Inguinal hernia

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide staff in the management of children who present to emergency with an inguinal hernia.

Background

  • Inguinal hernias may present in both sexes, and may present insidiously or as an emergency
  • Any acute swelling or pain of the scrotum warrants urgent review by a surgeon since torsion of the testis and incarcerated hernia are both surgical emergencies – refer to Scrotal pain or swelling.

 

Incidence

  • Ranges between 1-5%
  • Incidence is higher in premature infants: 15-25%
  • Boys are effected 9 times more than girls
  • Right sided predominance is well established (60% vs 30%)
  • 10% are bilateral in full term infants and nearly 50% in premature & low-birth-weight infants

 

Assessment

  • Infants develop a bulge/swelling in the inguinal region that does not reduce spontaneously
  • There is usually a cough impulse
  • When the child relaxes the hernia either reduces spontaneously or can be reduced with gentle pressure, firstly posteriorly to free it from the external ring, and then upward toward the peritoneal cavity
  • If testis is not in the scrotum, groin swelling may contain the retractile or undescended testis resembling a hernia
  • In girls, an ovary may be present in the hernia sac (risk of torsion/infarction); do not attempt reduction
  • Infants with incarcerated hernia are often irritable and crying due to discomfort and pain.

 

Management

  • Analgesia (e.g. morphine)
Bowel compromised
Tender tense swelling with redness and induration, with no impulse on crying in a distressed infant. 
  • Resuscitation 
  • Urgent surgical consult. Do not attempt to reduce the hernia in the ED
  • Prepare for theatre
  • Admit

Bowel not compromised
Gentle manual reduction can be attempted in the Emergency Department after appropriate analgesia is provided (e.g. morphine or fentanyl)

Less than one month of age

Neonates have a greater risk of complications from inguinal hernias. Even if the hernia is easily reduced – 

  • Discuss with surgeon regarding possible admission and surgery 

Greater than one month of age

  • Hernia is irreducible
    • Urgent surgical consult
  • Hernia reduced with difficulty
    • Surgical consult
  • Hernia Easily Reduced
    • Discharge home
    • Outpatient surgical review for elective surgery 

Bibliography

  1. Jones' Clinical Paediatric Surgery 7thEdition By: John M. Hutson (Editor), Michael O'Brien (Editor), Spencer W. Beasley (Editor), Warwick J. eague (Editor), Sebastian K. King (Editor) 2015
  2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
  3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 


Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Apr 2021


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