Inguinal Hernia in Female Infants and Children *

I. RICHARD

GOLDSTEIN, M.D., WILLIS J. POrrS, M.D.

From the Department of Surgery of the Children's Memorial Hospital, Chicago, Illinois

A REVIEW of our experience with inguinal hernias in female infants and children confirmed the suspected fact that the sliding type of hernia is very common. During the past ten years 173 female infants and children were admitted to the Children's Memorial Hospital for inguinal herniorrhaphy. A total of 211 hernias were repaired. A surprisingly large number, 44, or 21 per cent, were of the sliding type involving various parts of the genital tract. Medical literature contains little comment about sliding hernia in the female child. A recent article by Arnheim and Linder 1 mentions sliding hernia but gives no indication of its frequency. Kristiansen and Snyder 2 called attention to the high incidence of incarceration in their study of this subject but do not discuss sliding hernia. In fact, medical literature contains little on the subject of inguinal hernia in female children except to mention it as part of a study of hernia in the male child. The concept that inguinal hernia in girls as well as boys is of congenital origin is supported by the fact that in 43 per cent of the patients the hernia was found during the first three months of life (Table 1). Some were found by the mothers who noticed the typical inguinal bulge and some were discovered by the pediatrician during a routine examination. Review of the birth histories brought out the fact that 27 (15.6 per cent) of the patients had been born prematurely. Of interest, but probably of little significance, is the fact that six hernias appeared in one of twins.
'

Symptoms and Findings

The histories of 29 per cent of the patients contained notations of various symp-

Submitted for publication November 25,

1957.

by the mother. This rather high number included excessive crying, colic, irritability, pain, vomiting, constipation and so-called feeding problems. In many instances these symptoms promptly disappeared following repair of the hernia. Analysis of 173 patients showed that 102 (59 per cent) had right-sided hernias, 34 (20 per cent) left-sided hernias and 37 (21 per cent) bilateral inguinal hernias. When a patient with a unilateral hernia is seen we inquire carefully of the parents for a history of a bulge on the opposite, supposedly normal side. We then carefully palpate the area. The method of palpation used in male children is less accurate in detecting the presence of an inguinal hernia in females because of the absence of the cord structures. If the feeling of gliding silk is noted a hernia is almost certainly present and bilateral herniorrhaphy is advised. The absence of this characteristic palpable finding does not rule out the presence of a hernia. We routinely give more attention to the normal side than to the side on which the hernia is obviously present. Parents are justifiably somewhat annoyed if shortly after repair of a hernia they have to bring back their child for a second operation. Eleven of the patients who originally had unilateral herniorrhaphies later returned with a hernia on the other side. Of those appearing later, five were on the left and six were on the right side. In spite of careful examination one cannot by any means always identify a hernial sac on the pre819

toms observed

GOLDSTEIN 820 sumably normal side, nor can one be guided in advising bilateral herniorrhaphy solely by the fact that hernias are more common on the right side. Just because a hernia is found on the left it does not follow that there is another on the right side. Later appearance of a second hernia in this series was almost equally divided between both sides. There was a history of incarceration, or incarceration was present at the time of admission, in 31 (15 per cent) of the hernias. Interesting, and we believe significant, is the fact that all incarcerations except one were on the right side. This observation, incidentally, supports the advisability of giving special attention to the right side whenever a hernia is found on the left. Upon admission two children had irreducible incarcerations of the bowel. Although an ovary was frequently incarcerated only two showed signs of impaired blood supply. A tender, firm, movable lima beansized mass in the inguinal region is most likely an incarcerated ovary. It may be mistaken for a hydrocele of the canal of Nuck, for an enlarged lymph node, or for a small incarcerated segment of intestine.

AND POTTS

Annals of Surgery November 1958

TABLE 2. Pathology in 211 Inguinal Hernias in Female Infants and Children *Pathology

No. of Hernias
42 2

Sliding hernias of tube, ovary or both of uterus, tubes and ovaries

44

Other complex hernias incarcerated tube and/or ovary incarcerated ovary with compromised blood supply, but viable incarcerated small bowel tube or ovary free in sac appendix in sac hydrocele and hernia bilateral testes without uterus or ovaries but female external genitalia (pseudohermaphrodite) ovatestes with uterus and tube
Simple indirect inguinal hernia sac Total

8
2 2 3 1 1 1 1

19 148

211

Treatment of Simple Inguinal Hernia We believe that an inguinal hernia should be repaired when diagnosed provided the child is otherwise normal. Size or age of the child is not a contraindicaTABLE 1. Age of Female Children When Inguinal Hernia Was First Noted

Age
At birth 1-6 months 7 months-i year 2 years 3 years 4-6 years 7-9 years 10-16 years Total

No. of Hernias
16 70 19 19 23 46
13 5

211

tion to herniorrhaphy. The frequency of symptoms due to inguinal hernia in the female child, the real danger of incarceration and the simplicity of surgical repair make delay in operation unjustifiable. The method of repair which we use for simple inguinal hernias in female infants and children is essentially the same as that described by one of us 3 for males-high ligation of the sac. The round ligament is often intimately adherent to the hernial sac. In these cases we include it in the suture ligature of the neck of the sac. After cutting off the excess of sac and round ligament the stump is brought under the internal oblique muscle and fixed with a suture. Fixation of the round ligament to the muscle may not be important but seems a proper thing to do. It should be emphasized that the hernial sac is always widely opened and inspected before twisting and ligating. A loop of bowel is rarely caught in the sac but the fimbriated end of the Fallopian tube is apt to be adherent to the neck of the sac and must be carefully freed and pushed

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INGUINAL HERNIA IN FEMALE INFANTS

821

back into the abdomen before the suture ligature is placed. A summary of the findings at operation is given in Table 2.
Treatment of Sliding Hernias Under open drop ether anesthesia a transverse skin incision is made in the suprapubic crease (Fig. 1.A). The sucutaneous fat and superficial fascia are divided in the same direction. The fascia of the external oblique muscle is divided in the direction of its fibers from the lower edge of the indirect oblique through the external ring (Fig. 1.B). The hernial sac is grasped and freed from the fibers of the cremasteric muscle and connective tissue (Fig. 1.C). As one nears the postero-medial surface of the sac care is exercised to avoid damage to the ovarian or uterine vessels which are intimately adherent. The sac is opened and if the tube and/or ovary with their blood vessels form part of the sac-typical of a sliding hernia-the following procedure is carried out: (Fig. 1.D) A flap is fashioned from the side of the sac to which the adnexa and their vessels are adherent by

P sition of ovary
\yi
____ isipri
fod

making an incision in the sac on each side of the vessels and parallel with them. (Fig. 1.E) This tongue or flap of sac with its attached ovary or tube and vessels is then folded through the neck of the sac into the peritoneal cavity. (Fig. 1.F) The pursestring suture of 3-0 silk is so placed in the remaining portion of the sac that when it is made taut it will completely close the sac without encroaching upon the vessels to ovary or tube. (Fig. 1.G) The pursestring suture is snugly tied, carried around the neck of the sac and again tied. The redundant portion of the sac is excised and the stump allowed to retract beneath the internal oblique muscle (Fig. 1.H). The edges of the external oblique aponeurosis and the subcutaneous tissues are approximated with interrupted sutures of 4-0 silk (Fig. 1.1). If the patient is less than 18 months to two years old-untrained in toilet habits-the skin is closed with interrupted, subcuticular sutures of 6-0 white silk-white silk rather than black because the latter may prompt the question, "Doctor, what

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GOLDSTEIN AND POTTS

Annals of Surgery November 1958

are those dirty spots under the incision." In older children a continuous suture of black silk or nylon is used to close the skin. The wound is covered with a small piece of gauze, fixed with waterproof adhesive tape. Following operation the infants are usually taking fluid or formula in about four hours; the older children are given a full diet upon demand. All are discharged from the hospital the day after operation. The mothers are advised that infants and young children may carry on as they did before operation without restriction. Older children are allowed to be up and about but advised to avoid violent exercise for two weeks. Postoperative complications except for an occasional stitch abscess or minor wound infection and postoperative colds and coughs have been minimal. The only significant and unexplained complication occurred in a six-year-old girl whose wounds oozed blood for three days following bilateral herniorrhaphy. Hematologic studies revealed no abnormality and recovery was further uneventful.

There has been no mortality. To our knowledge there has been only one recurrence. This occurred in a 14-month-old girl who had had repair of bilateral sliding hernias of the ovaries eight months previously. The recurrence, again a sliding hernia of the ovary, was repaired successfully.
Summary In female infants and children 20 per cent, or 44 of 211 inguinal hernias repaired at the Children's Memorial Hospital, were of the sliding variety. Symptoms and findings of interest are reviewed. A method of repair of sliding hernia is presented. References
1. Arnheim, E. E. and J. M. Linder: Am. J. Surg., 92:436, 1956. 2. Kristiansen, C. T. and W. H. Snyder, Jr.: W. J. Surg., 64:481, 1956. 3. Potts, W. J., W. L. Riker and J. E. Lewis: Ann. Surg., 132:566, 1950.