Hernia Repair – Umbilical, Epigastric, and Inguinal

Inguinal Hernia

Herniorrhaphy and its variant hydrocele (fluid only, no bowel) repair are the most frequently performed operations in pediatric surgery.

Most pediatric hernias are indirect. They occur when the processus vaginalis (a small pouch of peritoneum dragged down to the scrotum during gonadal descent) fails to obliterate.

Umbilical Hernia

These tend to close over the first 5 years of life (95%) and are repaired when they are larger> than 2cm.

Epigastric Hernia

The epigastric hernia is usually between the belly button and the chest. Weakness in the abdominal muscle usually allows the peritoneum to push through the muscle wall. The hernia may not be noticeable unless the patient is crying, pushing to have a bowel movement, or another activity that creates abdominal pressure.

Usually repaired using a laparoscopic approach, it may require mesh placement if it is a large hernia.

Complications

Damage to the vas deferens or testicular vessels may cause an inguinal hernia to the contralateral side if not repaired initially, risk of infertility.

Surgery

Inguinal hernias and hydroceles are repaired through a lower-lateral abdominal skin crease incision, which may be laparoscopically. An umbilical hernia is repaired via a transverse incision in the infraumbilical skin fold.

Preoperative Considerations

Position

Supine

Antibiotics

Per surgeon

Surgical time

40 min

EBL

5 mL/kg

Morbidity

Apnea, recurrence

Pain score

3-5; Acetaminophen per rectum at the beginning of the case aids postop pain. May use caudal block.

Caudal block

Optimal up to age 12, then difficult to identify sacral hiatus.

Bupivacaine .25% +/- epi 1:200.000 at 1 mL/kg.

< 5 yr 22g catheter.

>5 yr 20g catheter.

Sacro coccygeal membrane.

Risk of dural puncture - adult L2/ peds S4.

Anesthetic considerations

Post-op apnea in infants < 55-60 weeks post-conceptual age (consider caffeine 10mg/kg iv).

Infants < 50 weeks post conception usually require overnight admission for monitoring of apnea/HR.

Warm OR.

Decreased FRC, HR, venous return with supine position, and insufflation.

Prevent coughing/straining during emergence to prevent dehiscence.

GETA

LMA or ETT depending on history (obstruction, incarceration, strangulation) and surgical need for relaxed abdominal wall

Vagal reflex due to bowel traction, leading to decreased HR and BP