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Pediatric Surgery (Pg 68-81) - page 7 / 33

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If distal processus is obliterated, fluid accumulates above the testicle as a hydrocele of the spermatic cord

If the proximal processus is obliterated, fluid may be trapped distally in the tunica vaginalis and produce a noncommunicating hydrocele

Presentation and evaluation:  About half of all inguinal hernias appear during the first year of life.

Inguinal hernias appear twice as often on the right side because the R testicle descends later embryologically and its processus is less likely to have closed

Ten percent of inguinal hernias are bilateral

Examination:  hernia - palpable as a firm mass that completely disappears with digital pressure.  If not obvious, may be brought out by asking older children to jump or strain.  Hydrocele - swelling of hemiscrotum, not reducible, does not extend upward to inguinal ring.  

Hydrocele of cord may resemble incarcerated hernia, but incarcerated hernias are very painful and may cause intestinal obstruction.

Treatment:

Inguinal hernias never resolve in children – should be repaired by high ligation of hernia sac at internal ring

Incarcerated hernia is emergency because of strangulation of hernial contents and the possibility of testicle ischemia.  Apply slow persistent pressure bimanually on mass and delay repair for 24 -48 hours to allow scrotal edema to subside.

Child with inguinal hernia is at increased risk of having another one on contralateral side

Umbilical Hernia

caused by failure of umbilical ring to contract completely

esp. common in African Americans, incidence is 50%

most resolve spontaneously during childhood with very low risk of incarceration

Presentation and evaluation:  see bulge within umbilicus, palpate fascial defect when mass is reduced

Treatment:  surgery when hernia persists beyond 4 years of age

Surgery if fascial defect is  >1.5 cm when child is 2 years old

Correct in pregnant girls because of increased risk with increased abdominal pressure

Cryptorchidism

Cryptorchid testes – testis has not descended into scrotum.  Usually occurs 7-9 months gestation.  Incidence – 3% term infants, 30% preterm

Most cryptorchid testes spontaneously descend within 1 year

10-40 x increase in testicular malignancy with undescended testes, orchidopexy (surgical descent of testical) does not decrease malignancy rates, but increases rate of detection

increased risk of testicular torsion, more vulnerable to trauma, and psychological concerns

usually associated with patent processus vaginalis, so also predisposed to inguinal hernias

undescended testes may be palpable in abdomen.  Distinguish from retractile testis where testes is transiently pulled up by cremasteric muscle.

Important to find undescended testicle.  May be totally absent or may be above internal ring.  Laparoscopy is best way to look for it.

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