Hernia Inguinal

Guidance for the Clinician in
Rendering Pediatric Care

CLINICAL REPORT

Assessment and Management of Inguinal Hernia in
Infants
abstract

Kasper S. Wang, MD, and the COMMITTEE ON FETUS AND
NEWBORN AND SECTION ON SURGERY

Inguinal hernia repair in infants is a routine surgical procedure. However, numerous issues, including timing of the repair, the need to explore the contralateralgroin, use of laparoscopy, and anesthetic
approach, remain unsettled. Given the lack of compelling data, consideration should be given to large, prospective, randomized controlled
trials to determine best practices for the management of inguinal hernias in infants. Pediatrics 2012;130:768–773

KEY WORDS
inguinal hernia, infants, surgery, anesthesia, laparoscopy

INTRODUCTION
Inguinal herniais a common condition requiring surgical repair in the
pediatric age group. The incidence of inguinal hernias is approximately
3% to 5% in term infants and 13% in infants born at less than 33 weeks
of gestational age.1 Inguinal hernias in both term and preterm infants
are commonly repaired shortly after diagnosis to avoid incarceration
of the hernia. Given the lack of definitive data, optimaltiming for
repair of inguinal hernias in infants remains debatable. This report
reviews the embryology and natural history of inguinal hernias as
well as published data regarding the timing and approach to inguinal
hernia repair in infants.

ABBREVIATION
PPV—patent processus vaginalis
This document is copyrighted and is property of the American
Academy of Pediatrics and its Board ofDirectors. All authors
have filed conflict of interest statements with the American
Academy of Pediatrics. Any conflicts have been resolved through
a process approved by the Board of Directors. The American
Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of
this publication.
The guidance in this report does not indicate anexclusive
course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be
appropriate.

EMBRYOLOGY AND NATURAL HISTORY OF THE PATENT
PROCESSUS VAGINALIS

www.pediatrics.org/cgi/doi/10.1542/peds.2012-2008

Complete understanding of the issues related to surgical repair of an
inguinal hernia requires an understanding of the embryologyof descent of the testes and the formation of the processus vaginalis.

All clinical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.

doi:10.1542/peds.2012-2008

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Testicular descent involves 2 phases: intra-abdominaland extra-abdominal.2
During the intra-abdominal phase, the testis, which derives from the
bipotential gonad originating at the urogenital ridge, is attached to the
diaphragm by the craniosuspensory ligament. In the male fetus, regression of the craniosuspensory ligament results in transabdominal
migration of the testis between 8 and 15 weeks postconception. Simultaneously, there isthickening of the gubernaculum, which attaches the
testis to the scrotum through the external and internal rings of the
inguinal canal. As the male fetus grows and the abdomen elongates,
the testis is essentially anchored by the thickened gubernaculum.3 In the
female fetus, the craniosuspensory ligament is maintained; hence,
the ovary retains its dorsal (retrocoelomic or retroperitoneal)
768

FROMTHE AMERICAN ACADEMY OF PEDIATRICS

Copyright © 2012 by the American Academy of Pediatrics

FROM THE AMERICAN ACADEMY OF PEDIATRICS

intra-abdominal location. In addition,
the gubernaculum does not thicken but
persists as the ovarian round ligament.
The second phase occurs between 25
and 35 weeks of gestation.4 The testis
descends from its retroperitoneal,
intra-abdominal location...