Child’s Hernia

http://kidshealth.org/parent/system/surgical/hernia.html

Many people are surprised to learn that hernias are fairly common in kids. Babies
(especially preemies) can even be born with them.

Hernias in kids can be treated (hernia repair is the one of the most common surgeries
performed on children), but it's important to recognize their symptoms so that you can get
your child the appropriate medical care.

About Hernias

When part of an organ or tissue in the body (such as a loop of intestine) pushes through
an opening or weak spot in a muscle wall, it can protrude into a space where it does not
belong. This protrusion is a hernia, which may look like a bulge or lump.

Some babies are born with various small openings inside the body that will close at some
point. Nearby tissues can squeeze into such openings and become hernias. Unlike hernias
seen in adults, these areas are not always considered a weakness in the muscle wall, but a
normal area that has not yet closed.

Sometimes tissues can squeeze through muscle wall openings that are only meant for
arteries or other tissues. In other cases, strains or injuries create a weak spot in the muscle
wall, and part of a nearby organ can be pushed into the weak spot so that it bulges and
becomes a hernia.

Types of Hernias

There are different types of hernias, and each requires different levels of medical care.

In many infant and childhood hernias, the herniated tissues may protrude only during
moments of physical pressure or strain. You may only notice a prominent bulge when
your child is crying, coughing, or straining, and it may seem to retract or go away at other
times. Hernias in this state are called reducible and are not immediately harmful.

Sometimes tissue can become trapped in an opening or pouch and do not retract. These
are incarcerated hernias, and are a serious problem requiring immediate medical
attention. For example, a loop of intestine that is caught and squeezed in the groin area
may block the passage of food though the digestive tract. The symptoms of an
incarcerated hernia can include pain, vomiting, and irritability. If you touch the bulge it
has created, it may feel hard.

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A doctor can usually free the trapped tissues by gently squeezing the lump and trying to
force it back into the body opening. Because incarcerated hernias can be painful, the
doctor usually provides pain medication during this procedure. Surgery is usually
required within a few days to prevent development of another incarcerated hernia.

The most serious type of hernia is a strangulated hernia, in which the normal blood
supply is cut off from the trapped tissue. Without that blood supply, the strangulated
tissue cannot get oxygen and will die. Surgery is required immediately to dislodge that
tissue so that oxygen can get to it again.

The two most common hernias in kids are inguinal hernias in the groin area and umbilical
hernias in the belly-button area.

Inguinal Hernias

In infants, an inguinal hernia is most often caused by a protrusion of a loop or portion of

intestine or a fold of membrane from the abdomen — or in girls, from an ovary or
fallopian tube — through an opening into the groin (the area where the abdomen meets
the top of the thigh). The opening is caused by the presence of a fold of the peritoneal
membrane, which produces a sac. Within this sac, the loop of bowel can protrude.

The hernia is apparent as a bulge in the groin area, especially when the child cries,
coughs, or stands.

Sometimes, in boys, the inguinal hernia extends beyond the groin into the scrotum (the
sac that holds the testicles). In girls, it can extend to one of the outer labia (the larger lips
of tissue around the vaginal opening). In these cases, an enlargement or swelling can be
seen that extends from the groin into the scrotum or labium.

More common on the right side, inguinal hernias occur far more often in boys than girls
and are most common in preemies, baby boys with undescended testicles, and kids with
cystic fibrosis. Kids with a family history of hernias are also at risk.

Other conditions that may look like inguinal hernias, but are not:

• A communicating hydrocele is similar to a hernia, except that fluid causes the

bulge rather than protruding tissue. Depending on its location, the hydrocele may
be left to disappear in a year or two or it may be treated as a hernia — with
surgery. In infants, the hydrocele may not require surgery, as many go away by
the second birthday. Some can change size depending on how much fluid goes in
and out, and some may appear bluish because the membrane that causes the
hydrocele is blue.
• Occasionally, a retractile testicle (a testicle that retracts from the scrotum from
time to time) causes a bulge in the groin area. It may not need treatment but
should be evaluated by a pediatric specialist.

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 • A femoral hernia is rare in kids and can be confused with an inguinal hernia. It
consists of tissues that have pushed in alongside an artery into the top of the thigh.
It appears as a bulge at the top of the thigh, just below the groin.

Umbilical Hernias

Some babies are born with a weakness or opening in the abdominal muscles around the
belly button (under the skin) through which some abdominal membrane or small intestine
protrudes.

The soft bulge this creates is an umbilical hernia. It is most obvious when the baby cries,
coughs, or strains. Umbilical hernias are more common in females, those of African
heritage, and low birth weight babies. These hernias range in size from less than ½ inch
(2 centimeters) to more than 2 inches (6 centimeters).

In most instances an umbilical hernia causes no discomfort. Usually, a doctor can easily
push it back in. An infant's umbilical hernia (unlike an adult's) rarely obstructs or
strangulates. In fact, most umbilical hernias, even the larger ones, tend to close up on
their own by age 2. That's why the doctor usually advises waiting and watching this kind
of hernia in an infant rather than operating.

Surgery is necessary only if the hernia is very large, grows in size after age 1 or 2, fails to
heal by age 4 or 5, or the child develops symptoms of obstruction or strangulation, like
swelling, bulging, vomiting, fever, and pain. If such symptoms develop, call the doctor
immediately.

Signs and Symptoms

If you think that your child may have a hernia, call your doctor immediately. And ask
yourself:

• Is the bulge present when your child is straining, crying, coughing, or standing,
but absent when your child is sleeping or resting? This could indicate a reducible
hernia.
• Is the bulge present all the time, but with no other symptoms? This could be a
hydrocele or something else.
• Has the groin area suddenly begun to swell? Do you notice any discoloration of
the bulging area or a "swollen" abdomen? Is your child irritable, complaining of
pain, constipated, or vomiting? These are signs of an incarcerated hernia, which
calls for immediate attention. See a doctor immediately or take your child to the
emergency department.
• Is the area swollen, red, inflamed, and extremely painful? Has your child
developed a fever? These might be symptoms of a strangulated hernia. Call your
doctor and then go directly to the hospital emergency department.

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Treatment

Once an inguinal hernia is diagnosed, surgery will be done to prevent it from becoming
incarcerated. During surgery, the herniated tissue is put back into its proper space, and
the opening or weakness that permitted it to form is closed or repaired.

Surgery to correct inguinal hernias is performed on kids of all ages, sometimes even on
premature babies.

Inguinal hernia surgery in kids is usually performed on an outpatient basis with no

overnight stay in the hospital, but some kids, particularly young infants, may be kept in
the hospital overnight for observation.

The period of recuperation for kids is fairly short. Most can resume normal activities
about 7 days after surgery, with the doctor's approval. Until that time, kids should avoid
strenuous activity such as bicycle riding and tree climbing. Of course, if you notice any
signs of problems after the surgery, such as bleeding, swelling, or fever, call your doctor.

Reviewed by: T. Ernesto Figueroa, MD

Date reviewed: June 2008

Pediatric Hernias
http://emedicine.medscape.com/article/932680-overview
Updated: Feb 25, 2010

Background

Approximately 400 years ago, a French surgeon named Ambroise Pare described the
reduction of an incarcerated pediatric hernia and the application of trusses. He recognized
that inguinal hernias in children were probably congenital in nature and that they could be
cured. Unfortunately, despite the many historical descriptions of conservative medical
management of inguinal hernias, no effective nonsurgical means of treating this condition
is recognized. All pediatric inguinal hernias require operative treatment to prevent the
development of complications, such as inguinal hernia incarceration or strangulation.

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Today, inguinal hernia repair is one of the most common pediatric operations performed.
Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure,
such as bowel or omentum, protrudes through a defect in the abdominal wall. Most
hernias that are present at birth or in childhood are indirect inguinal hernias. Other less
common types of ventral hernias include umbilical, epigastric, and incisional hernias.

In this article, the embryology, clinical presentation, and management of inguinal hernias
are discussed in relation to the pediatric population. Because inguinal hernias are
common, every clinician must be well versed in the subject and able to provide optimal
care to patients and their families, especially because hernias can be organ-threatening or
life-threatening if not expeditiously managed. Examples of hernias are shown in the
images below.

Typical appearance of an infant with a large right indirect inguinal

hernia. The right scrotal sac is enlarged and contains palpable
loops of bowel and fluid.

A premature baby boy with bilateral giant inguinoscrotal hernias.

Because of the large size of the hernias, operative repair typically
requires repair of the inguinal floor in addition to the high
ligation of the indirect hernia sac.

Pathophysiology

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The processus vaginalis is an outpouching of peritoneum attached to the testicle that trails
behind as it descends retroperitoneally into the scrotum. When obliteration of the
processus vaginalis fails to occur, inguinal hernia results.1 A review of embryonic
development of the inguinal region is important to understanding the pathophysiology
and surgical management of inguinal hernias.

Although the sex of the embryo is determined at fertilization, the gonads do not begin to
differentiate until 7 weeks' gestation. Primordial germ cells migrate along the dorsal
mesentery of the gut. They arrive at the primitive gonads early in the fifth week of
development and, during the sixth week, invade the genital ridges, which lie on the
medial aspect of the mesonephros. The coelomic epithelium proliferates, and the
underlying mesenchyme condenses, forming the primitive sex cords.

Under the influence of the Y chromosome, the cords in the male embryo proliferate to
form the testes. Near the end of the second month, the testis and mesonephros are
attached by the urogenital mesentery to the posterior abdominal wall. As the
mesonephros degenerates, only the testis remains suspended. At its caudal end, the
attachment is ligamentous and is known as the caudal genital ligament. The
gubernaculum, a mesenchymal structure rich in extracellular matrices, also extends from
the caudal pole of the testis. This structure attaches in the inguinal region between the
differentiating internal and external oblique muscles prior to descent of the testes. As the
testes begin to descend at about 28 weeks' gestation, an outgrowth of gubernaculum from
the inguinal region grows toward the scrotal area, and as the testis passes through the
inguinal canal, this portion of the gubernaculum comes in contact with the scrotal floor.

During this time, the peritoneum of the coelomic cavity is forming an evagination on
each side of the midline into the ventral abdominal wall. This evagination, known as the
processus vaginalis, follows the path of the gubernaculum testis into the scrotal swellings
and forms, along with the muscle and fascia, the inguinal canal. The descent of the testes
through the inguinal canal is thought to be regulated by both androgenic hormones
produced by the fetal testis and mechanical factors resulting from increased abdominal
pressure.

As each testis descends, the layers of the abdominal wall contribute to the layers of the
spermatic cord. The internal spermatic fascia is a reflection of the transversalis fascia, the
internal oblique muscle helps form the cremaster muscle, and the external spermatic
fascia results from the external oblique aponeurosis. In addition, a reflected fold of the
processus vaginalis covers each testis and becomes known as the visceral and parietal
layers of the tunica vaginalis.

In the female embryo, the ovaries descend into the pelvis but do not leave the abdominal
cavity. The upper portion of the gubernaculum becomes the ovarian ligament, and the
lower portion becomes the round ligament, which travels through the inguinal ring into
the labium majus. If the processus vaginalis remains patent, it extends into the labium
majus and is known as the canal of Nuck.

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Before birth, the layers of the processus vaginalis normally fuse, closing off the entrance
into the inguinal canal from the abdominal cavity. In some individuals, the processus
vaginalis remains patent through infancy, into childhood, and possibly even into
adulthood. The precise cause of the obliteration of the processus vaginalis is unknown,
but some studies indicate that calcitonin gene-related peptide (CGRP), released from the
genitofemoral nerve, may have a role in the fusion.

When luminal obliteration fails to occur, a ready-made sac is present where abdominal
contents may herniate. Even when the processus vaginalis is patent, the entrance may be
adequately covered by the internal oblique and transverse abdominal muscles, preventing
escape of abdominal contents for many years. Failure of fusion can result not only in an
inguinal hernia, but also in a communicating or noncommunicating hydrocele.

In infants, the most common type of hydrocele is the communicating type. A

communicating hydrocele results when the proximal portion of the processus vaginalis
remains patent, allowing fluid from the abdominal cavity to freely enter the scrotal sac.
When closure is present proximally but fluid remains trapped within the tunica distally, a
noncommunicating hydrocele results.

Frequency

United States

Although the exact incidence of indirect inguinal hernia in infants and children is
unknown, the reported incidence ranges from 1-5%. Sixty percent of hernias occur on the
right side. Premature infants are at increased risk for inguinal hernia, with incidence rates
of 2% in females and 7-30% in males. Approximately 5% of all males develop a hernia
during their lifetime.

International

International incidence rates are similar to those in the United States.

Mortality/Morbidity

An incarcerated or strangulated inguinal hernia can result in severe complications and

even death. An incarcerated or strangulated inguinal and/or femoral hernia may also
result in significant sequela, depending on which visceral structure is involved in the
hernia sac. Such sequela can range from life-threatening complications to gonadal
dysfunction, including intestinal necrosis and perforation, intestinal obstruction, intestinal
stricture, testicular necrosis, testicular atrophy, ovarian necrosis, ovarian atrophy, and
tubal stricture.

Race

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Inguinal hernia appears to occur equally among races. Umbilical hernias, on the other
hand, appear to be more common in blacks than in other races.

Sex

Inguinal hernias are much more common in males than in females. The male-to-female
ratio is estimated to be 4-8:1.

Age

Premature infants are at an increased risk for inguinal hernia, with the incidence ranging
from 7-30%. Moreover, the associated risk of incarceration is more than 60% in this
population. Most pediatric ventral and inguinal hernias are detected in the first year of
life. Occasionally, hernias may remain asymptomatic and unnoticed by the parents until
later in life. Finding an adult patient with an indirect inguinal hernia that has been present
since birth is not unusual.

Clinical

History

• The infant or child with an inguinal hernia generally presents with an obvious
bulge at the internal or external ring or within the scrotum. The parents typically
provide the history of a visible swelling or bulge, commonly intermittent, in the
inguinoscrotal region in boys and inguinolabial region in girls. The image below
depicts a 4-month-old baby boy with a large right-sided inguinal hernia.
•

Typical appearance of an infant with a large right indirect

inguinal hernia. The right scrotal sac is enlarged and contains
palpable loops of bowel and fluid.

• The swelling may or may not be associated with any pain or discomfort. More
commonly, no pain is associated with a simple inguinal hernia in an infant. The
parents may perceive the bulge as being painful when, in truth, it causes no
discomfort to the patient.

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 • The bulge commonly occurs after crying or straining and often resolves during the
night while the baby is sleeping.
• Indirect hernias are more common on the right side because of delayed descent of
the right testicle. Hernias are present on the right side in 60% of patients, on the
left in 30%, and bilaterally in 10% of patients.
• If the patient or the family provides a history of a painful bulge in the inguinal
region, one must suspect the presence of an incarcerated inguinal hernia. Patients
with an incarcerated hernia generally present with a tender firm mass in the
inguinal canal or scrotum. The child may be fussy, unwilling to feed, and
inconsolably crying. The skin overlying the bulge may be edematous,
erythematous, and discolored.

Physical

Examine the patient in both supine and standing positions. Physical examination of a
child with an inguinal hernia typically reveals a palpable smooth mass originating from
the external ring lateral to the pubic tubercle. The mass may only be noticeable after
coughing or performing a Valsalva maneuver, and it should be reduced easily.
Occasionally, the examining physician may feel the loops of intestine within the hernia
sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently
confused with a lymph node in the groin region. In boys, palpation of both testicles is
important to rule out an undescended or retractile testicle.

• Inguinal hernia incarceration: The bowel can become swollen, edematous,

engorged, and trapped outside of the abdominal cavity, a process known as
incarceration. Incarceration is the most common cause of bowel obstruction in
infants and children and the second most common cause of intestinal obstruction
in North America (second only to intra-abdominal adhesions from previous
surgeries). If entrapment becomes so severe that the vascular supply is
compromised, inguinal hernia strangulation results. In cases of incarceration,
ischemic necrosis develops, and intestinal perforation may result, representing a
true medical emergency. When an incarceration is encountered, an attempt should
be made to reduce it manually if the patient has no signs of systemic toxicity (eg,
leukocytosis, severe tachycardia, abdominal distention, bilious vomiting,
discoloration of the entrapped viscera). If the patient appears toxic, emergent
surgical exploration after appropriate resuscitation is necessary.
• Hernia and hydrocele: In boys, differentiating between a hernia and a hydrocele is
not always easy. Transillumination has been advocated as a means of
distinguishing between the presence of a sac filled with fluid in the scrotum
(hydrocele) and the presence of bowel in the scrotal sac. However, in cases of
inguinal hernia incarceration, transillumination may not be beneficial because any
viscera that is distended and fluid-filled in the scrotum of a young infant may also
transilluminate. A rectal examination may be helpful if intestine can be felt
descending through the internal ring.
• Silk sign: When the hernia sac is palpated over the cord structures, the sensation
may be similar to that of rubbing 2 layers of silk together. This finding is known

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 as the silk sign and is highly suggestive of an inguinal hernia. The silk sign is
particularly important in young children and infants, in whom palpation of the
external inguinal ring and inguinal canal is difficult because the patients' small
size.
• Spontaneously reducing hernia: Inguinal hernias that spontaneously reduce (ie,
they are only noticed by the parents or caregivers and elude the examining
physician) are not unusual. In such cases, maneuvers to increase the patient's
intra-abdominal pressure may be attempted. Lifting the infant's or the child's arms
above the head may provoke crying or a struggle to get free and thus increased
intra-abdominal pressure. Older children can be asked to cough or blow up a
balloon.
• Femoral hernia: A femoral hernia can be very difficult to differentiate from an
indirect inguinal hernia. Its location is below the inguinal canal, through the
femoral canal. The differentiation is often made only at the time of operative
repair, once the anatomy and relationship to the inguinal ligament is clearly
visualized. The signs and symptoms for femoral hernias are essentially the same
as those described for indirect inguinal hernias.

Causes

The cause of inguinal hernia in children can be termed an abnormality of embryologic

development of the fetus. However, some children may present with an acquired form of
inguinal hernia, also called a direct inguinal hernia. In this type of hernia, weakness of the
inguinal floor is present, which allows for protrusion of viscera from the abdominal
cavity. The hernia sac is composed of the peritoneal fold that contains the hernia.

Anatomically speaking, indirect and direct inguinal hernias differ in that the direct hernia
bulges through the inguinal floor medial to the inferior epigastric vessels and the indirect
hernia arises lateral to the inferior epigastric vessels. Either hernia may cause fullness or
a palpable bulge in the inguinal region, and distinguishing between the two types on the
basis of physical examination findings may be difficult. The clinician may assume, until
proven otherwise, that the pediatric patient with an inguinal hernia has indirect inguinal
hernia.

• The following are associated with an increased risk of inguinal hernia:

o Prematurity and low birth weight (Incidence approaches 50%.)
o Urologic conditions
 Cryptorchidism
 Hypospadias
 Epispadias
 Exstrophy of the bladder
 Ambiguous genitalia
o Patent processus vaginalis, which may be present because of increased
abdominal pressure due to ventriculoperitoneal shunts, peritoneal dialysis,
or ascites
o Abdominal wall defects

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  Gastroschisis
 Omphalocele
o Family history
 Meconium peritonitis
 Cystic fibrosis
 Connective tissue disease
 Mucopolysaccharidosis
 Congenital dislocation of the hip
 Ehlers-Danlos syndrome
 Marfan syndrome
 Cloacal exstrophy
 Fetal hydrops
 Liver disease with ascites
 Ventriculoperitoneal shunting for hydrocephalus
• Figures regarding inguinal hernia incarceration indicate the following risk
patterns:
o Incarceration occurs in 17% of right-sided hernias and 7% of left-sided
hernias.
o More than 50% of cases of incarceration occur within the first 6 months of
life; the risk gradually decreases after age 1 year.
o Premature infants have twice the risk of incarceration than the general
pediatric population.
o More than two thirds of all incarcerations occur in children younger than 1
year.
o Girls are more likely to develop incarceration of an inguinal hernia; the
incidence in girls is 17.2%, whereas the incidence in boys is 12%.

Differential Diagnoses

Hydrocele and Hernia in Children

Varicocele in Adolescents

Other Problems to Be Considered

Inguinal adenitis
Femoral adenitis
Psoas abscess
Saphenous varix
Hydrocele
Retractile testis
Varicocele
Testicular tumor
Undescended testis

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Workup

Laboratory Studies

• No laboratory studies are needed in the assessment of a patient with a suspected

inguinal hernia and/or hydrocele.

Imaging Studies

Imaging studies are generally not indicated to assess for inguinal hernia. However,
ultrasonography can be helpful in the assessment of selected patients.

• Ultrasonography: Some advocate the use of ultrasonography to differentiate

between a hydrocele and an inguinal hernia. Ultrasonography is capable of
finding a fluid-filled sac in the scrotum, which would be compatible with a
diagnosis of hydrocele. However, if the patient has an incarcerated inguinal
hernia, ultrasonography may not be sensitive enough to differentiate between the
two conditions. Thus, this study is rarely helpful in the treatment of a pediatric
patient with a suspected inguinal hernia. When presentation and examination
suggest a diagnosis other than hernia or hydrocele, appropriate imaging, including
ultrasonography, may be necessary. An enlarged inguinal lymph node can mimic
an incarcerated inguinal hernia, and surgical exploration may occasionally be
necessary to confirm the diagnosis.
• Peritoneography: Injection of contrast in the peritoneal cavity has been used to
determine the presence of a patent processus vaginalis. Although this test is very
sensitive, its use is limited. Because of possible complications, including bowel
perforation and sepsis, injection of contrast is rarely performed today.

Procedures

• Laparoscopy: Diagnostic laparoscopy is a very effective method for determining

the presence of an inguinal hernia but is used only selectively because it requires
anesthesia and surgery. Laparoscopy can be useful to assess the contralateral side
(see Treatment) or to evaluate for presence of a recurrent inguinal hernia in
patients with a history of operative repair.

Histologic Findings

• Hernia sacs are composed of fibrous and connective tissue. Embryonal müllerian
remnants are recognized in 1-6% of surgical specimens; therefore, the finding of
vas or epididymis on the surgical pathology specimen of a hernia sac does not
necessarily imply injury.
• Specific histologic features of the remnant include a smaller diameter and failure
to show a prominent muscular wall with Masson trichrome staining.

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Treatment

Medical Care

Inguinal hernias do not spontaneously heal and must be surgically repaired because of the
ever-present risk of incarceration.2 Generally, a 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. Parents may be instructed on the application of gentle
pressure on the bulge of an inguinal hernia to prevent incarceration until the elective
operative repair is performed.

• Hydrocele without hernia in neonates: This is the only exception in which surgical
treatment may be delayed. Repair of hydroceles in neonates without the presence
of hernia is typically delayed for 12 months because the connection with the
peritoneal cavity (via the processus vaginalis) may be very small and may have
already closed or be in the process of closing. Fluid in the hydrocele comes from
the peritoneal cavity and is gradually absorbed if the communication has closed.
If the hydrocele persists after this observation period, operative repair is indicated
and appropriate.
• Anesthetic management for elective surgery: General endotracheal anesthesia is
safe for most surgical repairs of inguinal hernia in infants and children. In
addition, either a caudal anesthetic or intraoperative injection of bupivacaine in
the inguinal region is used for postoperative analgesia and to minimize the need
for intravenous use of narcotics, depending on the parents' wishes and on
anesthetic expertise. Occasionally, operative repair is performed under strict local
anesthesia, particularly in premature babies, in whom the anesthetic risk is higher.
• Umbilical hernias: Most umbilical hernias do not cause any symptoms and do not
require surgical repair until approximately age 5 years. For that reason, almost all
umbilical hernias in young children and infants are managed by simple
observation.

Activity

• No specific limitations are indicated once the diagnosis of an inguinal hernia has
been established; however, following operative repair, avoidance of major
physical activity for 1 week is recommended. After that time, the patient is
allowed to participate in physical activities (eg, sports, swimming, running).
• Children younger than 5 years are likely to recover extremely quickly from
surgery; they are typically capable of returning to their normal level of activities
within 24-48 hours of surgery.

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