1. Interns Hour
5 February 2011

2. General Data 2 month old male Calamba, Laguna
Born term via LT CS, twin pregnancy

3. Chief complaint
Right scrotal mass

4. History of Present Illness
At 3 weeks of age – noted to have a right inguinal mass, prominent when patient is crying. Mass is reducible when patient is relaxed. No changes in bowel movement, no abdominal distention, no diifficulty urinating. Patient had good suck and activity.
Consult was done at a local hospital and was advised surgery once the patient is older.
At 2 months of age – persistence of above symptoms with noted extension of the mass to the scrotal area. Mass was reducible when palpated. No tenderness, no changes in color noted. No changes in bowel movement, no difficulty urinating, no abdominal distention. Patient had good appetite.

5. Few hours prior to consult, patient was noted to be crying
Few hours prior to consult, patient was noted to be crying. Scrotal mass was noted to be enlarged with deviation of the penis to the left side. Noted tenderness. No discoloration noted. No vomiting, no changes in bowel movement, no difficulty urinating. Patient was noted to have poor appetite. Patient was immediately brought to PGH. Hence consult.

6. Review of systems (-) fever, weight loss
(+) rashes, inguinal area, (-) jaundice, pallor
(-) eye pain/discharge, (-) nasoaural discharge
(-) dyspnea, hemoptysis
(-) cyanosis
(-) abdominal pain, diarrhea/constipation
(-) dysuria, hematuria, nocturia
(-) seizures

7. Prenatal History Born to a 25 year old mother
No known maternal illness
No intake of medications
Regular monthly prenatal check-up at (6x) LHC

8. Birth History
Born term via LTCS due to twin pregnancy at St. John Hospital
No known fetomaternal complications
Good suck, good cry and goo activity

9. Feeding history Breastfed up to 1 month of age
Started drinking formula milk at 1 month of age (2 cups/ 80ml bottle)
Feeds ~8 times a day
No food preferences

10. Developmental History
Social smile at 1 month of age

11. Past Medical History (+) vaccinations: DPT1, Hepa B1, BCG, OPV1
No known illnesses
No allergies to food/drugs

12. Family Medical History
(+) heart disease
(+) similar inguinal mass – twin sibling
(-) hypertension
(-) PTB
(-) Diabetes
(-) Bronchial asthma

13. Personal/Social History
Eldest of twins
Lives with parents and grandparents in bungalow type of house with 2 bedrooms and 1 comfort room

14. PHYSICAL EXAMINATION

15. Vital Signs & Anthropometric Measurements
Measures
Heart Rate
136 bpm
Length
58 cm
Respiratory Rate
34 cpm
Weight
5.41 kg
Temperature
36.8
Head Circumference
37 cm
Abdominal Circumference
Chest Circumference
39 cm

16. Physical Findings
HEENT
Pink conjunctivae, anicteric sclerae, fontanels not tense
(-) CLAD , (-)NVE
Chest
Clear breath sounds (-)crackles/wheezing
Distinct Heart Sounds, normal rate regular rhythm (-) murmur
Abdomen
Soft globular, normoactive bowel sounds
no guarding,non-tender (-) hepatomegaly

17. Physical Findings Pink nailbeds (-) cyanosis (-) edema
Extremities
Pink nailbeds (-) cyanosis (-) edema
Good CRT Full & equal pulses
Genitalia
3 x 3 firm, tender, non-reducible left inguino-scrotal mass. No discoloration noted.
1cm patent inguinal ring
Desceneded testis, bilateral.
Neurologic Exam
Good cry good activity good suck
Pupils 2mm EBRTL OU, brisk corneal bilateral

18. Primary Working Impression
Inguinoscrotal hernia, incarcerated

19. Differential DIAGNOSIS

20. Differential Diagnosis
Findings
Hydrocele (communicating)
Cystic swelling
Increase in size when upright or when intra- abdominal pressure increases
Usually congenital
Transilluminates
Hydrocele (noncommunicating)
Does not change in size with changes in position of intra-abdominal pressure
Often a simultaneous scrotal abnormality (eg, tumor, epididymitis)
Spermatocele
Cystic mass at the upper pole of the testis, adjacent to epididymis

21. Differential
Diagnosis
Findings
Inguinal hernia
Increases in size when upright or when intra-abdominal pressure increases
May disappear when recumbent or be reducible or compressible
Possibly bowel sounds
Absence of normal spermatic cord structures above the mass
Possibly palpable in the inguinal canal
Varicocele
Palpable when standing, feeling like a bag of worms
Usually on left side
Possibly pain and fullness when standing
Possibly testicular atrophy
Hematocele
Tender swelling
Risk factors (eg, trauma, surgery, bleeding disorder or use of anticoagulants)
Testicular cancer
Mass attached to or part of testis
Is solid or does not transilluminate
Possibly dull, aching pain or acute pain due to hemorrhage

22. Hydrocele accumulation of fluid within the tunica vaginalis nontender
transilluminates

23. Hernia indirect inguinal hernia Bulge that appears on straining
Bowel sounds may be heard over the hernia
(-) transillumination test

24. Hematocele Blood in the tunica vaginalis
Swelling resembles a hydrocele
(-) transillumination test
(+) history of trauma

25. Spermatocele
painless fluid-filled sac with sperm that is often located above and posterior to the testicle
(+) transillumination test

26. Inguinal Hernias

27. Inguinal Hernias Usually indirect (99%)
High incidence in premature infants (30%)
Risk for incarceration and strangulation highest in the 1st year of life (30-40%)
The testes descend from the urogenital ridge in the retroperitoneum to the area of the internal ring by about 28 wk gestation.
The testis passes through the inguinal canal in a few days but takes about 4 wk to migrate from the external ring to the scrotum.
In the last few weeks of gestation or shortly after birth, the layers of the processus vaginalis normally fuse together and obliterate the patency from the peritoneal cavity through the inguinal canal to the testis. The processus vaginalis also obliterates just above the testes, with the portion of the processus vaginalis that envelops the testis becoming the tunica vaginalis.

28. Inguinal hernias
Intra-abdominal contents enter the inguinal region through the patent processus vaginalis
Usually congenital, due to a patent processus vaginalis
Twice as common on the right side
peritoneal outpouching that extends through the internal inguinal ring and accompanies the testis as it exits the abdomen and descends into the scrotum
related to later descent of the right testis and interference from the developing inferior vena cava and external iliac vein

29. Patent processus vaginalis

30. Predisposing Factors PREMATURITY UROGENITAL Cryptorchidism
Exstrophy of the bladder or cloaca  
Ambiguous genitalia  
Hypospadius/epispadius
INCREASED PERITONEAL FLUID  
Ascites  
Ventriculoperitoneal shunt  
Peritoneal dialysis catheter
INCREASED INTRA-ABDOMINAL PRESSURE  
Repair of abdominal wall defects  
Severe ascites (chylous)  
Meconium peritonitis
CHRONIC RESPIRATORY DISEASE  
Cystic fibrosis
CONNECTIVE TISSUE DISORDERS  
Ehlers-Danlos syndrome  
Hunter-Hurler syndrome
 Marfan syndrome  
Mucopolysaccharidosis

31. bulge in the inguinal region or extending through the inguinal region into the scrotum or in the upper portion of the labia majora.
most visible at times of irritability or increased intra-abdominal pressure
smooth, firm mass that emerges through the external inguinal ring lateral to the pubic tubercle and enlarges with increased intra-abdominal pressure
“silk glove sign” as the layers of the hernia sac (processus vaginalis) slide over the spermatic cord structures

32. Incarcerated hernia Strangulated hernia
cannot be reduced into the abdominal cavity
small bowel, appendix, omentum, colon, Meckel diverticulum
ovary, fallopian tube
irritability, pain in the groin and abdomen, abdominal distention, and vomiting
Strangulated hernia
hernia contents have become ischemic or gangrenous

38. MANAGEMENT

39. DIAGNOSTICS

40. DAIGNOSTIC STRATEGIES
diagnosis of IH in an overwhelming majority of cases is clinical history and examination
If diagnosis cannot be made immediately, the child needs to be re-examined over a period of time to make a definitive diagnosis

41. Physical Exam Ultrasound MRI Comparative Sp and Sn Technique
Sensitivity
Specificity
Physical Exam
74.5
96.3
Ultrasound
92.7
81.5
MRI
94.5
86.3
sensitivity (percentage of patients with a correct positive diagnosis)
specificity (percentage of patients with a correct negative diagnosis)

42. IMAGING TECHNIQUES imaging studies are generally not indicated
Ultrasonography- can confirm IH in selected patients
not the gold standard for diagnosing IH in children

43. Gold Standard
Laparoscopy - considered the final means of determining the true groin pathology

44. Pre-Operation Labs Complete blood count with differential count
blood urea, creatinine, serum electrolytes - helpful in cases of strangulation and obstruction

45. Available Labs Ultrasound:
Both testicles are normal with fine homegenous echogencity, epididymis not dilated
No fluid collection in scrotal sac, no mass density demonstrated
Omental structures seen in widened left inguinal canal with descent upon valsalva

46. Available Labs Blood Typing: B Positive Complete Blood Count
Hemoglobin
107
Hematocrit
0.333
Platelet
443
WBC
15.93
Neutrophils
0.185
Lymphocytes
0.653
Monocyte
0.130
Eosinophils
0.029
Basophils
0.003
Electrolytes
Na 142
K 4.4
Cl 102
BUN
5.4
CREA 37

47. SURGICAL MANAGEMENT

49. MANAGEMENT
Inguinal hernias do not spontaneously heal and must be surgically repaired because of the risk of incarceration.
Surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.
Application of gentle pressure on the bulge of an inguinal hernia to prevent incarceration until the elective operative repair is performed.

50. MANAGEMENT: Surgical Elective herniorrhaphy
Involves closing of the patent processus vaginalis
indicated to prevent incarceration and subsequent strangulation
Controversy exists regarding the role for exploration of an asymptomatic opposite side in a child with an inguinal hernia.
Explore only under certain conditions such as in premature infants or in patients in whom incarceration is present.

51. Management of Incarcerated Hernia
Manual reduction should be attempted if the patient has no signs of systemic toxicity like:
leukocytosis, severe tachycardia, abdominal distention, bilious vomiting, and discoloration of the entrapped viscera
If the patient appears toxic, emergent surgical exploration is necessary.

52. Management of Incarcerated Hernia
Successful reduction of an incarcerated inguinal hernia results in immediate patient comfort, relief of obstruction, and prevention of strangulation.
Immediate surgery is performed if the reduction is unsuccessful; otherwise, elective operation is scheduled within hours after reduction because recurrent incarceration is quite common.

53. Management of Hernia Strangulation
reduction without operative intervention is not possible
significant swelling from the compromised bowel, the presence of intestinal ischemia secondary to incarceration precludes the possibility of reducing the hernia back into the peritoneal cavity
immediate operative intervention is indicated, and the viability of the intestine must be carefully assessed at the time of surgery
If necrosis has developed, resect the affected segment of bowel

54. Course of the Patient Prepared for OR: (maintained on NPO)
IVF: D5 IMB @ 23CC/HR
started on Cefuroxime (100) 190 mg Q8
Metronidazole (30) 60 mg Q8H
Underwent herniotomy, L under GA
High ligation of the hernia sac
Discharge the next day….
Take home meds:
1) Paracetamol 0.6 ml every 6H X 2days
2)Amoxicillin 2 drops (100mg/ml) Q6H X 7 days

55. PROGNOSIS
Inguinal hernias in children recur in less than 1 percent of patients, and recurrences usually result from missed hernia sacs at the fisrt procedure, a direct hernia, or missed femoral hernia.
Overall prognosis is excellent; most patients do extremely well after operative repair of their inguinal hernia.
Mortality is extremely rare but, unfortunately, continues to be reported as a consequence of delayed recognition of an incarcerated and strangulated inguinal hernia.

56. END