List of Abbreviations
UH – Umbilical hernia
IH – Inguinal hernia
OIH – Oblique inguinal hernia
US – Ultrasound
LAH – Linea alba hernia
Terms and Definitions
Disease – a disturbance of bodily function, working capacity, and the ability to adapt to changing environmental conditions arising from the impact of pathogenic factors, accompanied by alterations in the body's protective-compensatory and protective-adaptive reactions and mechanisms.
Instrumental diagnostics – diagnostics performed by examining a patient using various devices, apparatuses and instruments.
Quality of medical care - a set of characteristics reflecting the timeliness of medical care, the appropriateness of the choice of preventive, diagnostic, treatment, and rehabilitation methods during the provision of medical care, and the degree of achievement of the planned result.
Criteria for assessing the quality of medical care - indicators used to characterize both positive and negative aspects of medical activity, its individual stages, sections, and areas, and used to evaluate the quality of medical care for patients with a specific disease or condition (group of diseases, conditions).
Laboratory diagnostics – a set of methods aimed at analyzing the test material using various specialized equipment.
A syndrome is a set of symptoms sharing a common etiology and pathogenesis.
Condition - changes in the body arising from the action of pathogenic and (or) physiological factors and requiring medical care.
Level of evidence certainty – reflects the degree of certainty that the found effect of a medical intervention is true.
Surgical intervention – an invasive procedure that may be used for diagnostic purposes and/or as a method of treating diseases.
Surgical treatment - a method of treating diseases by separating and joining tissues during a surgical operation.
Severity of condition – a composite assessment of vital bodily functions
Hernioplasty - the general term for methods of closing the hernia ring during a herniotomy
Strangulated inguinal hernia - sudden or gradual compression of the hernia contents within its ring
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
1.1.1 Inguinal hernia — an abdominal hernia emerging through the superficial inguinal ring of the inguinal canal. An inguinal hernia is characterized by the presence of a hernia bulge in the inguinal region caused by the displacement of abdominal cavity contents into the inguinal canal and scrotum.
Indirect inguinal hernia — an abdominal hernia emerging through the deep and superficial inguinal rings of the inguinal canal. An indirect inguinal hernia is characterized by the presence of a hernia bulge in the inguinal region caused by the displacement of abdominal cavity contents into the inguinal canal and scrotum.
Direct inguinal hernia – an abdominal hernia emerging through a congenital defect of the posterior wall of the inguinal canal and characterized by the presence of a hernia bulge in the inguinal region not associated with the inguinal rings.
1.1.2 Umbilical hernia is characterized by non-closure of the aponeurosis of the umbilical ring, through which the peritoneum protrudes, forming a hernial sac. The contents of the sac are typically the omentum and/or loops of the small intestine.
1.1.3 Hernia of the linea alba is characterized by a defect in the aponeurosis of the linea alba, which serves as the hernia ring. Preperitoneal fatty tissue typically protrudes through the defect in the aponeurosis into the subcutaneous fat; a hernial sac is absent in this case [1; 2].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
1.2.1 Inguinal hernia.
Indirect inguinal hernia in children is congenital and forms as a result of the non-closure of the processus vaginalis of the peritoneum. The processus vaginalis of the peritoneum forms in the third month of gestation from a protrusion of the peritoneum that lines the ventral abdominal wall and forms a diverticulum at the level of the deep inguinal ring [3]. Between the seventh and ninth months of gestation, the testes in boys descend through the internal canal into the scrotum, pushing the processus vaginalis forward and protruding into its cavity. Once this process is complete, the processus vaginalis spontaneously obliterates, usually by two years of life [4].
Nuck's diverticulum in girls corresponds to the processus vaginalis in boys and is a peritoneal pouch extending from the uterus to the labia majora. It usually closes spontaneously around the seventh month of gestation [5].
Persistence of smooth muscle may prevent the closure of the processus vaginalis. Myofibroblasts, which are thought to represent smooth muscle dedifferentiation and impaired apoptosis, have been detected by electron microscopy in all inguinal hernial sac samples [6].
1.2.2 Umbilical hernia. After birth, closure of the umbilical ring is the result of a complex interaction between the lateral body wall folding medially, the fusion of the rectus abdominis muscles with the linea alba, and the contraction of the umbilical orifice, facilitated by elastic fibers from the obliterated umbilical artery. Fibrous proliferation of the surrounding lateral connective tissue plates and mechanical tension from the rectus abdominis muscles may also contribute to spontaneous closure. Disruption of these processes leads to an umbilical hernia. The hernial sac consists of the peritoneum and is usually closely adherent to the dermis of the umbilicus.
In addition, after the umbilical cord stump falls off, the umbilical ring closes tightly only in its lower part, where the two umbilical arteries and the urachus pass in the embryo, which together with the surrounding embryonic tissue form dense connective tissue and subsequently fibrous tissue. This gives the lower part of the scar tissue greater density. The upper section of the umbilical ring, through which only the umbilical vein passes without a sheath, is significantly weaker than the lower part. Furthermore, in some cases, the underdeveloped fascia of the abdomen closes it only partially. In cases of fascia hypoplasia, as well as in areas where it is not sufficiently dense, small defects form that contribute to the development of a hernia. Under these anatomical conditions, the umbilicus is a weak point of the anterior abdominal wall, predisposing to hernia formation [1, 7].
1.2.3 Hernia of the linea alba in children is congenital. Anatomically, the linea alba consists of a three-layered network of intersecting oblique and transverse collagen fibers [8]. Four main theories of the pathogenesis of linea alba hernias have been proposed. The first is congenital weakness of the linea alba caused by a perforating blood vessel [9, 10]. The second is congenital weakness due to the variable arrangement of the intersecting fibers that make up the linea alba [11]. The third is an acquired defect of the linea alba due to strong contraction of the tendinous fibers of the diaphragm attached to the posterior part of the linea alba, for example, during coughing [11]. The fourth is changes in the composition, density, and thickness of collagen and elastin in the linea alba [8, 12, 13].
1.3 Epidemiology of the Disease or Condition
1.3.1 Inguinal hernia. Indirect inguinal hernia occurs in 1% to 5% of all newborns and in 9% to 11% of premature infants [3, 14]. In newborns with low and very low birth weight, the incidence of inguinal hernia varies depending on birth weight, with the highest frequency in extremely premature infants [15].
The incidence in boys is three to four times higher than in girls, with the right side being more frequently affected in both groups [16]. In boys, the incidence is highest during the first year of life and peaks during the first month [17, 18]. The right-sided predominance is associated with the later descent of the right testis and later obliteration of the processus vaginalis of the peritoneum. The incidence of bilateral hernias is approximately 10% in full-term infants and nearly 50% in premature and low birth weight infants [19, 20].
Strangulation – the incidence of indirect inguinal hernia strangulation ranges from 14% to 31% and typically occurs in younger children under one year of age [3, 21]. In 65% of cases, strangulation is the first symptom of a hernia [22]. It is more common in right-sided hernias compared to left-sided ones (17% vs. 7%) [23]. Strangulation is also more common in girls compared to boys (17.2% vs. 12%). In girls, the ovary rather than the intestine is more frequently found in the hernial sac during strangulation.
Direct inguinal hernia is rare in children (0.5%). It can occur in both girls and boys.
1.3.2 Umbilical hernia. The cumulative incidence of umbilical hernia in children is high, ranging from 15% to 30% [24, 25]. The highest incidence of umbilical hernia is observed in premature infants and newborns with low birth weight compared to full-term infants [26]. In addition, newborns and children with comorbidities such as Beckwith-Wiedemann syndrome, Hurler syndrome, trisomy 13, 18, 21, congenital hypothyroidism, as well as children undergoing peritoneal dialysis, have a high incidence of umbilical hernia [27, 28].
1.3.3 Hernia of the linea alba. The incidence of linea alba hernias ranges from 1% to 4% among all pediatric hernias [29, 30]. The mean age at clinical presentation is 4.3 years, and multiple linea alba defects occur in 13% of cases [31].
1.4 Features of Coding the Disease or Condition
1.4.1 Inguinal hernia.
K40.0 Bilateral inguinal hernia with obstruction, without gangrene.
K40.1 Bilateral inguinal hernia with gangrene.
K40.2 Bilateral inguinal hernia without obstruction or gangrene.
K40.3 Unilateral or unspecified inguinal hernia with obstruction, without gangrene.
K40.4 Unilateral or unspecified inguinal hernia with gangrene.
K40.9 Unilateral or unspecified inguinal hernia without obstruction or gangrene.
1.4.2 Umbilical hernia.
K42.0 Umbilical hernia with obstruction, without gangrene
K42.1 Umbilical hernia with gangrene
K42.9 Umbilical hernia without obstruction or gangrene
1.4.3 Hernia of the linea alba.
K43.6 Other and unspecified anterior abdominal wall hernia with obstruction, without gangrene.
K43.7 Other and unspecified anterior abdominal wall hernia with gangrene
K43.9 Other and unspecified anterior abdominal wall hernia without obstruction or gangrene
1.5 Classification of the disease or condition
1.5.1 Inguinal hernia.
By origin: all inguinal hernias in children are congenital (persistence of the processus vaginalis of the peritoneum, defect of the posterior wall of the inguinal canal)
Indirect hernia
Direct hernia
By clinical forms:
Boys:
Indirect inguinal hernia (funicular)
Indirect inguinoscrotal hernia
Communicating hydrocele of the testis
Direct inguinal hernia
Girls:
Indirect inguinal hernia
Direct inguinal hernia
Nuck's canal cyst
They are classified into:
Reducible inguinal hernia
Irreducible inguinal hernia
Strangulated inguinal hernia
By anatomical location of inguinal hernias:
Indirect: congenital inguinal, due to the persistence of the processus vaginalis peritonei;
Direct: due to a defect in the posterior wall of the inguinal canal. Rare in children. [32,33,34, 1].
1.5.2 Hernias of the linea alba are subdivided into paraumbilical (immediately above the umbilicus) and epigastric (located from the xiphoid process down along the midline of the abdomen) [2].
1.6 Clinical presentation of the disease or condition
1.6.1 Inguinal hernia.
The clinical presentation of an uncomplicated inguinal hernia is characterized by a soft-elastic, painless mass in the inguinal region that is easily reducible into the abdominal cavity. If a bowel loop is the content of the hernia sac, the mass reduces with a characteristic gurgling sound. In boys, the mass may reach the bottom of the scrotum. In a direct hernia, the hernial protrusion is defined only in the inguinal region. The hernial protrusion most often appears during tension of the anterior abdominal wall muscles, crying or agitation in the child, in the upright position—that is, in any situation accompanied by increased intra-abdominal pressure. The cough impulse test is positive. In an irreducible inguinal hernia, the hernial protrusion cannot be reduced into the abdominal cavity, but its palpation is painless, with no edema of the periinguinal tissues or skin hyperemia over the projection of the mass. In girls, the content of an irreducible inguinal hernia is usually the ovary; therefore, upon palpation, the consistency of the hernial protrusion is firm-elastic. Pain syndrome is not characteristic of the clinical picture of an uncomplicated inguinal hernia.
Clinical symptoms of a strangulated inguinal hernia
Strangulation of an inguinal hernia manifests as an acute symptom complex of pain (complaints of pain in the inguinal region or testis in older children; agitation and crying in younger children). The hernial protrusion becomes dense, sharply painful on palpation, and is not reducible into the abdominal cavity. A characteristic symptom of hernia strangulation is vomiting, which is reflex in nature during the first hour of the disease. From 8 to 12 hours after strangulation, signs of microcirculation impairment appear: tissue edema in the area of the hernial protrusion, skin hyperemia, and increasing symptoms of intoxication and intestinal obstruction (when a bowel loop is strangulated); vomiting becomes persistent. In the absence of timely treatment, the process can lead to necrosis of the strangulated organ. [1].
1.6.2 Umbilical hernia. The diagnosis of an umbilical hernia is based on a clinical examination of the child and consists of a soft-elastic protrusion in the umbilical ring area that is freely reducible into the abdominal cavity. In newborns and infants, an umbilical hernia presents as a rounded or oval protrusion of varying sizes. In a calm state and with the child lying down, the hernial protrusion easily reduces into the abdominal cavity, making the open umbilical ring readily palpable. The diameter of the actual fascial defect can range from a few millimeters to 5 cm or more. The degree of skin protrusion does not always indicate the size of the defect. Often, small defects can lead to alarmingly large protrusions resembling a proboscis. Thus, it is important to palpate the actual fascial defect by reducing the hernia to evaluate the feasibility of surgical or conservative treatment.
1.6.3 Hernia of the linea alba.
The diagnosis of a hernia of the linea alba is based on a clinical examination of the child and consists of a soft-elastic protrusion along the midline of the abdomen, painless on palpation, and not reducible into the abdominal cavity. Pain syndrome occurs in up to 30% of cases and is characterized by localized or diffuse tenderness of the anterior abdominal wall.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
Inguinal hernia.
The diagnosis of an inguinal hernia is established on the basis of:
1. Anamnestic data indicating the presence of a periodic or constant protrusion in the inguinal region (unilateral or bilateral) that increases when the child is agitated or strains
2. Physical examination findings characteristic of an inguinal hernia
Umbilical hernia.
The diagnosis of an umbilical hernia is established on the basis of:
3. Anamnestic data indicating the presence of a periodic or constant protrusion in the umbilical region that increases when the child is agitated, strains, or undergoes physical exertion.
4. Physical examination findings characteristic of an umbilical hernia.
Hernia of the linea alba.
The diagnosis of a hernia of the linea alba is established on the basis of:
Anamnestic data indicating the presence of a constant protrusion along the linea alba that increases when the child is agitated, strains, or undergoes physical exertion.
Physical examination findings characteristic of a hernia of the linea alba
2.1 Complaints and Anamnesis
2.1.1 Inguinal hernia.
It is recommended to check all patients (or their parents) for the presence of a mass in the inguinal region or enlargement of the scrotum [1, 35, 36].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Comments. In most patients, the history reveals a non-constant soft-elastic mass that can spontaneously reduce into the abdominal cavity. Patients or parents may note that the mass appears during moments of increased intra-abdominal pressure (agitation, crying, coughing).
2.1.2 Umbilical hernia.
It is recommended to check all patients (or their parents) for the presence of a mass in the umbilical region [1, 38].
GCP CLEL 4Grade of Recommendation C (Level of Evidence 4)
Comments. In most patients, the history reveals a non-constant soft-elastic mass that can spontaneously reduce into the abdominal cavity. Patients or parents may note that the mass appears during moments of increased intra-abdominal pressure (agitation, crying, coughing).
2.1.3 Hernia of the linea alba.
It is recommended to check all patients (or their parents) for the presence of a soft-elastic protrusion along the course of the linea alba [38, 39].
GCP CLEL 4Grade of Recommendation C (Level of Evidence 4)
Comments. In most patients, the history reveals a soft-elastic mass that does not reduce intoumia the abdominal cavity. Patients or parents note that the mass may appear during moments of increased intra-abdominal pressure (agitation, crying, coughing).
2.2 Physical Examination
2.2.1 Inguinal hernia
To establish the diagnosis of an inguinal hernia, the patient is examined in the upright position. To clarify the diagnosis, it is recommended to ask the patient to strain [1, 35, 36].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Comments: inspection and palpation of the inguinal region reveal a soft-elastic, painless swelling that is reducible into the abdominal cavity.
When diagnosing a strangulated inguinal hernia, it is recommended to pay attention to complaints from the child or parents regarding constant, intense pain in the area of the hernial protrusion and its irreducibility, child agitation, and vomiting [1, 35, 36, 23, 40].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Comments: inspection and palpation of the inguinal region reveal a painful, dense mass that is irreducible into the abdominal cavity.
2.2.2 Umbilical hernia
To establish the diagnosis of an umbilical hernia, the patient is examined in the upright position. To clarify the diagnosis, it is recommended to ask the patient to strain [1].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Comments: inspection and palpation of the umbilical region reveal a soft-elastic, painless swelling that is reducible into the abdominal cavity. It is necessary to palpate the actual fascial defect by reducing the hernia to evaluate the feasibility of surgical or conservative treatment.
2.2.3 Linea alba hernia
To establish the diagnosis of a hernia of the linea alba, the patient is examined in the upright position. To clarify the diagnosis, it is recommended to ask the patient to strain [2, 38].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
2.3 Laboratory Diagnostics
Laboratory tests are of no significance in the diagnosis of anterior abdominal wall hernias in children.
2.4 Instrumental Diagnostics
2.4.1 Inguinal hernia
When an inguinal hernia is detected in a child with a clear clinical diagnosis, additional instrumental examinations are not recommended [32, 33, 34].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Children with a history of a hernial protrusion in the inguinal region and no convincing evidence of an inguinal hernia upon general physical examination are recommended to undergo scrotal ultrasound [41–44].
GR BLE 2Grade of Recommendation B (Level of Evidence 2)
Comments: ultrasound has high sensitivity and specificity in diagnosing inguinal hernias, amounting to 96.6% and 84.8%, respectively. The examination makes it possible to determine the contents of the hernia sac, its structure, the presence of masses simulating an inguinal hernia, and also allows for the suspicion of an inguinal hernia on the contralateral side.
In a strangulated inguinal hernia, ultrasound reveals dilated bowel loops and absent peristalsis. The diagnostic accuracy of ultrasound in acute conditions of the inguinal region is 93% [41, 45].
2.4.2 Umbilical hernia
When an umbilical hernia is detected in a child with a clear clinical diagnosis, additional instrumental examinations are not recommended [1].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
2.4.3 Linea alba hernia
When identifying an epigastric hernia in a child and having a clear clinical diagnosis, additional instrumental studies are not recommended [38].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
For children with a history of a hernia protrusion along the linea alba and no convincing findings for an epigastric hernia upon general physical examination, it is recommended to perform an ultrasound examination of the soft tissues of the linea alba [46].
GCP CLEL 4Grade of Recommendation C (Level of Evidence 4)
Comments. Ultrasound allows visualization of the defect in the linea alba and its dimensions, which can facilitate preoperative marking of the hernia level [46].
2.5 Other Procedures
Not provided
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Inguinal hernia
The only effective method for treating inguinal hernias is surgical treatment. In indirect hernias, its essence consists in disconnecting the communication of the vaginal process of the peritoneum—which essentially represents the hernia sac—with the abdominal cavity to prevent abdominal organs from protruding beyond the abdominal wall. Inguinal canal plasty in indirect hernias in children is of no significant importance for recurrence prevention, but may lead to impaired blood supply to the gonad. The rationale for surgical treatment is to prevent the possibility of inguinal hernia strangulation.
3.1.1 Surgical treatment
Surgical treatment of all types of inguinal hernias in children is the main and only treatment option and is prescribed as soon as the diagnosis is made, regardless of age. However, for newborns without a tendency toward strangulation, it is recommended to perform surgery starting from 6 months of age. Exceptions are premature infants with frequent episodes of strangulation, large hernia defects causing constant anxiety in the child, episodes of bronchospasm and hypoxia, and gastrointestinal dysfunction. Herniorrhaphy is contraindicated in newborns on systemic hormone therapy, with generalized infection, or severe neurological pathology, until the child's condition stabilizes and the underlying disease improves [3, 65].
GCP BLEL 3Grade of Recommendation B (Level of Evidence 3)
In the surgical treatment of inguinal hernia in children, an individualized approach is recommended, taking into account the capabilities of the medical organization, resources, and the experience of the surgical team [47].
GGR BLOC 2Grade of Recommendation B (Level of Evidence 2)
Children with an established clinical diagnosis of IH are recommended to undergo elective surgical treatment for inguinal hernia [2,3,5].
GCP CLEL 4Grade of Recommendation C (Level of Evidence 4)
Comment. The rate of complications associated with IH in children decreases by up to 90% if surgical treatment is performed within 30 days of diagnosis, and surgery within 2 weeks reduces the risk of strangulation by 50% [1, 48].
Children with an established clinical diagnosis of strangulated IH are recommended to undergo emergency surgical treatment for inguinal hernia:
- in the presence of inflammatory changes in the hernia protrusion area;
- complications from the abdominal cavity;
- unsuccessful conservative treatment;
- female patients;
- in case of indirect inguinal hernia [1, 2, 40].
GCP CLEL 4Grade of Recommendation C (Level of Evidence 4)
Comment. The risk of recurrent strangulation ranges from 16% to 35%, and the time to recurrent strangulation varies from 0.5 days to 120 days after the first episode of strangulation [22, 49].
An attempt at conservative treatment is recommended for children with strangulated inguinal hernias without inflammatory changes in the hernia protrusion area and in the absence of abdominal complications [3, 36, 50].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Comment. The efficacy of conservative therapy is determined by the patient's age and the duration of strangulation. The efficacy of conservative therapy has been demonstrated in children aged 3 months compared to 5 months, and with a strangulation duration of 12 hours compared to 34 hours [51]. The efficacy of conservative therapy can be increased by using pharmacotherapy. The efficacy of conservative therapy is 70%–90% [40].
In cases of spontaneous reduction of a strangulated hernia with a strangulation duration of less than 12 hours and no symptoms of scrotal and/or abdominal complications, it is recommended to monitor the child in a hospital setting and perform urgent-elective surgical treatment for the inguinal hernia [3, 51].
LoR CGoE 4Level of Recommendation C (Grade of Evidence 4)
Urgent-elective surgical treatment is recommended after spontaneous reduction of a strangulated IH to be performed within 24 hours to 5 days [22, 49, 53].
GGR BLOC 3Grade of Recommendation B (Level of Evidence 3)
Comment: surgical treatment following spontaneous reduction eliminates the risk of recurrent strangulation. However, performing an emergency surgery can be technically challenging, increasing the risk of a direct hernia as a complication. In addition, tissue edema after strangulation can distort anatomical landmarks. On the other hand, delaying surgery carries the risk of recurrent strangulation and the need for emergency surgery. A time interval of 24 hours to 5 days allows the normal anatomy of the inguinal canal to be restored through the reduction of soft tissue edema [22, 49, 52, 53].
The choice of surgical treatment method (open, laparoscopic, or video-assisted) for indirect IH in children is recommended to be determined by the surgical team and the capabilities of the medical organization [54].
GR BLE 2Grade of Recommendation B (Level of Evidence 2)
Comment. There is no convincing evidence of the superiority of open or laparoscopic treatment methods for IH in children regarding perioperative, postoperative complications, and the recurrence rate of IH [54, 55].
In laparoscopic (intracorporeal suture) or video-assisted (extracorporeal ligation – PIRS) treatment of IH in children, the technique for closing the deep inguinal ring is recommended to be determined by the surgical team [54].
GR BLE 2Grade of Recommendation B (Level of Evidence 2)
Comment. There are no convincing data showing the superiority of one method over the other regarding postoperative complications and the rate of IH recurrence; however, the video-assisted variant of eliminating the communication between the abdominal cavity and the hernia sac appears technically simpler and more accessible to a wide range of surgeons [54].
When a latent contralateral hernia is detected during laparoscopic surgery for unilateral indirect IH, performing bilateral hernioplasty is recommended [3, 54].
GGR BLOC 2Grade of Recommendation B (Level of Evidence 2)
For strangulated indirect inguinal hernia, it is recommended to perform surgical treatment via an "open" traditional inguinal approach, since strangulation usually occurs in the superficial (external) inguinal ring, which is inaccessible during laparoscopy. Before dissecting the strangulating ring, the hernia sac must be opened and the condition of the strangulated organ assessed. If necessary, resection of the strangulated organ is performed. Inguinal canal plasty is minimal (suturing its dissected anterior wall) to prevent testicular ischemia [56].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
Surgical treatment of inguinal hernia using video-endoscopic technologies is recommended for strangulation in cases where the hernia spontaneously reduces on the operating table upon induction of anesthesia [14].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
In direct inguinal hernia, which is usually an intraoperative finding, the abdominal wall defect is visualized during laparoscopy in the medial inguinal fossa above the inguinal ligament. Excision of the hernia sac and closure of the hernia ring formed by the inguinal ligament and the edge of the oblique muscle are recommended [35, 36, 57, 40].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
3.2 Umbilical hernia
The natural course of an umbilical hernia involves spontaneous closure of the umbilical ring defect. Up to 93% of UHs regress by 1–2 years of age [58, 59, 60]. Furthermore, if the UH persists at 4–5 years of age, its spontaneous closure is recorded by age 11 [61].
The main complication associated with UH is its strangulation, the frequency of which is less than 1% [59, 62, 63].
3.2.1. Conservative treatment
Children with an established clinical diagnosis of umbilical hernia are recommended conservative therapy: a pediatric umbilical hernia belt and an adhesive pressure bandage [59, 60, 64].
GCP BLEL 3Grade of Recommendation B (Level of Evidence 3)
The decision on whether to perform conservative therapy or use an adhesive pressure bandage is recommended to be determined by a pediatric surgeon [59].
LoR CGoE 3Level of Recommendations C (Grade of Evidence 3)
Comment: the efficacy of an adhesive pressure bandage for UH compared to patient observation shows no advantage except for more rapid closure of the visceral defect. At the same time, the rate of skin irritation when using the bandage can reach 23.6% [59, 64].
3.2.2 Surgical treatment
Surgical treatment of uncomplicated umbilical hernia in children is recommended to be performed after 5 years of age [1, 60, 59]. Children with an established clinical diagnosis of uncomplicated umbilical hernia are indicated for surgical treatment of the umbilical hernia (tight closure of the umbilical ring defect). The method of surgical treatment is determined by the pediatric surgeon.
GCP BLEL 3Grade of Recommendation B (Level of Evidence 3)
In cases of umbilical hernia complicated by strangulation and in the absence of an effect from conservative therapy, surgical treatment of the umbilical hernia on an emergency basis is recommended. The method of surgical treatment is determined by the pediatric surgeon [40, 66].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
3.3 Linea alba hernia
3.3.1 Surgical treatment
Children with an established clinical diagnosis are recommended elective herniotomy for linea alba hernia [38, 2].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
3.2 Antibiotic prophylaxis
According to Order No. 203n of the Russian Ministry of Health dated May 10, 2017 "On approval of the criteria for assessing the quality of medical care" (Registered with the Ministry of Justice of Russia on May 17, 2017, No. 46740), perioperative antibiotic prophylaxis is performed for uncomplicated anterior abdominal wall hernias.
It is recommended to prescribe systemic antibacterial drugs (Cefazolin**) (in the absence of medical contraindications) to patients 30 minutes before surgical intervention for anterior abdominal wall hernia for the prevention of infectious complications [67].
GCR CLEL 5Grade of Recommendations C (Level of Evidence 5)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
There are no reliable methods for preventing inguinal hernia in children, as it is congenital.
6. Organization of Medical Care
The organization of medical care for children with anterior abdominal wall hernia is carried out in accordance with the Procedure for Providing Medical Care in the Profile "Pediatric Surgery" (Order of the Ministry of Health of the Russian Federation No. 562n dated October 31, 2012).
Indications for hospitalization in a medical organization:
Presence of a diagnosis of uncomplicated anterior abdominal wall hernia to perform elective surgery.
Indications for emergency hospitalization:
Presence of a diagnosis of incarcerated inguinal, umbilical, or linea alba hernia to perform emergency surgery.
Indications for patient discharge from a medical organization
Patient mobilization after surgery, absence of complications from the postoperative wound, internal organs, and body systems.
7. Additional Information
Not provided.
Criteria for Evaluating the Quality of Medical Care
References
Show references
Pediatric Surgery: National Guidelines / ed. by A.Yu. Razumovsky. – 2nd ed., rev. and supp. – Moscow: "GEOTAR-Media", 2021. – 1280 p.
Isakov Yu.F., Stepanov E.A., Krasovskaya T.V. Abdominal surgery in children: A guide. Moscow: Meditsina, 1988. 416 p.
Khan FA, Jancelewicz T, Kieran K, Islam S; COMMITTEE ON FETUS AND NEWBORN; SECTION ON SURGERY; SECTION ON UROLOGY. Assessment and Management of Inguinal Hernias in Children. Pediatrics. 2023 Jul 1;152(1): e2023062510
Rowe MI, Copelson LW, Clatworthy HW. The patent processus vaginalis and the inguinal hernia. J Pediatr Surg. 1969 Feb;4(1):102-7
Aiken JJ. Inguinal hernias. In: Nelson Textbook of Pediatrics, 17th, Behman RE, Kliegman RM, Jenson HB (Eds), Saunders, Philadelphia 2004. p.1293
Tanyel FC, Müftüoglu S, Dagdeviren A, Kaymaz FF, Büyükpamukçu N. Myofibroblasts defined by electron microscopy suggest the dedifferentiation of smooth muscle within the sac walls associated with congenital inguinal hernia. BJU Int. 2001 Feb;87(3):251-5.
Umbilical and Other Abdominal Wall Hernias. Joseph A. Sujka, George W. Holcomb in Holcomb and Ashcraft"s Pediatric Surgery, 7ed.,2020., 780-782.
Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths. I. General scheme and morphological aspects. J Surg Res 2001;96(01):127–134
Lang B, Lau H, Lee F. Epigastric hernia and its etiology. Hernia 2002;6(03):148–150
Moschcowitz AV. Epigastric hernia without palpable swelling. Ann Surg 1917;66(03):300–307
Askar OM. Aponeurotic hernias. Recent observations upon paraumbilical and epigastric hernias. Surg Clin North Am 1984;64 (02):315–333
Korenkov M, Beckers A, Koebke J, Lefering R, Tiling T, Troidl H. Biomechanical and morphological types of the linea alba and its possible role in the pathogenesis of midline incisional hernia. Eur J Surg 2001;167(12):909–914;
Fachinelli A, Trindade MR, Fachinelli FA. Elastic fibers in the anterior abdominal wall. Hernia 2011;15(04):409–415
Dreuning K, Maat S, Twisk J, van Heurn E, Derikx J. Laparoscopic versus open pediatric inguinal hernia repair: state-of-the-art comparison and future perspectives from a meta-analysis. Surg Endosc. 2019 Oct;33(10):3177-3191
Kumar VH, Clive J, Rosenkrantz TS, Bourque MD, Hussain N. Inguinal hernia in preterm infants (< or = 32-week gestation). Pediatr Surg Int. 2002 Mar;18(2-3):147-52
Pan ML, Chang WP, Lee HC, Tsai HL, Liu CS, Liou DM, Sung YJ, Chin TW. A longitudinal cohort study of incidence rates of inguinal hernia repair in 0- to 6-year-old children. J Pediatr Surg. 2013 Nov;48(11):2327-31.
Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. 1998 Aug;45(4):773-89;
Aboagye J, Goldstein SD, Salazar JH, Papandria D, Okoye MT, Al-Omar K, Stewart D, Lukish J, Abdullah F. Age at presentation of common pediatric surgical conditions: Reexamining dogma. J Pediatr Surg. 2014 Jun;49(6):995-9.
Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: clinical considerations. J Pediatr Surg. 1984 Dec;19(6):832-7;
Rowe MI, Clatworthy HW Jr. The other side of the pediatric inguinal hernia. Surg Clin North Am. 1971 Dec;51(6):1371-6
Puri P, Guiney EJ, O"Donnell B. Inguinal hernia in infants: the fate of the testis following incarceration. J Pediatr Surg. 1984 Feb;19(1):44-6.
Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg. 1993 Apr;28(4):582-3
Rowe MI, Clatworthy HW. Incarcerated and strangulated hernias in children. A statistical study of high-risk factors. Arch Surg. 1970 Aug;101(2):136-9
Miller, R., Khakar, A., Clarke, S. (2018). Umbilical Hernia in Babies and Children. In: LeBlanc, K., Kingsnorth, A., Sanders, D. (eds) Management of Abdominal Hernias. Springer, Cham.
Zens T, Nichol PF, Cartmill R, Kohler JE. Management of asymptomatic pediatric umbilical hernias: a systematic review. J Pediatr Surg. 2017 Nov;52(11):1723-1731
Vohr BR, Rosenfield AG, Oh W. Umbilical hernia in the low-birth-weight infant (less than 1,500 gm). J Pediatr. 1977 May;90(5):807-8.
Smith DW, Jones KL. Abdominal wall. In: Jones KL, ed. Smith’s Recognizable Patterns of Human Malformation. 4th ed. Philadelphia: Saunders; 1988:778.
Tank ES, Hatch DA. Hernias complicating chronic ambulatory peritoneal dialysis in children. J Pediatr Surg. 1986 Jan;21(1):41-2.
Woods GE. Some observations on umbilical hernia in infants. Arch Dis Child. 1953 Dec;28(142):450-62.
Almeflh W, AlRaymoony A, AlDaaja MM, Abdullah B, Oudeh A. A Systematic Review of Current Consensus on Timing of Operative Repair Versus Spontaneous Closure for Asymptomatic Umbilical Hernias in Pediatric. Med Arch. 2019 Aug;73(4):268-271
Hall DE, Roberts KB, Charney E. Umbilical hernia: what happens after age 5 years? J Pediatr. 1981;98:415–417.
Snyder CL, Escolino M, Esposito C. Inguinal hernia. In: Holcomb III GW, MurphyJP, St Peter SD, editors. Holcomb & Ashcraft’s Pediatric Surgery. 7th ed;
Parkinson EJ, Pierro A. Inguinal and umbilical hernias. In: Stringer MD, Oldham KT, Mouriquand PDE, editors. Pediatric Surgery and Urology: Long-term Outcomes. 2nd ed. Cambridge: Cambridge, University Press; 2006. p.286-95;
Hebra A, JB. Inguinal Hernia and Hydrocele. In: Mattei P, editor. Fundamentals of Pediatric Surgery. New York: Springer. 2011. p. 673-72
Inguinal hernia / S.Ya. Doletsky, A.B. Okulov // Khirurgiya. – 1978. – No. 12. – P. 55-63.
Inguinal hernia in children: / V.N. Stalmakhovich, M.V. Shchebenkov, G.I. Songolov [et al.]; Edited by V.I. Stalmakhovich. – 2nd ed., revised and enlarged. – Irkutsk: Irkutsk State Medical Academy of Postgraduate Education, 2013. – 198 p.
Miller, R., Khakar, A., Clarke, S. (2018). Umbilical Hernia in Babies and Children. In: LeBlanc, K., Kingsnorth, A., Sanders, D. (eds) Management of Abdominal Hernias. Springer, Cham.
Coats RD, Helikson MA, Burd RS. Presentation and management of epigastric hernias in children. J Pediatr Surg. 2000 Dec;35(12):1754-6
Tinawi GK, Stringer MD. Epigastric Hernias in Children: A Personal Series and Systematic Review of the Literature. Eur J Pediatr Surg. 2022 Apr;32(2):139-145
Abdulhai SA, Glenn IC, Ponsky TA. Incarcerated Pediatric Hernias. Surg Clin North Am. 2017 Feb;97(1):129-145.
Sameshima YT, Yamanari MG, Silva MA, Neto MJ, Funari MB. The challenging sonographic inguinal canal evaluation in neonates and children: an update of differential diagnoses. Pediatr Radiol. 2017 Apr;47(4):461-472;
Robinson A, Light D, Nice C. Meta-analysis of sonography in the diagnosis of inguinal hernias. J Ultrasound Med. 2013 Feb;32(2):339-46;
Erez I, Rathause V, Vacian I, Zohar E, Hoppenstein D, Werner M, Lazar L, Freud E. Preoperative ultrasound and intraoperative findings of inguinal hernias in children: A prospective study of 642 children. J Pediatr Surg. 2002 Jun;37(6):865-8;
Kaneda H, Furuya T, Sugito K, Goto S, Kawashima H, Inoue M, Hosoda T, Masuko T, Ohashi K, Ikeda T, Koshinaga T, Hoshino M, Goto H. Preoperative ultrasonographic evaluation of the contralateral patent processus vaginalis at the level of the internal inguinal ring is useful for predicting contralateral inguinal hernias in children: a prospective analysis. Hernia. 2015 Aug;19(4):595-8.
Erez I, Schneider N, Glaser E, Kovalivker M. Prompt diagnosis of "acute groin" conditions in infants. Eur J Radiol. 1992 Oct;15(3):185-9
König TT, Oerters LS, Spiller L, Schwind M, Born M, Oetzmann von Sochaczewski C, Heydweiller AC. Epigastric hernias in children and the use of ultrasound in its diagnosis. World J Pediatr Surg. 2023 Apr 6;6(2):e000544
Morini F, Dreuning KMA, Janssen Lok MJH, Wester T, Derikx JPM, Friedmacher F, Miyake H, Zhu H, Pio L, Lacher M, Sgró S, Zani A, Eaton S, van Heurn LWE, Pierro A. Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons" Association Evidence and Guideline Committee. Eur J Pediatr Surg. 2022 Jun;32(3):219-232
Glick PL, Boulanger SC. Inguinal hernias and hydroceles. In: Coran AG, Adzick NS, Krummer TM, et al., eds. Pediatric Surgery. 7th ed. Philadelphia: WB Saunders Elsevier; 2012:985–1001
Gahukamble DB, Khamage AS. Early versus delayed repair of reduced incarcerated inguinal hernias in the pediatric population. J Pediatr Surg. 1996 Sep;31(9):1218-20.
Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J Surg. 1989 Sep-Oct;13(5):506-15.
Davies N, Najmaldin A, Burge DM. Irreducible inguinal hernia in children below two years of age. Br J Surg. 1990 Nov;77(11):1291-2.
Vaos G, Gardikis S, Kambouri K, Sigalas I, Kourakis G, Petoussis G. Optimal timing for repair of an inguinal hernia in premature infants. Pediatr Surg Int. 2010 Apr;26(4):379-85
Niedzielski J, Kr l R, Gawłowska A. Could incarceration of inguinal hernia in children be prevented? Med Sci Monit. 2003 Jan;9(1):CR16-8
Morini F, Dreuning KMA, Janssen Lok MJH, Wester T, Derikx JPM, Friedmacher F, Miyake H, Zhu H, Pio L, Lacher M, Sgró S, Zani A, Eaton S, van Heurn LWE, Pierro A. Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons" Association Evidence and Guideline Committee. Eur J Pediatr Surg. 2022 Jun;32(3):219-232
Dreuning K, Maat S, Twisk J, van Heurn E, Derikx J. Laparoscopic versus open pediatric inguinal hernia repair: state-of-the-art comparison and future perspectives from a meta-analysis. Surg Endosc. 2019 Oct;33(10):3177-3191
Miller, R., Clarke, S. (2018). Inguinal Hernias in Babies and Children. In: LeBlanc, K., Kingsnorth, A., Sanders, D. (eds) Management of Abdominal Hernias. Springer, Cham
Endovideosurgical treatment of children with pathology of the vaginal process of the peritoneum / M.V. Shchebenkov // Detskaya khirurgiya. – 2002. – No. 4. – P. 24.
Woods GE. Some observations on umbilical hernia in infants. Arch Dis Child. 1953 Dec;28(142):450-62
Zens T, Nichol PF, Cartmill R, Kohler JE. Management of asymptomatic pediatric umbilical hernias: a systematic review. J Pediatr Surg. 2017 Nov;52(11):1723-1731.
Almeflh W, AlRaymoony A, AlDaaja MM, Abdullah B, Oudeh A. A Systematic Review of Current Consensus on Timing of Operative Repair Versus Spontaneous Closure for Asymptomatic Umbilical Hernias in Pediatric. Med Arch. 2019 Aug;73(4):268-271.
Hall DE, Roberts KB, Charney E. Umbilical hernia: what happens after age 5 years? J Pediatr. 1981;98:415–417.
Zendejas B, Kuchena A, Onkendi EO, et al. Fifty-three-year experience with pediatric umbilical hernia repairs. J Pediatr Surg. 2011;46: 2151–2156.
Lassaletta L, Fonkalsrud EW, Tovar JA. The management of umbilicial hernias in infancy and childhood. J Pediatr Surg. 1975;10: 405–409
Sugimoto T, Tahara K, Uchida K, Yoshimoto K. Efficacy of adhesive strapping on umbilical hernia in children: a systematic review and meta-analysis of cohort studies. World J Pediatr Surg. 2023 Oct 17;6(4):e000633
Masoudian P, Sullivan KJ, Mohamed H, Nasr A. Optimal timing for inguinal hernia repair in premature infants: a systematic review and meta-analysis. J Pediatr Surg. 2019 Aug;54(8):1539-1545.
Chirdan LB, Uba AF, Kidmas AT. Incarcerated umbilical hernia in children. Eur J Pediatr Surg. 2006 Feb;16(1):45-8.
Dobrokvashin S.V., Volkov D.E. Perioperative antibiotic prophylaxis in surgery // Kazansky medical journal, 2004, vol. 85, no. 5.
Appendix A1. Working Group Composition
Kozlov Yury Andreevich – MD, Corresponding Member of the RAS. Head of the Department of Pediatric Surgery and Pediatrics, Faculty of Continuing Professional Education, ISMU, Head
Stalmakhovich Viktor Nikolaevich – MD, Prof., Head of the Department of Pediatric Surgery, IGMAPO, member of the working group
Shchebenkov Mikhail Valentinovich – MD, Professor, Department of Pediatric Surgery, North-Western State Medical University named after I.I. Mechnikov, member of the working group
Novozhilov Vladimir Alexandrovich – MD, Prof., Head of the Department of Pediatric Surgery, ISMU, member of the working group
Podkamenev Alexey Vladimirovich – MD, Associate Professor, Head of the Department of Pediatric Surgical Diseases named after Acad. G.A. Bairov, SPbSPMU, member of the working group
Svarich Vyacheslav Gavrilovich, MD, Associate Professor, Professor of the Department of Pediatric Surgical Diseases named after Acad. G.A. Bairov, SPbSPMU, member of the working group
Rudykh Natalya Vitalievna – Head of the Quality Control and Safety Department of Medical Activity of OGAUZ GIMDKB, Secretary of the working group
All members of the working group are members of the All-Russian Public Organization "Russian Association of Pediatric Surgeons"
There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of the clinical guidelines:
Pediatric surgeons
Resident physicians in pediatric surgery
Evidence gathering methodology:
Methods used for evidence collection/selection:
Search for publications in peer-reviewed journals with an impact factor >0.3;
Electronic database search:
Databases used for evidence collection/selection:
The evidence base for the recommendations includes publications from the Cochrane Library, PUBMED, and MEDLINE databases. The search depth was 10 years.
Methods used for evidence analysis:
reviews of published meta-analyses;
systematic reviews with evidence tables.
Methods used for assessing the quality and strength of evidence:
expert consensus;
evaluation of the significance of evidence in accordance with the rating scheme for evidence (Tables A2.1 – A2.3).
These clinical guidelines present the levels of certainty of evidence for recommendations in accordance with the draft methodological guidelines for assessing the certainty of evidence and the strength of recommendations of the Center for Expertise and Quality of Medical Care of the Russian Ministry of Health.
In accordance with this draft of recommendations, certain generally accepted diagnostic methods are assigned the level GPP (Good Practice Point) based on expert consensus.
Related Documents
These clinical guidelines were developed taking into account the following regulatory and legal documents:
Order of the Ministry of Health of the Russian Federation No. 562n dated October 31, 2012 "On approval of the Procedure for providing medical care in the profile 'pediatric surgery'"
Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care."
Methodology for validation of guidelines
Methods for guideline validation:
External peer review;
Internal expert review.
Description of the guideline validation methodology
The recommendations have been discussed and approved by leading specialists of specialized Federal Centers of Russia and practicing physicians.
Procedure for updating clinical guidelines
Updating is carried out at least once every three years or earlier, taking into account newly emerged information on the diagnosis and management tactics of patients suffering from IH. The decision on the update is made by the Russian Ministry of Health based on proposals submitted by medical professional non-profit organizations. The formulated proposals must take into account the results of a comprehensive assessment of surgical methods, medical devices, and the results of clinical approbation.
Table 1.Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | There is only a rationale for the mechanism of action or expert opinion |
Table 2.Scale for assessing levels of evidence (LE) for methods of prevention, treatment, medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, therapeutic, rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion |
Table 3. Scale for assessing grades of recommendation (GR) for methods of prevention, diagnostics, treatment, medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of evidence of proper quality; all considered efficacy criteria [outcomes] are unimportant, all studies have low methodological quality, and their conclusions regarding outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Not provided
Appendix B. Physician Action Algorithms
Diagram: Inguinal hernia
Diagram: Linea alba hernia
Appendix C. Patient Information
Inguinal hernia
Inguinal hernia is a pathological condition in which internal organ tissues protrude through the abdominal wall in the inguinal region. The disease is characterized by a painless protrusion in the groin area, which may disappear in the supine position, at rest, and increases with tension of the abdominal wall muscles.
In most cases, inguinal hernia is congenital. Before birth, a boy's testes are located in the abdomen. As the fetus grows, its testes move through a tunnel into the scrotum, which also exists in girls. Normally, this tunnel should close as the child develops. When this does not happen, a communication remains between the abdominal cavity and the groin. Through it, abdominal organs can enter the inguinal canal (inguinal region).
Inguinal hernia in children can be noticed as early as the neonatal period. Its main manifestation is a hernia protrusion (swelling) in the inguinal region, which increases when the child strains, coughs, or cries, and decreases or completely disappears at rest. When pressed, the swelling is easily reduced and does not manifest itself at rest. The swelling in the inguinal region is painless and has an oval or round shape. In inguinal-scrotal hernia in boys, the hernia sac descends into the scrotum, leading to stretching and asymmetry of one of its halves. In girls, the hernia protrusion may descend into the labium majus.
Only incarceration of an inguinal hernia is accompanied by characteristic signs in children. It is an extremely dangerous condition requiring immediate surgical treatment. Symptoms of inguinal hernia incarceration in children include: sharp pain in the area of the protrusion, inability to reduce the swelling, general intoxication, vomiting. In infants, incarceration can be suspected by pronounced anxiety, attempts to take a forced posture, crying, and fussiness.
Acquired inguinal hernias are extremely rare and occur mainly in teenage boys. The cause may be: intense physical exertion, weight lifting, frequent constipation, etc.
Inguinal hernia is an indication for surgical treatment, which is performed electively. There are two methods of surgical treatment: open – in which a small incision is made in the inguinal region and the communication between the abdominal cavity and the laparoscopic method is sutured using small instruments, with which the communication with the abdominal cavity is also sutured.
The postoperative period after surgical treatment proceeds favorably. Patient mobilization is possible the day after surgery. Edema of the postoperative wound may be observed for a short time. After discharge from the hospital, children are usually recommended to limit physical activity. Subsequently, the child is followed up by a surgeon at the local outpatient clinic.
Linea alba hernia
Linea alba hernia is formed as a result of a small defect in the connective tissue structure of the anterior abdominal wall, which runs along the midline of the abdomen, hence the name of the disease.
The hernia can be located anywhere from the navel to the xiphoid process of the sternum. If the hernia is located near and above the navel, it is called paraumbilical.
As a rule, children or parents notice a tumor-like formation of soft-elastic consistency located along the midline of the abdomen. When pressure is applied, the hernia is not reduced into the abdominal cavity and remains in place. The presence of a hernia may be accompanied by pain syndrome. If the pain is constant, in the area of the protrusion or throughout the abdomen, palpation of the protrusion is painful, and there is edema, redness – this may indicate hernia incarceration, and you should consult a doctor immediately.
Treatment of linea alba hernia is exclusively surgical, performed electively after examination and consultation by a pediatric surgeon.
During the surgery, the defect that forms the hernia is tightly sutured.
The postoperative period after surgical treatment proceeds favorably. Patient mobilization is possible the day after surgery. Edema of the postoperative wound may be observed for a short time. After discharge from the hospital, children are usually recommended to limit physical activity. Subsequently, the child is followed up by a surgeon at the local outpatient clinic.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
None provided.