Essentially all inguinal hernias in children are congenital and indirect. Rarely, a child with a connective tissue disorder like Ehlers–Danlos will present with a true direct hernia. A second recurrence in any child should probably be repaired with reconstruction of the floor of the inguinal canal, such as a Cooper’s ligament repair. Children with a connective tissue disorder might be best served with a mesh repair; otherwise its use in children should be avoided because of uncertainty about long-term effects. The hernia “defect” is actually a normal hiatus that allows passage of the cord structures or round ligament and should therefore not require repair per se. In fact, cinching the internal ring in boys risks entrapment of the cord structures. Instead, simple ligation and division of the hernia sac should allow the hiatus to close down to a normal and more functional size.
The standard repair has withstood the test of time: it is extremely safe, well-tolerated, associated with a recurrence rate of a fraction of 1%, takes less than 10–15 min per side, and leaves a scar that is small and nearly invisible. At the risk of seeming old-fashioned, I will suggest that laparoscopic repair is unlikely to ever replace the traditional operation because of an unacceptable recurrence rate and the fact that parents will not happily accept the hydrocele that results from failing to excise the distal portion of the sac. Nevertheless, I hope to someday be proven incorrect. On the other hand, laparoscopy (2.7 mm 70° scope placed through the hernia sac) is very useful as a diagnostic maneuver to rule out a contralateral patent processus and should be used in all prepubescent children who are having an inguinal hernia repair.
The risk of incarceration is higher than once thought, especially in neonates and prematures. Though in this day and age the risk of bowel injury is extremely low, there is a significant risk of testicular atrophy and a higher complication rate of the subsequent repair, including recurrence. Therefore, repair should be undertaken soon after diagnosis, within 1–2 months, if possible, and on the same admission for those who present with incarceration. Incarcerated ovaries are rarely reducible and these hernias should be repaired within 1–2 weeks to avoid ischemia or injury to the ovary.
Reduction of an incarcerated hernia is a skill that is learned by experience. Tricks include using sedation whenever possible, which increases the success rate and minimizes discomfort; applying constant pressure over a long period of time (2–3 min straight) rather than ever-increasing pressure over a short period of time; and maintaining patience despite the resistance of the patient and the anxiety of the parents. Often, the fact that the hernia will eventually be able to be reduced is signaled by the frictional sensation of two edematous surfaces being rubbed together (similar to that of two pickles). It is useful to take a very short break between 2–3 min sessions and to try again several times before giving up. When there is doubt regarding the distinction between an incarcerated hernia and a tense hydrocele, the patient should undergo urgent surgical exploration rather than an ultrasound regardless of how asymptomatic they appear.
Ligation of the sac should be performed with absorbable suture, as there is no advantage to using silk and it can occasionally create a foreign body reaction or a cutaneous fistula. There is no need for routine pathologic analysis of the sac. The distal sac should be partially excised, but to avoid injury to the vas deferens, the portion of the sac that is adherent to the spermatic cord should be left intact. Sliding hernias can pose a challenge and should be repaired using a purse-string suture placed at the level of the internal ring with care to avoid the vas. The fallopian tube in a sliding hernia usually has an avascular “mesentery” medially that can be divided longitudinally up into the peritoneum. The first two bites of the purse-string suture should then be placed so as to effectively close the resultant slit in the hernia sac at the internal ring.
Postoperatively, since repair does not involve muscular reconstruction, most children need no activity restrictions, with the possible exception of avoiding competitive sports for 1 week. They should also be allowed to bathe the next day and seen in routine follow up in 3–4 weeks. Infection is exceedingly rare and recurrence should occur in less than one in about 200–300 repairs. Recurrence is most common in very young premature boys, sometimes becoming evident by the morning after surgery.