Pediatr Surg 2000;35:1151–1154.)

Fig. 50.18 This laparoscopic view shows evidence of a pantaloon hernia

(hernia-en-pantaloon) that is composed of a direct (asterisk) and indi-
rect (arrow) hernia on the same side.

Fig. 50.17 At 1 year of age, this infant underwent left inguinal hernia
repair with diagnostic laparoscopy to evaluate for a right patent pro-
cessus vaginalis (PPV). At laparoscopy, it was felt that a contralateral
PPV did not exist. This is the photograph taken at that time. However, 2
years later, he presented with a symptomatic right inguinal hernia. The
incidence of false negative evaluations for contralateral hernia using
laparoscopy is approximately 1%.82
in one study, when given the options of unilateral repair
alone versus unilateral repair with contralateral evalua-
tion, parents overwhelmingly chose contralateral evalua-
tion with laparoscopy.86
LAPAROSCOPIC REPAIR
The advent of minimal access techniques has changed the
conventional approach for treatment of inguinal hernias in
many infants and children.87,88 An accurate description of
the current state of pediatric laparoscopic inguinal hernia
repair (LIHR) is a moving target.
LIHR in children was first introduced as an alternative
to conventional OHR by Montupet in 1993.32,89 The pro-
posed advantages of the laparoscopic approach include
visualization of a contralateral PPV, identification of less
common (direct, femoral, pantaloon) hernias (Fig. 50.18),
diminished postoperative pain, more rapid return to normal
function, and improved cosmesis. Potential disadvantages
include a possible increase in length of operative time and
costs, a definite learning curve, and the need for orotracheal
intubation for anesthesia.32,90
Most studies of inguinal hernia repair published in the
last 20 years are focused on the laparoscopic approach,
with many different techniques now used for LIHR.90 The
different repair options can be categorized as either intra-
corporeal or extracorporeal/percutaneous.
Montupet’s 1993 report described an intracorporeal
technique, with a purse-string suture placed in the peri-
orificial peritoneum at the level of the internal inguinal ring
 50 • Inguinal Hernia 793

A B C

Fig. 50.19 These operative photographs depict the intracorporeal technique for laparoscopic inguinal hernia repair as initially described by Montupet.
The needle has been introduced through the abdominal wall (A). A purse-string suture is then placed around the orifice of the internal inguinal ring (B).
The purse-string suture has been tied intracorporeally and the hernia is closed (C).

A B

Fig. 50.20 These two operative photographs depict the technique for laparoscopic inguinal hernia repair as described by Schier. An N-shaped suture
has been placed on the peri-orificial peritoneum at the open internal ring (A). On the right (B) the suture has been tied and the defect is closed.

the knot using percutaneous techniques. Many variations

Fig. 50.21 A modification of Montupet’s original technique is to incise
the peri-orificial peritoneum around the internal inguinal ring using
monopolar cautery before pursestring closure.
(Fig. 50.19).91 In 1998, Schier reported using an N-shaped
suture on the peri-orificial peritoneum (Fig. 50.20).92 In
1999, Montupet and Esposito modified two important
aspects of the technique: before closing the defect, the peri-
orificial peritoneum around the internal inguinal ring is cut
(Fig. 50.21) and a nonabsorbable suture is used to repair
the hernia defect.93
The extracorporeal approach involves the placement of a
suture circumferentially around the internal ring and tying
of this approach have been described (Fig. 50.22).94–98
Recently, Ostlie and Ponsky reviewed the literature and
stated that there was insufficient evidence to support one
approach over another.90
We prefer the transperitoneal approach for LIHR using
three ports.99 The surgeon is positioned at the head of the
patient, and the camera operator is contralateral to the side
of pathology. The video column is positioned at the patient’s
feet. The patient is placed in a supine position with a 15°–
20° Trendelenburg inclination of the operative table to
reduce the abdominal contents. The average intra-abdominal
pressure is 6–8 mmHg in patients under 1 year of age and
8–10 mmHg in older children. The bladder should be emp-
tied before beginning the operation.
A 0°, 5- to 10-mm telescope is inserted through the umbil-
ical port, allowing good visualization of the deep (internal)
inguinal rings. The use of a 5- or 10-mm telescope leaves
nearly the same invisible scar in the umbilicus. Selection
of a 5- or 10-mm optic depends on the surgeon’s prefer-
ence. Two 3-mm ports are then placed in triangulation for
good ergonomics. Some surgeons prefer to use screw-type
cannulas for the 3-mm ports (Fig. 50.23). The advantage
of using screw ports is most evident in infants under 10 kg
in whom the skin and the underlying tissues are very thin
and the smooth cannulas are often displaced, which can
result in subcutaneous emphysema. Screw ports are more
stable and allow for changing instruments rapidly, without
794 Holcomb and Ashcraft’s Pediatric Surgery

1 2

3 4

5 6

7 8

Fig. 50.22 (1) This 2-month-old infant presented with a right inguinal hernia. (2) Saline is instilled transabdominally just outside the peritoneum overly-
ing the vas deferens and testicular vessels in order to create a space to place the suture around the hernia opening. A 5-mm port and telescope have
been introduced in the umbilicus, and a Maryland dissecting instrument has been inserted through a stab incision in the right upper abdomen (arrow).
(3) A small incision is made in the skin at the level of the internal ring, and a 3-0 Ethibond (Ethicon, Inc., Somerville, NJ) suture that has been threaded
through the eye of an awl is then introduced extracorporeally around the medial aspect of the open internal ring (4). The awl is then withdrawn and
reintroduced with another 3-0 Ethibond suture, and the awl is placed extracorporeally around the lateral aspect of the open internal ring (5). This suture
is then used to help exteriorize the first suture. The first Ethibond suture is tied around the processus vaginalis (6), and the hernia has been repaired (7).
An external view shows Steri-Strips placed over the two right-sided stab incisions and closure of the umbilical fascial defect and skin (8).
 50 • Inguinal Hernia 795

A B

Fig. 50.23 This photograph shows the 3-mm screw-type cannulas (A) that are advantageous for infants under 10 kg in whom the skin and underlying
tissues are very thin. Smooth cannulas are often displaced, which can result in subcutaneous emphysema. If only the smooth cannulas are available, a
piece of Nelaton (arrow) can be placed around the cannula, which is then sutured to the skin to stabilize the port (B).

A B

Fig. 50.24 When using an intracorporeal approach, the needle is introduced through the abdominal wall into the abdominal cavity. It can then be
removed either transperitoneally or through the umbilical port as is seen in these two photographs. On the left, the needle is visualized at the tip of the
cannula (A). On the right (B), an instrument has been introduced through the port to grasp the needle and exteriorize it through the port.

dislodgement of the cannulas or gas leak. If only smooth
ports are available, a piece of Nelaton catheter can be placed
around the cannula, which is then fixed the skin to stabi-
lize the port (see Fig. 50.23). Some surgeons prefer to use
instruments without ports via stab incisions.
The laparoscopic approach allows confirmation of the
diagnosis. The first step of the laparoscopic procedure con-
sists of checking the patency of the known hernia as well as
inspection of the contralateral side for the presence of a con-
tralateral PPV (CPPV). If there is an incarcerated hernia,
the incarcerated contents can be released before closing the
defect. The next step is circumferentially cutting the peri-
orificial peritoneum, distal to the internal inguinal ring, by
using monopolar hook cautery (see Fig. 50.21). Section of
the peri-orificial peritoneum is a key part of the technique
because it allows collapse of the distal sac and consequently
no tension on the suture line when closing the defect with
purse-string suture. Also, in a rabbit study, it was shown
that inducing trauma and scarring at the internal ring
may lead to a more durable laparoscopic repair.100 It is also
important to close the medial part of the ring well, in par-
ticular the peritoneum between the inner spermatic vessels
and the vas, because this is the most frequent location for
recurrence.30
The internal ring is then closed with either an absorb-
able or nonabsorbable suture, performing either a purse-
string suture as described by Montupet (see Fig. 50.19), or
an N-shaped suture as described by Schier (see Fig. 50.20).
In general, if the diameter of the inguinal orifice is 10 mm
or larger, a purse-string suture is preferable. For internal
openings of about 5 mm or smaller, an N-shaped suture and
a purse-string suture are equally efficacious. The needle is
introduced transperitoneally into the abdominal cavity and
then removed transperitoneally or through the umbilical
port (Fig. 50.24). The preferred needle is 3/8 of a circle with
a 20- to 22-mm needle. For unilateral closure, the length of
suture should be 13–15 cm. For bilateral repair, it should be
15–20 cm, but this may vary according to surgeon prefer-
ence. The cannula sites are closed with fine suture, adhe-
sive strips, or glue.
In the preperitoneal approach (needlescopic approach),
a small hook or awl (see Fig. 50.22) loaded with a suture is
passed around the deep ring after making a small inguinal
skin incision. The passage of the suture is observed via an
796 Holcomb and Ashcraft’s Pediatric Surgery
A B
Fig. 50.25 In infants, in order to safely introduce the cannula and sharp stylet, it can sometimes be preferable to introduce the stylet in the working port
through the cannula of the umbilical optic port—“trocar in trocar.” (A) The trocar and working cannula are about to pierce the peritoneum. (B) The tip
of the trocar has penetrated the peritoneum. (C) In order to prevent injury to the underlying bowel, the cannula and trocar are placed into the optical
cannula to protect the underlying bowel. The trocar is then removed, and an instrument is introduced through the cannula.
endoscope through the umbilical port. The ligature is then
brought extracorporeally and tied, thus closing the hernia
orifice (see Fig. 50.22).101,102
The currently preferred technique for management of an
isolated hydrocele without a hernia is to treat it via the open
inguinal approach. In the case of a communicating hydro-
cele, the LIHR approach can be used. In these patients, fluid
is aspirated and the PPV is closed with either an intracorpo-
real or extracorporeal technique
Inguinal Hernia Repair in Infants
Laparoscopy has several advantages when compared with
open repair in the treatment of an inguinal hernia in infants.
First, with laparoscopy, there is a reduction in postoperative
infections. This may result because laparoscopic scars are
located higher compared with the inguinal incisions (inside
the diaper area), which are subject to urine or fecal contam-
ination. Recent reports have found fewer wound infections
following laparoscopic repair versus open repair in infants
of similar ages (0 vs 2.3%).68,103
The major technical challenge of the LIHR in infants is
the very limited working space that can result from bowel
distention. It can be helpful to perform a bowel prep with
simethicone and one or two enemas the day before the
operation to empty the intestinal loops to create a larger
working space.104 In small infants, there is no true triangu-
lation between the telescope and cannulas because the two
operative port sites are located higher than usual and are
positioned on the umbilical plane at the same level as the
telescope to establish an adequate working distance from
the internal inguinal ring.
In infants it is sometimes preferable to insert the work-
ing ports through the cannula of the umbilical optic
port—“trocar in trocar” (Fig. 50.25) to prevent injury to
the bowel. Also, the length of the needle should be a maxi-
mum of about 17–20 mm because bigger needles are dif-
ficult to manipulate in infants and may have a higher risk
of complications.
C
Comparison of Open Versus
Laparoscopic Repairs
Advocates of the LIHR technique cite better visualization of
the vital cord structures, thereby making dissection of these
structures safer. There is no dissection of the abdominal wall
or spermatic cord structures, thus theoretically reducing
the risk of testicular atrophy, secondary cryptorchidism, or
other complications. Serious intraoperative complications
such as bladder injury or rupture, which can occur with
the open repair with excessive mobilization of the sac, are
less likely with the laparoscopic technique due to improved
visualization of the anatomy.
Another advantage of laparoscopy is identification and
treatment of a CPPV, present in up to half the patients,
particularly the younger ones (Table 50.1).105 Repair of a
CPPV, if needed, should be offered to all families, because
90% desire to have the CPPV repaired at the same operative
setting.86
Whether the laparoscopic technique is superior to the
OHR is currently widely debated in the literature. It should
be noted that the recent inguinal hernia literature describ-
ing outcomes following OHR is scanty, and the real inci-
dence of complications of OHR may be underestimated.
To clarify the real impact of laparoscopy in pediatric ingui-
nal hernia repair, 90 studies were reviewed. Thirty-eight
papers focused on operative time (Table 50.2). The opera-
tive time varied widely, depending on the technique and
operative experience. The average operative time for OHR
of a unilateral inguinal hernia was 30.1 minutes, versus
23.7 minutes via laparoscopy. In most laparoscopic studies,
there were no conversions (see Table 50.2).89,92,93,106–110
In our review, the mean recurrence rates were similar
between the OHR and LIHR, both ranging from 0–6%. In
infants, the recurrence rate seems to be higher after OHR
compared with LIHR.68,103,110 Wound infection, post-
operative hydrocele, iatrogenic cryptorchidism, and tes-
ticular atrophy were significantly higher after OHR than
LIHR.59,68,101,111,112 Rare hernias were identified in the
 Table 50.1 Incidence of Rare Hernias and Contralateral Patent Processus Vaginalis Identified During Laparoscopic Hernia Repair
Reference Patients Rare Hernias Percent CPPV Incidence (%)
Gorsler and Schier 200388 403 11 DH 2.7 45.2
Parelkar et al. 2010105 576 19.9
Esposito et al. 2009161 315 1 DH 0.3 39
Schier 200689 22 57.1
Becmeur et al. 2004181 96 3 DH 3.1 7.3
Ehsan et al. 2009177 363 39.7
Esposito et al. 2013114 1 1 AH
Tsai et al. 2010111 100 31
Shalaby and Desoky 2002108 169 7.2
Schier et al. 2002115 933 22 DH 2.3 38
Oak et al. 2004109 110 24.5
Spurbeck et al. 200594 120 33.3
Chan et al. 2007170 451 39
Lipskar et al. 2010172 241 34
Montupet and Esposito 2011173 596 15.9
Esposito et al. 2012103 89 2 DH 2.2 44.9
Yerkes et al. 1998174 759 42
Saha et al. 2013110 30 66
Nah et al. 201159 63 54
Becmeur et al. 2007117 212 3 DH, 2 FH 2.3
Schier and Klizaite 2004118 275 10 DH* 7.2
Handa et al. 2006178 171 22.2
Steinau et al. 2008179 368 6
Kalantari et al. 2009180 301 9.3
Valusek et al. 200680 1603 40.1
Bhatia et al. 2004119 284 29.9

*AH, amyand hernia; CPPV, contralateral patent processus vaginalis; DH, direct hernia; FH, femoral hernia; HP, hernia en pantaloon; IH, indirect hernia.
Also: 5 FH, 3 HP, 1 IH+FH, and 1 IH+DH+FH.

Table 50.2 Operative Time and Conversion Rate of Hernia Repair Performed via Open or Laparoscopic Approach*
Reference LIHR OHR Unilat LIHR (min) Bilat LIHR (min) Unilat OHR (min) Bilat OHR (min) Convert (%)
Gorsler et al.200388 403 14 21 1.0–0.25
Parelkar et al. 2010105 576 23 29
Esposito et al. 2009161 315 18.5 30.5
Schier 200689 712 20
Schier 199892 22 18 0
Becmeur et al. 2004181 96 25.5 35
Montupet 199993 47 30 0
Bharathi et al. 2008162 51 34 25.3 30.6
Alzahem 2011163 1300 1399 10 30 14 28
Kaya et al. 200663 29 0
Koivusalo et al. 2007107 18 15 39 29 0
Niyogi et al. 2010101 58 248 42.2 37.5 45.1 66
Shalaby et al. 2006102 186 13.2 25.6
Esposito et al. 2012103 67 22
Esposito ans Montupet 1998122 225 0
Chan et al. 2005164 42 44 14.7 20.1 12 26.2
Tsai et al. 2010111 100 57 36 45.5 46 62
Misra et al. 1995165 16 20
Kamaledeen et al. 1997166 24 30
Usang et al. 2008167 104 41 58
Shalaby and Desoky 2002108 169 12.6 14 0
Chan 2007146 5 15.2 35
Chang et al. 2008168 52 31.2
Yamoto et al. 2011169 92 22.4 30.5
Schier et al. 2002115 933 16 23
Oak et al. 2004109 110 25 35 0
Spurbeck et al. 200594 120 38 47
Chan et al. 2007170 451 15.7 19.7
Bharathi et al. 2008162 180 25 40 1.0–0.9
Dutta and Albanese 2009171 275 17
Lipskar et al. 2010172 241 20.8 26.7 3.0–1.7
Montupet 2011173 596 18.5 25.5
Esposito et al. 2012103 89 11 17.5 20
Shalaby et al. 2012112 125 125 11.1 14.1 17.3 29.1
Yerkes et al. 1998174 627 132 44.8 51.6 42.2 48.3
Saha et al. 2013110 30 32 47.6 57.1 28.7 33.5
Yang et al. 2011175 1543 657 15 20 19 35
Shalaby et al. 2007176 250 10

*Columns 3, 4, 5, and 6 reflect the mean operative times in minutes.

798 Holcomb and Ashcraft’s Pediatric Surgery

LIHR studies, with an incidence ranging from 0.3–7.2%
(see Table 50.1).88,93,113–118 The most common “rare”
hernia was a direct hernia (81.5%), followed in order of
frequency by femoral hernia (10%), pantaloon hernia
(4.3%), a combination of indirect hernia with femoral her-
nia (1.4%), indirect hernia with direct and femoral hernia
(1.4%), and Amyand/Littre hernia (1.4%). No rare hernias
were reported in the OHR studies.
Twenty-three studies reported the coexistence of a uni-
lateral inguinal hernia with a CPPV (see Table 50.1), for
a highly variable incidence of contralateral patency of
between 19.9% and 66%. More CPPVs were reported in the
smaller infants.110,119
In summary, there is no definitive conclusion in the
current literature about which technique is preferable for
inguinal hernia repair in infants and children. The surgeon
should inform the parents of a child with an inguinal her-
nia that two different approaches exist, and be aware of the
advantages and disadvantages of each option.
medial to the femoral vessels and below the inguinal ligament
should alert the clinician to this possibility. Femoral hernias
are bilateral in 10–20% of cases.29 A Danish series evaluated
3970 adult femoral hernia repairs and found that the laparo-
scopic repair had a lower risk of reoperation compared with
the open repair.125 Small pediatric series have documented
low recurrence rates as well.126–128 Open repairs with mesh
or a mesh plug or a Cooper ligament (McVay) repair are alter-
natives to the laparoscopic repair.
DISORDERS OF SEXUAL DEVELOPMENT
Complete androgen insensitivity syndrome (normal female
appearance and external genitalia, with an XY karyotype)
is rare (1 in 20,000–60,000 live births). It is commonly
associated with an inguinal hernia.129 The incidence of
this abnormality in premenstrual girls with inguinal her-
nias (particularly when bilateral) may approach 1–2% (Fig.
50.27).129,130 Abnormal gonads in a hernia sac should

Special Circumstances
DIRECT INGUINAL HERNIAS
Direct inguinal hernias are rare in children, even in older
teenagers.29 The incidence ranges from 2–4% in large lapa-
roscopic series (where they are more readily detected).113,115
Direct and femoral hernias are often unrecognized preop-
eratively.120–122 Some recurrences after indirect inguinal
hernia repair are direct inguinal hernias.22,29,122
Direct inguinal hernias in children and adolescents can
be managed with an open McVay repair (approximation
of the transversalis aponeurotic arch and internal oblique
aponeurosis to the anterior ileopubic tract and shelving
edge of the inguinal ligament), a Bassini approach, or with
mesh.
The laparoscopic repair of a direct inguinal hernia is also Fig. 50.26 This young child underwent open repair of an indirect right
an attractive option.113 However, the laparoscopic tech- inguinal hernia. Note the nonabsorbable suture at the level of the
nique is different for a direct inguinal hernia repair as there right internal ring (solid arrow). However, the child’s inguinal bulge
persisted. Diagnostic laparoscopy was performed, which shows a right
is a large lipoma adherent to the hernia sac with a direct femoral hernia as the etiology of the bulge (dotted arrow).
hernia. Reduction of the lipoma into the abdominal cav-
ity followed by excision using a hook cautery is important
and easy to perform laparoscopically. The key points of the
direct repair are excision of the lipoma, closure of the defect
using several interrupted nonabsorbable sutures, and the
use of the vesical ligament to reinforce the closure of the
defect without tension.113,123
Combinations of direct and indirect hernias, the so-called
pantaloon hernias (see Fig. 50.18) or even combinations of
all three hernia forms (indirect plus direct plus femoral) can
be rarely found in children, and the laparoscopic approach
is the optimal way to identify and treat them.

FEMORAL HERNIAS
Femoral hernias are relatively equally distributed by gender,
with a mean age at diagnosis of about 5–7 years.124–127 They
are rare, constituting about 0.2% of pediatric hernias.7,8,29
Most are not suspected before operation. They are often not Fig. 50.27 This young girl was undergoing right inguinal repair. With
identified with an open approach and can be incorrectly manipulation of the sac, this testis (arrow) was identified in the hernia
treated as an indirect inguinal hernia (Fig. 50.26). A mass sac. This child had complete androgen insensitivity syndrome.
 50 • Inguinal Hernia 799

Fig. 50.28 This young boy was undergoing a laparoscopic appendec-

tomy and was found to have a right patent processus vaginalis (PPV).
A recent study found the incidence of PPV to be approximately 20% in
children undergoing laparoscopic operations. Only 13% of those found
to have a PPV proceeded to develop symptoms with a median follow-
up of 8 years.131 Most pediatric surgeons recommend observation for
incidental asymptomatic PPVs.

undergo biopsy (and be preserved). Phenotyping, andro- Fig. 50.29 This infant was undergoing left orchiopexy. The patient also
gen receptor (AR) gene determination, and abdominal US had a left inguinal hernia, which was repaired. This adrenal rest (at the
may be helpful adjunctive tests. Laparoscopic hernia repair tip of the forceps) was identified along the left spermatic cord.
allows identification of intersex abnormalities, and iden-
tification of the presence or absence of the fallopian tube,
ovary, and uterus. (See Chapter 62 for more information on
differences of sexual development.)

INCIDENTAL PATENT PROCESSUS VAGINALIS

Often an incidental PPV is discovered in a child undergoing
laparoscopy for an unrelated problem (e.g., appendectomy)
(Fig. 50.28).131,132 In a series of 1548 infants and children,
the incidence of PPV was 20% (72% male, with a mean age
of 4.8 months; most were younger than 1 year of age).131
Only 13% of those found to have a PPV developed a clini-
cal hernia and at a median of 9 months from the original
laparoscopy. The surgeon should inform the family of the
findings, but most pediatric surgeons recommend observa-
tion for incidental asymptomatic PPVs.
OTHER CONDITIONS
Incidentally discovered yellow nodules along the spermatic
cord or testis are due to adrenal rests (Fig. 50.29). In one
study, the incidence was 1.7% in 1862 pediatric hernia
repairs.133 These should be removed if possible. Splenogo-
nadal fusion is a very rare entity that may be difficult to
distinguish preoperatively from a neoplasm (Fig. 50.30).
It may be continuous (cryptorchid testis, when the band
attaches the gonad to the spleen) or discontinuous (usu-
ally in the scrotum). The left side is usually affected. Frozen
section confirmation can be useful. Gonadal preservation is
important.134
The presence of an acutely inflamed appendix in an ingui-
nal hernia sac is an extremely rare entity. Patients often
complain of crampy, dull, lower abdominal pain combined
with an irreducible, tender mass in or near the inguinal
canal. Because of the nonspecific presentation of the pain,
the diagnosis of appendicitis is rarely considered. The exact
Fig. 50.30 Rarely, sphenogonadal fusion is found at the time of ingui-
nal hernia repair. The splenic remnant (white arrow) and testis (black
arrow) are fused. The splenic issue was safely excised.
mechanism is unknown. Some think it may begin upon
entry of the appendix into the inguinal canal that compro-
mises the blood supply to the appendix and increases its
vulnerability to trauma (external or internal), resulting in
inflammation and bacterial overgrowth. The laparoscopic
approach is a safe and effective option for the treatment of
this rare finding.
ANESTHESIA
Most infants and children undergo inguinal hernia repair
under general anesthesia. Regional anesthesia is an alter-
native, attracting resurgent interest due to neurodevelop-
mental concerns about general anesthesia in newborns and
children up to age 4 years.76,135,136 A 2015 Cochrane meta-
analysis found moderate-quality evidence that the adminis-
tration of spinal, when compared with general, anesthesia
800 Holcomb and Ashcraft’s Pediatric Surgery
without preoperative or intraoperative sedative administra-
tion may reduce the risk of postoperative apnea by nearly
half in preterm infants undergoing inguinal herniorrhaphy
at a postmature age.136 Combinations of caudal analgesia,
dexmedetomidine (potentially neuroprotective), and other
agents have been used as an alternative to general or spinal
anesthesia.137
Inguinal hernia repair for healthy children or term
infants is an outpatient procedure. However, the lower the
postconceptual age at the time of operation, the higher the
risk of postoperative apnea in premature infants (inverse
correlation). Also, infants with complex comorbidities, ane-
mia, history of apnea, or lower birth weight and infants who
need supplemental oxygen or have chronic lung disease
have an increased risk of postoperative apnea as well.66,75
Overnight monitoring may be necessary in high-risk
patients, but the overall risk of significant apnea appears
to be low (2–5%).66,138–140 The postconceptual age prior to
which admission and monitoring is required varies among
institutions, typically between 50–60 weeks.66,139–141
Complications
Complications are relatively infrequent after inguinal her-
nia repair. Parents are often concerned about bruising and
swelling in the scrotum or labial region, but this is usually
transient and minor. Large scrotal hematomas/seromas
can compromise the blood flow to the testis, and Doppler
US may be useful to define the nature of the swelling and
evaluate for ischemia. The hematoma should be promptly
evacuated if there is evidence of impaired blood flow to the
testis. Residual asymptomatic hydroceles are common,
especially if a large hydrocele was present preoperatively.
Most will eventually reabsorb, but if persistent for 6–12
months, aspiration may be indicated. Only rarely is formal
hydrocelectomy required.
A recurrent hernia is seen in less than 2% of repairs in
the absence of predisposing factors,142,143 such as prema-
turity, incarceration, disease processes that increase the
intra-abdominal pressure (CF, VPSs, ascites), connective
tissue disorders, and teenage patients.7,8,22,128,129 Many
authors advocate a laparoscopic approach for recurrent
hernias because the technical difficulty and risk of injury
to cord structures is likely increased in the scarred, previ-
ously operated inguinal canal. Operative times are reduced
with a laparoscopic approach for the recurrence, and com-
plications have been minimal in several small series.144,145
Finally, for recurrence of an inguinal hernia after an open
inguinal approach, laparoscopy is likely the best approach
to identify and treat the cause of the recurrence.146
Injury to the vas or testis is a rare complication, both
under 1%. In Ein’s personal series of 6361 open inguinal
hernia repairs, vasal injuries were found in 0.6 per thou-
sand and testicular atrophy was noted in 0.3%.8 Similar
numbers are found in other reports.147–149 The incidence of
vasal injury may be underestimated as instrument manipu-
lation of the cord causes microscopic injury and scarring
in animal models.150–152 Long-term follow-up after laparo-
scopic repairs is not yet available. In the open era, a review
of 7314 male pediatric hernia specimens found either vas
deferens or epididymis in 0.53% of specimens.153 However,
some of these may represent remnants rather than true
injuries. As discussed, ischemic injury to the testis or ovary
is increased dramatically by incarceration, but gonadal
preservation should be the rule.
In an adult meta-analysis, there was no evidence of an
association between prior inguinal hernia repair (without
mesh) and male infertility or obstructive azoospermia.154
Conversely, in series of adults who have obstructive azo-
ospermia, pediatric inguinal hernia repairs are a common
cause.155 The success of vasal repairs in adulthood is vari-
able, with vas patency rates of about 60–65% and preg-
nancy rates of 25–40%.19,156
Iatrogenic cryptorchidism, or ascending testis, is another
infrequent complication of inguinal hernia repair.7 In a
recent report, Wang et al. reviewed over 17,000 pediat-
ric inguinal hernia repairs (approximately equally divided
between open and laparoscopic repairs) and found an inci-
dence of 0.058%.157 This was attributed to adhesion of the
cord that fixes the testis in position. Reoperative orchido-
pexy is usually required.
Small infants with very large inguinal hernias may have
respiratory insufficiency from loss of abdominal domain
after the bowel is reduced. Although uncommon, this con-
cern needs to be taken into consideration, particularly in
NICU infants with large hernias who are already oxygen or
ventilator dependent. Staged repair of bilateral hernias may
be necessary in such patients.158
Chronic pain after inguinal hernia repair is widely rec-
ognized in adults (10–15%), but less so in children. Few
studies have assessed inguinodynia in children, but in two
studies, the incidence was about 5%, which is half of the
incidence in adults.159,160 Mortality directly related to an
inguinal hernia or its repair is exceedingly rare (<1%).
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