Here’s help with distinguishing hernias from hydroceles and knowing when delaying the repair is wise. Pediatric surgeon Aaron R. Jensen, MD, FACS, FAAP, offers a straightforward diagnostic method, surprising tips on imaging, and the evidence on anesthesia’s risks and long-term repercussions for the very young.
see if I can make these advance. There we go. I don't have any disclosures. I do get a little bit of money from the government to work on pediatric readiness and trauma care and critical access hospitals, but none of that should impact our talk here today. Really, what I like is for you guys to understand what the surgeon is thinking when you refer a hernia to us and why we fix some of them, Why we don't fix other ones. Why we might delay good luck getting inside my brain but we'll do the best that we can here are the objectives for today. I think really understanding the natural history of these hernias, which ones go away. Which ones don't go away is really important in having an understanding when you should get fixed. Um also understanding when they're going to become symptomatic and what the potential complications of them becoming symptomatic is also important because that also impacts when we're going to repair these. I'm going to talk a little bit about complications of anesthesia and optimal timing of many of these hernias, particularly in the premature population. Where anesthesia can be a little more high risk. And then finally I'll try to give you a cheat sheet on the final slide as to you know when when can you expect the surgeon to proceed with these repairs and that would impact when you would send them over to meet us. So I I really like interactivity. I'm gonna do my best to make this interactive. I have a couple of whole questions that hopefully will stimulate some discussion, the questions are intentionally a little bit they in terms of the responses and if you don't quite agree with the responses, there's another and if you do click other, I'd like you to put that in the chat just so we can see um what your thought processes or what other options there might be. Um And I love being interrupted. I think these are much more educational. Again, if this is sort of a two way interactive street and you know, the best we can do is the chat feature, but it's actually worked pretty well when we've done this in the past, so feel free to chime in with questions as we go. So let's start with the case and Tabatha will have you pull the pole in one second. So you referred a three month old to your clinic with new onset of scrotal swelling. What do we want to do now send him to the er right away from your clinic. Do you want to send an elective or maybe urgent referral to a pediatric surgeon to be seen within the next week. Should we order an ultrasound or just provide reassurance to the family because this is likely to go away on its own and at the next well child check we can provide a repeat examination or or maybe something else. So let's go ahead and open up that pole to have to see what people have to think comes to your clinic, screw them. A swollen baby seems to be fine. He's eating doesn't seem to be too fussy. So yeah, 50% want to send to the pediatric surgeon for elective referral. Uh, 40% want to get an ultrasound. 11% are going to send to the er um and I don't see any additional stuff in the chat. So nobody, nobody disagreed with any of my responses. All right, perfect. So, I think the answer here is that this spends and I think there's a lot that this depends on. So that's what I'm going to go through in the next several slides. I think any of those potentially could be appropriate depending on what the physical exam is, like, what the baby looks like. Um But, you know, scrotal swelling in and of itself, there's a pretty well not pretty broad. There are several things that this could be, but the differential um, you know, could guide you in a few different directions. So let's get started. So, the first thing we need to figure out is is this a hernia? Or is this a hydro steel? Because I think these are going to get treated very differently. Hernia, I think is a little more urgent. The hydrocephalus Sergent. We'll get into why that is. Um So the difference is really um, it's semantic sort of, but hydro seals. Really. Here's a communicating hydro seal, which it's sort of a variant of a hernia because it's a patent processes vaginal is where there is a communication with the peritoneal space. It's just that this communication is so narrow and so tight that bowel or momentum or any of the visceral contents can't get through it. The only thing that can get through is fluid. Okay, a non communicating hydro steel, there is no communication, there's just some residual fluid in the scrotum and the non communicating hydro sales almost always go away on their own. Um and seldom requires surgical management. In Children communicating hydro seals, I'll show some data on uh most of them will resolve on their own. Some of them will will progress to becoming hernias and require repair. Um and then these things called hydro seals of the cord, um which are non commuting hydro seals in two different spots, also will generally go away on their own. These pictures that are often found on the internet are a little bit deceiving because they show the hydro seal only in the scrotum, but the top part of the hydro sail can extend very far up towards the internal ring. Um If you just imagine all of this one, you know this and this has one communicating up the hydro sales can be very hard to differentiate from hernias when they extend all the way up into the inguinal canal, but most of them will go away by a year of age. So how do you tell the difference. So the photo on the left is an inguinal hernia. The one on the right that I presented with the question is actually a hydro seal. You can see this hydro seal is it does extend all the way up into the growing. This was a communicating hydro steel but looks very much like an inguinal hernia. But I'll point out here that this inguinal bulge can be pushed up in is discrete from the testis. Hydro seals should always involve the base of the scrotum and testes. So something like this where you can't feel the testes in the middle of hydro steel, um, suggests that there that this is a hydro steel. Now, this also could be a hernia with a hydro seal because oftentimes, um reactive hydro seals, uh, hydro sales will be reactive to an incarcerated hernia hernia in the canal. But if you can feel the testes independent of the bulge and it's probably a hernia. Um, and if you can't reduce it, that probably does need to go to the er, and I'll talk a little bit about how to reduce any little hernia in a few slides. But if you can be convinced that it's a hydro steel and the baby's looking well, there's no obstructive symptoms. Um, and you can feel a normal cord above this and on the next slide, I'll show how to feel for that, you can observe these and send for elective consultation with a pediatric surgeon. Now, if there's any concern that this is an incarcerated hernia, then yes, just send a city year and haven't evaluated. But if you can convince yourself that this is a hydro seal, it probably can be watched for a little bit. And so this is a hernia right? So bow coming down through the internal ring into the internal canal and sometimes all the way down into the scrotum. But if you put your finger right over the internal ring, you will feel that the cord has something in it. It's vacant hydro seal. If you put your finger right at the internal ring, you should be able to feel a very small cord or absence of a chord and right below that you'll feel this big balloon of fluid. So over here you you potentially could push this down and you could feel a hernia right here. Now this one is pretty large and I will give you this one was quite challenging in order to feel the court above it. And we did end up getting an ultrasound on this particular patient because the hydro steel was so big and a little bit atypical. But really feeling the internal ring where the court comes out feeling whether or not that court is thickened or if the inguinal canal is empty in my opinion is the best way to tell the difference between these. A lot of people like to trans illuminate these. I have seen hernias particularly in very small kids trans illuminate. So I don't rely entirely on trans illumination. I rely more on what the court feels like as it comes out of that internal ring. So here's the best study that I've seen. It looks at the natural history of communicating hydro seals is 174 patients. This data is about 10 years old now, but I don't think it's changed much. Have those 174, of them at the initial follow up had a decrease in size and did not have complete 18 month follow up. Um of those that had followed up, 69 of them had complete resolution of their hydro seals, 60% overall complete resolution without an operation. Okay, 41 patients, the hydro still persisted and they were taken to the operating room and six of them at the time of surgery were found to have in England a hernia. So the hydro steel, that small little hernia, um communication actually dilated up and became a hernia. So we do know that this can happen. So that's why, you know, we don't just dismiss them and say, oh this is gonna be on its own because sometimes they don't sometimes they progressed to hernias. Um, I see a question that chat what was the male to female ratio? I would have to go back and look. But hernias are four times more common in boys than girls when you're looking at infants. So um and actually I don't have to go back and look at this. I don't think I've ever seen a hydro seal and a girl. So this paper only looks at hydro seals. So I would suspect that all the patients in this world boys. Um, so, um, but this sort of highlights that, you know, some of these will need surgery and some of them will progress from a communicating hydro sail onto anyone. Um, medium time to resolution of these hydro seals is nine months. Generally, if they persist to be on a year, they're not going to go away, particularly. You know, the kids become ambulatory and the gravitational pull when you're standing all day pulls the fluid just down into the scrotum and it just keeps it open. So I generally watch these until 9-12 months. But if they persist beyond 12 months, then I do recommend surgery to litigate the communication between the parent medium and the hydro steel, essentially converting a communicating hydro seal over to a non communicating hydro steel. And then they just go away by disrupting that connection to the peritoneal cavity. And that also prevents them from progressing to anymore hernia. So hydro seals, watch till a year. Sometimes they'll get worse generally they'll get better. All right, So hernias. So hernias is a different story in terms of urgency hydro seals. We just watch them hernias. We need to fix them. The classic data and I say classic is from 84. It's not super classic. But um, the longstanding teaching is that premium car premiums have very high incarceration rates and they really need to be fixed and many of them will get fixed prior to discharge from the niCU. Now, there's a randomized trial going on nationally now about fixing them before they leave the niCU versus sending them home with interval follow up outpatient repair. I think the jury is still out there, but it is known that preemies as particularly boys have very high incarceration rates within the first year, up to 30 In term infants. The incarceration rate is a little bit lower. This study has a median follow up of nine weeks to repair. Um, and they reported a 4% incarceration rate. So prematurity really does impact the incarceration rate in these kids. But even if you're a term baby your incarceration rate is not trivial. And the reason that matters is because when we operate for an incarcerated inguinal hernia, the risk of complications is much much higher As is hernia recurrence. Hernia recurrence goes up 5-10 fold if you have to operate in uh, incarcerated setting because all the tissues are so adamant us and they don't hold future very well. The other thing that goes up is the injury. The rate of injury to the vast difference. So we really don't want to be operating on these in an incarcerated state. If we can help it, we would like to repair them before they incarcerate and obviously a incarceration at home that goes unrecognized and you progress to bala sena could make a child very sick. So when it is a hernia, it really should be repaired soon. It's not an emergency unless it's incarcerated, but we really do try to get to these pretty quick. Um 667 Nicky grads than these are. These are 28 workers mostly. So these are really creamy had a delayed repair and in this particular study, which is a little newer data than that, 30% back in the 80s shows about an 8% incarceration rate. Um Now this is interesting, I thought. So this is a study where they looked at Canada and they look to the United States in the United States, we tend to repair these about a month and a half sooner than they're doing in Canada. Um, in the United States, in this study, there were no incarcerations reported waiting 53 days. Okay. In Canada median wait time of 99 days. So really, we're looking kind of two months versus three months. Their incarceration rate was almost 20%. Um, so I think the longer you wait in these, the more likely they are to incarcerate. So we really do try to get to these. My recommendation, um, is that, you know, when you see a kid in clinic, you should get them on the surgery schedule, usually within the next few weeks. But surely within two months now there occasionally as a kid who has complex cardiac disease, single ventricle and they're just not safe to put to sleep. And you have to have that discussion with the cardiologist and the family and the patient. So sometimes there are kids that we don't fix right away. It's a risk benefit assessment that we have to make right. In general, healthy kids, we fix inguinal hernias when they're diagnosed within the next few weeks. So this sort of transitions into anesthesia in timing of surgery. So I think that this This was a big deal about 10 years ago and I think it's becoming less of a deal as more and more research comes out that demonstrates the safety of anesthesia in young kids. Um But neonatal I think, and particularly we have concerns about postoperative after anesthesia, particularly in premature infants. Risk factors for postoperative apnea are it's less than 40 weeks. Total gestational age. So if you're a term baby, we're generally gonna wait a month to do outpatient anesthesia if we have to operate before that, you have to get admitted to the hospital for apnea monitoring post op This particular study said any premium that was less than 60 weeks. Total gestational age at the time of repair. Had a very high risk of post op at Mia and anemia, which many of these kids are at their physiologic nadir when they're coming to see the pediatric surgeon for the hernia repair because they present a little bit later and then certainly anybody on home oxygen or chronic lung diseases at very high risk for post operative avenue. So all of this comes into play when we talk about timing of surgery. Because the longer you wait to do surgery and these kids, the lower the risk of post op apnea is and particularly during RSV season or any covid or other reasons that families just don't want their kids in the hospital for risk of pathogenic infection. We often will wait uh in order to avoid the risk of postoperative apnea. And I'll show you in a few slides, there's a sliding scale, you know, the more premium you are, the longer you have to wait. But there are some strategies that we use. But if we have to operate on babies that are young, particularly premiums and particularly kids on home oxygen, they're going to need to be admitted post operatively for monitoring. So this gets a little bit more towards that question of should we be doing elective surgery and kids, particularly young kids. I like this study because it compares matched sibling pairs, healthy kids. These these are not Nikki patients. These are just healthy kids that underwent routine surgery as kids. Um I mean of 17 months. So not a lot of neonatal surgery here but this was prior to 36 months and then 10 years old. They did. Um I. Q. Testing and a battery of neuropsychological testing and they really found no differences. So this as well as a few other studies are starting to suggest that brief single anesthetic for kids, particularly for outpatient surgery like England Hernias and Bill Carney, things like that is safe. Um This is a follow up study of um A large cohort that started way back in 1991 And they went back retrospectively and looked at anesthesia exposures that occurred prior to four years of age. And then they went back when these kids were between seven and 16 years of age and they looked at neurocognitive outcomes. They had over 1000 kids that had a single anesthetic that they were able to analyze. And 200 of them had multiple anesthetics. Um I think the large numbers contributes to some of the findings of this because there's a very powerful study and they were able to detect some pretty trivial differences and and I'm not sure they're clinically significant. But you know this this pretty much I want to point out all of these show that a single exposure of anesthesia. These are all pretty much close to the midline in the motor domain. You see some very small statistically significant impairment in kids but all of these are like .12.2 standard deviations below the main .12.2. So these are all within one standard deviation. I mean so I think this is all because this is such a high-powered study. Maybe there's some small differences, but I don't think any of these are clinically significant. Okay, so um, I think for the most part surgery and young kids is safe unless they have comorbidities. If they're healthy, it should be safe. This is the sliding scale that I use for preemies. So if you're, if you're a Nikki grad or Primi and you need to have outpatient surgery and your next 30 weaker, I'm going to wait until you're 60 weeks total corrected age in order to do outpatient surgery. Because prior to 60 weeks and Your risk of post up at me as high and if I have to do it before 60 weeks, I'm going to admit you post out for monitoring. Um it doesn't seem like a long time, but That's like a 78 month old kid by the time you get out of the Nick, even go home and hit 60 weeks for some of these extremely premature babies. So a lot of these kids will be at home for four or five months with an unrepaired hernia with a high risk of incarceration. So for the families that live up in Ukiah or Eureka or way up by the Oregon border, we oftentimes will just repair them because the transport time down here is going to be greater than six hours. So we do have to take into those, we have to take the social factors into account in terms of what is the risk of sending these kids home Without repairing them prior to 60 weeks. The less premium you are, the less you have to wait. So the near preterm kids up to 37 weeks, you only have to wait until they're 52 weeks, corrected gestational age. And for term babies. Um 44 weeks. And after that, your risk of postoperative at MIA is almost zero. Um At Oakland Children's we try to fix these prior to nicu discharge because they're already in the nicu so they can get monitored post op without any additional um need for hospital admission or infectious risk. Um But many patients get discharged from community nick use that don't have a pediatric surgical coverage and we meet them in clinic. So this is the reason if if you do have one of these patients and you send them to us, if we say, you know, we're gonna wait. Um it's really to avoid the post op respiratory complications. Um You know, back in my training, uh there was a patient who had a hernia repair and was admitted for observation and had an ethnic arrest and had um substantial hypoxia. So uh post op at me is no joke and I think we really have to pay attention to that. So, um you know, if you send me a patient that's an extreme e I'm probably going to wait until these dates unless there's some compelling reason to fix them sooner. Because even in the hospital with that monitored you still can have that make events with complications. So in my opinion it's best to wait as long as you can. And these kids particularly until you meet these thresholds. Um And then yeah, just to summarize the other studies we as more and more data emerges and there's now a randomized trial us, I'm sorry, a prospective trial. Looking at kids that have a single brief anesthetics that's ongoing that the preliminary data is also suggesting that there is minimal uh neurocognitive outcomes. But those assessments really done it like three or four years of age, we're really waiting for the 10 year follow up at a really put a lot of weight into those trials. Um And really the bottom line of anesthesia is as well. Even though all the data suggesting it's safe, you know, we don't know what we don't know. So it's really you have something that doesn't need to be fixed urgently and there's no harm in waiting. Well then what's the rush? Why do we need to fix the hernia when there are two months old if we could fix it when they're four. Um And it's not going to have any long term health morbidity and there's no risk to waiting um and we'll get into this one. We talk about epic gastric hernias. I don't fix them when they're babies because you know, we think that anesthesia is safe. But what's the rush? You know, maybe there is some unknown long term causes. You know are problems associated with anesthesia with inguinal hernias. However, there are known complications of waiting and those complications are pretty high and we're talking about incarceration rates. So I think for urgent or semi urgent things we know that the risk of anesthesia are pretty low and we generally proceed even in early infancy with England. Um and last but not least um when you refer a patient to me, Yes, you get me. But more importantly you get a pediatric anesthesiologists. And I think particularly for these extreme ease, particularly for neonatal anesthesia. Even for little 234 year old kids, pediatric anesthesia makes a huge difference in the safety of these cases. I think a pediatric anesthesiologist is a must for these patients. So I don't do this surgery in the community. I don't do it with adult anesthesiologist. I will not fix an infant hernia with an adult anesthesiologist. I always will work with the pediatric anesthesiologist and I think that's the biggest benefit of having the attorney is repaired with the team at many of Children's hospitals is our wonderful pediatric anesthesia team um that facilitates these cases. All right ultrasound. So a couple of people picked ultrasound and I do use ultrasound from time to time for cases that I really um I think that it's an alternative diagnosis. But if I think it's a hernia and it feels like a hernia, then we don't need an ultrasound. So if you have a kid in your office that has a hernia on exam, I don't need an ultrasound to operate. And honestly, ultrasounds sometimes can be misleading. They're not entirely reliable. I once had a kid come to my office and had an ultrasound that said he had a hernia. He had a perfect story for a hernia. He pointed right to where the bulge would be for a hernia. uh and this was uh 12 or 13 year old boy. So you know, he would know and I could never feel a hernia on exam. But uh the patient and his father convinced me he had a hernia and I operated on him and he didn't have one. Um So I and many other pediatric surgeons will not operate based on ultrasound findings alone. We really need to see the hernia or a picture of the hernia or feel the hernia. Um So if you have a patient in your clinic that you think that you need to get the ultrasound to convince the surgeon that there's a hernia there. Um It's not necessarily just refer them. And if we think that we need an ultrasound will go ahead and get it. But many patients come to me with an ultrasound already having been done and it's not really necessary if they have a clear early on exam. If I do order um an ultrasound, I actually prefer to have them done at Children's because our sin agua furs. Um Mhm. They don't just take still pictures of what they're looking at. They take dynamic videos of the bow going in and out of the canal and like they're really really good studies and they're very convincing. So when we do them in our radiology department, the data that we get is very high quality. Um And it's and it's a dynamic study. Um So when we do get them, we want to make sure that we do them in the hands of a pediatric photographer with the ability to capture video loops so that myself and the radiologist can review those together. Or sometimes I'll even be present for the exam if it's done the day of the clinic visit. So ultrasound does have a role but not necessarily routine role. Um A report of a hydro steel on an ultrasound I think is really important. Just because it says there's a hydro steel does not mean they don't also have heard yet because if you've got a piece of bowel stuck high in the inguinal canal, you are going to get a reactive hydro steel. So I have seen in the past where patients have been seen in an urgent care facility, they're getting off on. That says it's just a hydro steel and they get sent home. But in reality it was a missed incarcerated hernia that was high in the groin and they end up in our E. R. 12 hours later and not the best shape because they had an incarcerated inguinal hernia. So, um just because the report says it's a hydro still doesn't entirely rule out a hernia. So don't have any artificial or false sense of security from. Um, I think the best use for ultrasound is if you think that there's an underlying testicular mass or varicose seal or particularly testicular torsion, um that's where scribble in England ultrasound really has the greatest role. And that's where we order most of the ultrasounds. So it does have a role in grind pathology, but generally not for routine anymore. Honey evaluation. Mhm. Um All right. How to make the diagnosis in your clinic of an England hernia is how I make the diagnosis. I take all their clothes off. Uh and you know, I make them cry and the way we make them cry, babies hate having their legs straight and their hands over their heads. So I just take their legs down and their hands over their head and they don't like it and they cry cry cry. And when they cry, the hernia pops out, I am, you know, and of course I tell the mom I need baby to cry and I'm not going to hurt him. Um, If I can see the hernia when they cry great, we're looking for an operation. So I think that's the best way to make a baby. They'll sell. But I think this is not a trick. You need to be, I think most of you are probably already utilizing this. But babies don't like to be cold and they don't have to, they don't like to have their legs stretched out and their arms above their head. Um, and that's kind of the trick I use for older kids. Um, I have some balloons in my office and I have them blow up a balloon and or I have them jump 20 times. But really anything you can do to have a kid val salva and increase their inter abdominal pressure, increases the chances that you're able to actually capture the hernia. If the family is telling you that they're seeing intermittent bulge um, but more importantly, and this is one crucial point I like to make today. I would much rather have a picture of the bulge on mom or dad's camera on their phone, then an ultrasound report because if the kid comes to my clinic and I can't see the bulge on my exam. And even if we make them cry or blow up the balloon or whatever, you know, sometimes it doesn't come out, I will then have the families come back once they're able to get a picture on their phone. Um, so if you are sending us a referral. Please just ask the family like, hey, you know, when your child hernia pops out and it is really big, snap a picture. Put it on your phone because the surgeon will want to see that I will operate based on a good history and a good picture on mom's phone of a hernia. I think that most pediatric surgeons will do that as well because we all recognize the challenge of getting the hernia pop out during a clinic visit because oftentimes it just doesn't happen. But if there's a good picture on the phone, we will operate. So if in your discharge from your clinic visit, just asked the family to take a picture on the off chance that they don't show up with a hernia in our clinic, we know it's still there. Put that picture really helps. All right. Finally how to reduce an inguinal hernia. So if you have an incarcerated hernia in your clinic, you should send them to the er but ideally if you could get a reduced first, that would be much better. So this is showing hernia reduction in general. If you just push on the top, it makes the mushroom sort of come over the top and it's not going to go in okay? In order to get any hernia reduced. Whether it be umbilical inguinal incision or whatever it is, the neck of the hernia has to be straight so that the contents can be reduced straight in and you apply pressure to the top while keeping this tight. Um and getting the stuff in. So here's a picture of the inguinal canal, an inguinal hernia and um sorry, I need to move my go to presenter stuff because it's blocking my view. Okay, well um so rather than just squeezing this in, what you want to do is you want to grab the testicle and you want to pull this chromatic chord in a straight line. Okay, so you can see this hand is pulling down and this hand is either squeezing at the cord or massaging at the level of the internal ring to try to get the contents at that ring to go in. And once you start to get it reduced, you can now apply pressure from the top while while keeping things pinched at the level of the internal ring. But really the crucial maneuver is putting tension on the testes to the contra lateral side to keep that this chromatic chord in a straight line and then applying pressure at the ring and that's how you get these reduced. It just takes a lot of practice and I don't know how many hernias I've reduced in my life, but um you eventually get the feel of it. But I think a lot of people don't realize you have to pull down on the testicle to get the cord straight and you have to really reduce it from the level of the internal ring before you can get the whole thing in. So those are my two tricks that I use here is just one more picture of how we do this. So this is that sort of mushroom that I was showing earlier. When you apply tension to the testicle, you can you convert this mushroom to more of a tubular sort of structure and then you can squeeze things in okay. As opposed to just pushing the mushroom down. Another picture of sort of pulling the scream in the direct, in the direction away from the hernia. So pulling towards the right when you're reducing a lifting order, hopefully that makes sense. If not, I'm happy to discuss that a little bit further. Um so here's my very simple algorithm. If you have an England a bulge and it's clearly a hydro steel, just refer them electively. If it's clearly and easily reducible, just refer them electively. But when you do refer them electively, ask mom and taking pictures so that when they show up the clinic, they've got a great piece of evidence that there is a hernia because invariably the kid shows up in the hernia doesn't pop out in clinic. If it's incarcerated, try to reduce it because I think that's good. We really want these to be reduced sooner rather than later because the longer they remain incarcerated, the more edema builds up and the harder they become to reduce. So if you're saying the er that's going to be probably an hour to an hour and a half before they get to the er and that's more and more a demo. So the best chance of getting and reduces right away, so try to reduce it in your office is possible using the techniques that we outlined today.