Hernias

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice points

Management

Referral pathways

Hernias are common in childhood, particularly infants. The guideline will cover:

• umbilical hernias
• inguinal hernias

Diagnosis

Hernias are generally simple to diagnose clinically and rarely need imaging.

Umbilical hernias are compressible extensions of abdominal contents protruding through the umbilicus and are extremely common in newborns and infants. They are rarely symptomatic or of any clinical significance and do not represent a significant incarceration risk, even when large.

Inguinal hernias are a protrusion of abdominal content through the inguinal canal. Clinically, one can normally reduce the swelling, although not generally get above the protrusion. They can be

• indirect (through failure of closure of the internal inguinal ring): found in infants, more commonly males.
• direct (through weakness is abdominal wall fascia): generally seen in adults.

Differentials

• hydrocele - generally non-compressible, transilluminable, located primarily in the scrotum, and you should be able to get above it.
• lymphadenopathy - generally non-compressible/reducible and fixed
• encysted hydrocele of the cord - immobile, non-compressible

Practice points

• Investigations, including ultrasound, is generally not required in the diagnosis or management of hernias.
• Umbilical hernias rarely ever require surgical intervention, even if large.
• Inguinal hernias generally require repair given the risk of incarceration.

Management

Investigations, including ultrasound, is generally not required in the diagnosis or management of hernias unless it is clinically very difficult to distinguish differentials (see above).

Umbilical hernias rarely ever require surgical intervention, even if large. They rarely ever lead to incarceration. The majority will resolve spontaneously by 12 months of life. Should they not resolve by a few years of age and are causing symptoms (e.g. pain), surgical correction can be considered.

Inguinal hernias generally require repair given the risk of incarceration. Should they become irreducible, painful and discoloured, immediate surgical opinion is required. Otherwise, referral for semi-urgent surgical correction is recommended:

• within 2 days if child < 6 weeks
• within 2 weeks if child < 6 months
• within 2 months if child > 6 months

Referral pathways

• Surgical services
  • Referral for surgical opinion is generally recommended for inguinal hernias, but not for umbilical hernias.
    • Ballarat Health Services offers general surgical services appropriate for inguinal hernia repairs of children without other significant co-morbidites.
    • For complex children refer to the Royal Children's Hospital surgical services is appropriate.
• Paediatrician
  • Referral to paediatric outpatient services is not appropriate in the majority of hernias.
  • Referral to paediatric outpatient services can be considered when an alternative diagnosis is being considered.
• Other resources
  • Kids Health Info site for inguinal hernias for parents