What's the deal with the abdoimno-scrotal hydrocele?

As it's name implies, an abdomino-scrotal hydrocele is a hydrocele that extends into the peritoneal cavity. It is a rare variant that makes up 3% of pediatric hydroceles. A recent meta-analysis by Dout et al published in the Journal of Pediatric Surgery looked at a total of 116 cases of abdomino-scrotal hydroceles in an attempt to better define this entity in terms of natural history, management, and clinical implications.

The authors describe a wide variability in natural history reported; ranging form hydroceles that spontaneously resolved to ones that continued to grow. The management strategies were equally varied; ranging from a combined inguinal/laparoscopic approaches to a more simple scrotal approach.

What I found most useful in this study was the association between these hydroceles and testicular dysmorphism.  Based on this report, the incidence of dysmorphism was around 28%. This was felt to be related to the amount of pressure exerted by these hydroceles on the surrounding tissue, including the testicular vessels.

This is relevant because it suggests that there may be benefit to more urgent intervention for an abdomino-scrotal hydrocele compared to the garden-variety non-communicating hydrocele, which one may opt to observe for a period of time.

Laparoscopic repair of inguinal hernias in female children: the Inversion/ligation technique

The open repair for inguinal hernias in children is a time honored technique used by most pediatric surgeons. Different variations of laparoscopic repair techniques have been adopted by some pediatric surgeons, with the main criticism of those techniques being a high rate of recurrence (4% compared to 1% with the open repair).

Despite my overall skepticism with laparoscopic repair techniques and their outcome, one particular version used for repair of hernias in females is quite appealing.

The inversion-ligation technique for repair entails passing a laparoscopic grasper into the inguinal canal through the internal ring, grasping the distal aspect of the sac, and inverting it into the abdomen. The inverted sac is then twisted and doubly ligated with an endo-loop.

Lipskar et al looked at the outcome of 173 girls who underwent a total of 241 hernia repair operations. The mean age was 5 years. One third of patients were found to have a contralateral patent processus vaginalis/hernia. All were successfully repaired in an average time of 40 minutes and 90% were discharged home the same day. Recurrence rate was 0.8%.

The appealing part of this operation is that, unlike other laparoscopic hernia repair techniques, the hernia sac is not left within the canal, which may be a major contributor to the reported high recurrence rate in other techniques. Because of the absence of any important structures (vas etc..), the hernia sac in girls can be bluntly pulled off the round ligament and inverted.

Lipskar et al. Laparosocpic inguinal hernia inversion and ligation in female children: a review of 173 consecutive cases at a single institution. Journal of Pediatric Surgery (2010) 45,1370-1374

Laparoscopic inguinal hernia repair in children. Why?

Inguinal hernia repair with high ligation of the hernia sac through an inguinal approach is one of the most commonly performed operations in the pediatric population. The laparoscopic approach to IH repair in children is certainly an attractive option, given that it entails no manipulation of cord structures, allows for the repair of recurrent hernias (initially repaired by an inguinal approach) through fresh tissue, and allows for the inspection of the contralateral internal ring (whatever implications that my have!). However, the fact that an intact hernia sac is left behind within the inguinal canal when hernias are repaired laparosocopically makes me wonder about recurrence.

Two main techniques for the closure of the internal ring from a peritoneal approach are described; the lap assisted/percutaneous closure (SEAL) and the totally laparoscopic approach. Both entail closing the internal ring (using a "purse string" or "N"-shaped type of suture) while avoiding the vas and vessels.

A recent series out of Mainz, Germany looked at over 500 patients who underwent a totally laparoscopic repair with a suture used in an "N"-shaped fashion. After a median follow up of 40 months, the recurrence rate was 4%. This dropped to 2% with the last 100 patients; an improvement that the author attributed to a refinement of the technique of internal ring closure.

Understandably, the concept of laparoscopic repair is very attractive, particularly in the setting of recurrent hernias. However, one must keep in mind that even in the most experienced hands, the recurrence rate of laparoscopic hernia repair is still 4 times higher than the classic repair.


References

Harrison et al. The subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: a novel technique. Journal of Pediatric Surgery (2005) 1177-1180

Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. Journal of Pediatric Surgery (2006) 41, 1081-84

Laparoscopic contralateral groin exploration: is it cost effective

The authors addressed the cost effectiveness of laparoscopic exploration of the contralateral groin in children undergoing inguinal hernia repairs. lap exploration identified a 10% (8/78) rate of contralateral patent processus vaginalis. Assuming all substantial PPV's (defined by the authors as those that could admit a scope, those whose distal aspect could not be visualized, and those that result in gas reaching the scrotum) eventually became hernias, the authors estimated the total cost of contralateral exploration/repair vs. repair when clinical hernias developed in the 8 patients with PPV to be $13,080 and $20,440, respectively. Thus they concluded that contralateral exploration and repair is a cost effective approach to inguinal hernias in children. This did not take into account the expense of the use of laparoscopic instruments.

Lee et al. Journal of Pediatric Surgery (2010);45:793-795

A picture is worth a "silk glove" sign?

How often do we make decisions to fix a hernia based on what the parents describe? have you ever ordered an u/s to check when you couldn't feel a hernia or a "silk glove"? How about just ask the parents to take a picture and email/text it to you to confirm?

A study by Kawaguchi et al (JPS 2009;44:2327-9) looked at 23 patients who underwent surgery based on history and a photograph sent by the parents showing the hernia. All patients underwent operative repair and were noted to have a hernia. two patients who's photographs were not consistent with an inguinal hernia were observed, and were not found to have hernias on follow up.

The use of digital photographs can potentially avoid unnecessary repeat office visits as well as wrong side surgery if the parents' description of a non palpable hernia is not correct.

Now that I reduced this baby's incarcerated hernia, can I send him home?

So what's the natural history of a truly incarcerated hernia after ED reduction and, subsequently, is it safe to send an infant home for an elective repair? I've had different experiences ranging from admitting infants and repairing their hernia after 24-48 hours (giving time for edema/tissue swelling to resolve) to discharging them home (to "reliable" parents) for a scheduled elective repair.

This subject was addressed by Baguley et al (Pediatr Surg Int 1992.7:366-7). The authors looked at 94 infants with incarcerated inguinal hernias and compared those who were admitted to those who were sent home. In 20% of patients admitted, the hernia reincarcerated prior to it's repair. A much higher rate of reincarceration (74%) in the discharged group reflected the longer time interval before operative repair (Mean 10 days compared to 2 days for the inpatient group). In comparison, 35% of infants with known inguinal hernias (but no history of incarceration), experience hernia incarceration while waiting for their elective operation, a median time of 22 days (Stylianos et al. J Ped Surg 1993;4:582-3).


The paper does not address the issue of potential bowel ischemia/necrosis and the need to monitor infants until that possibility is ruled out. This may have been a source of selection bias, where infants with hernias that were more difficult to reduce were admitted, while those who were reduced more easily were allowed to go home.

The way I see it, and based on this limited study, and given the 1/5 chance of reincarceration within a couple of days, it seems safest to keep patients inhouse until the hernia is repaired.

On the other hand, it is also reasonable to discharge patients home, as long as they live close enough to a center where the incarceration can be promptly treated if it recurs, have guardians who understand the signs and symptoms of incarceration and the need to address them promptly, perform the "elective repair" within 72 hours, and the patient is observed long enough to r/o the presence of compromised bowel after the hernia is reduced.

As to the issue of the 24 to 48 hour delay in repair resulting in a safer operation, secondary to resolution of tissue edema and inflammation, there does not seem to be any data to support or negate that concept.