Notes in Chapter 50

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Published	11/02/2024	The abdominal cavity is lined by the {{c1::parietal peritoneum}}.
Published	11/02/2024	The {{c1::processus vaginalis}} is first seen during the {{c2::2nd or 3rd month}} of gestation in boys.
Published	11/02/2024	{{c1::Germ cells}} are found in the urogenital ridge by the {{c2::6th week}} of gestation.
Published	11/02/2024	By the {{c1::7th week}}, the {{c2::testes}} have begun to differentiate.
Published	11/02/2024	Testicular descent occurs in two stages: the {{c1::abdominal phase}} (8–15 weeks gestation) and the {{c2::inguinoscrotal phase}} (25–35 weeks gestatio…
Published	11/02/2024	The abdominal phase of testicular descent involves the influence of {{c1::insulin-like hormone 3 (Insl3)}}.
Published	11/02/2024	Fetal testosterone causes regression of the {{c1::cranial suspensory ligament}}.
Published	11/02/2024	By 25–35 weeks, the gubernaculum extends to the base of the {{c1::scrotum}}.
Published	11/02/2024	Androgenic hormones lead to the release of {{c1::neurotrophins}} that regulate the genitofemoral nerve.
Published	11/02/2024	The release of {{c1::calcitonin gene-related peptide (CGRP)}} provides a local chemotactic gradient for the gubernaculum.
Published	11/02/2024	The testis passes through the inguinal canal to reach the base of the {{c1::scrotum}}.
Published	11/02/2024	The female equivalent of the processus vaginalis is the {{c1::canal of Nuck}}.
Published	11/02/2024	Failure of the processus vaginalis to obliterate results in an {{c1::indirect inguinal hernia}} or {{c2::hydrocele}}.
Published	11/02/2024	Disorders with increased abdominal pressure are associated with an increased incidence of {{c1::indirect inguinal hernias}}.
Published	11/02/2024	Prematurity is associated with an increased incidence of {{c1::inguinal hernia}} ranging from {{c2::10–30%}}.
Published	11/02/2024	The {{c1::internal spermatic fascia}} is a continuation of the transversalis fascia.
Published	11/02/2024	The cremaster muscle derives from the {{c1::internal oblique}}.
Published	11/02/2024	The external spermatic fascia originates from the {{c1::external oblique aponeurosis}}.
Published	11/02/2024	The processus vaginalis envelops the testis as the {{c1::visceral}} and {{c2::parietal}} layers of the tunica vaginalis.
Published	11/02/2024	The most common association with {{c1::inguinal hernia}} is {{c2::prematurity}}.
Published	11/02/2024	{{c1::Cystic fibrosis}} carries an increased incidence of {{c2::15%}} for inguinal hernia.
Published	11/02/2024	Genetic factors and {{c1::chronic lung disease}} contribute to the increased risk of inguinal hernia in children with {{c2::cystic fibrosis}}.
Published	11/02/2024	Vasal abnormalities in children with {{c1::cystic fibrosis}} suggest an {{c2::embryologic component}} to inguinal hernias.
Published	11/02/2024	A small or absent vas during inguinal hernia repair may indicate {{c1::ipsilateral renal agenesis}}, warranting a {{c2::renal ultrasound}}.
Published	11/02/2024	Abnormalities of the vas should prompt an evaluation for {{c1::cystic fibrosis}}.
Published	11/02/2024	{{c1::Ventriculoperitoneal shunts}} (VPSs) for hydrocephalus are associated with an increased incidence of inguinal hernia ({{c2::15–25%}}).
Published	11/02/2024	Inguinal hernias are more likely to develop in neonates with VPS than in older children.
Published	11/02/2024	Other conditions with excess intra-abdominal fluid, such as {{c1::peritoneal dialysis}}, {{c2::ascites}}, and hydrops, are associated with inguinal he…
Published	11/02/2024	Indirect inguinal hernias are {{c1::lateral}} to the inferior epigastric vessels and are the most common in children.
Published	11/02/2024	Direct inguinal hernias are uncommon even in young adults ({{c1::16–18}} years old).
Published	11/02/2024	Femoral hernias account for less than {{c1::1%}} of pediatric inguinal hernias.
Published	11/02/2024	{{c1::Sliding hernias}} involve viscera such as bowel, bladder, or reproductive structures in the hernia sac.
Published	11/02/2024	{{c1::Pantaloon hernias}} consist of both direct and indirect inguinal hernias and are more common in {{c2::neonates}}.
Published	11/02/2024	An {{c1::Amyand hernia}} involves the appendix in the hernia sac.
Published	11/02/2024	A {{c1::Littre hernia}} involves a {{c2::Meckel diverticulum}} in the hernia sac.
Published	11/02/2024	A {{c1::Richter hernia}} involves the ischemic antimesenteric border of the bowel in the hernia.
Published	11/02/2024	The diagnosis of an inguinal hernia is clinical, based on {{c1::history}} and {{c2::physical examination}}.
Published	11/02/2024	A usual presentation of a hernia in a child is an asymptomatic, intermittent, unilateral {{c1::inguinal bulge}}.
Published	11/02/2024	Activities that increase intra-abdominal pressure, such as {{c1::crying}}, {{c2::coughing}}, and straining, can elicit the hernia.
Published	11/02/2024	The most common examination finding is a {{c1::reducible inguinal or scrotal bulge}}, more prominent during {{c2::Valsalva maneuvers}}.
Published	11/02/2024	Pertinent history elements include prior {{c1::prematurity}}, family history, and prior genitourinary anomalies.
Published	11/02/2024	The differential diagnosis of inguinal hernia includes {{c1::retractile testis}}, lymphadenopathy, hydrocele, varicocele, and prepubertal fat.
Published	11/02/2024	Diagnostic laparoscopy is useful in patients with {{c1::equivocal examinations}} or persistent symptoms with no other apparent cause.
Published	11/02/2024	The "silk glove sign" involves feeling the thickened peritoneum of the {{c1::patent processus vaginalis}} as the cord is palpated.
Published	11/02/2024	In girls, a hard mass felt in the inguinal region may indicate an {{c1::ovary}} protruding into the sac.
Published	11/02/2024	Radiologic assessment is not usually necessary or helpful in diagnosing {{c1::inguinal hernia}}.
Published	11/02/2024	Ultrasound (US) can identify a {{c1::patent processus vaginalis}} by detecting widening of the {{c2::internal inguinal ring}}.
Published	11/02/2024	The presence of fluid in the scrotum or inguinal canal in boys or the inguinal/labial area in girls indicates a {{c1::hydrocele}}.
Published	11/02/2024	Hydroceles are commonly seen in {{c1::infancy}} and have a secondary peak in {{c2::adolescent boys}}.
Published	11/02/2024	Noncommunicating hydroceles in infants are usually observed until the child is {{c1::1–2 years}} of age.
Published	11/02/2024	Factors indicating a communicating hydrocele include a new hydrocele after birth, {{c1::waxing and waning}} fluid size, and failure to resolve by {{c2…
Published	11/02/2024	Communicating hydroceles in infants are treated as a {{c1::hernia}} and repaired electively after diagnosis by some surgeons.
Published	11/02/2024	A survey found that {{c1::54%}} of North American pediatric surgeons in 2005 preferred {{c2::observation}} for communicating hydroceles.
Published	11/02/2024	In the UK, {{c1::61%}} of pediatric surgeons and urologists in 2017 deferred repair of hydroceles until {{c2::2–3 years}} of age.
Published	11/02/2024	Resolution of apparently communicating, asymptomatic hydroceles is reported in {{c1::60–90%}} of cases.
Published	11/02/2024	A cord hydrocele is due to obliteration of the proximal and distal processus with retention of a {{c1::fluid-filled sac}} along the {{c2::spermatic co…
Published	11/02/2024	Cord hydroceles present as a {{c1::smooth, sausage-link}} mobile mass in the inguinal canal.
Published	11/02/2024	{{c1::Ultrasound}} may be helpful to distinguish cord hydroceles from an {{c2::incarcerated inguinal hernia}} in irritable babies.
Published	11/02/2024	Management of cord hydroceles is controversial, with some favoring {{c1::operation}} and others favoring {{c2::observation}}.
Published	11/02/2024	{{c1::Giant hydroceles}} are considered an indication for operation by some surgeons, even without evidence of communication.
Published	11/02/2024	{{c1::Abdominoscrotal hydrocele}} is a large scrotal mass with inguinoscrotal and abdominal components in a dumbbell configuration.
Published	11/02/2024	The "springing back ball" sign suggests the diagnosis of {{c1::abdominoscrotal hydrocele}}.
Published	11/02/2024	Most adolescent hydroceles are {{c1::noncommunicating}}.
Published	11/02/2024	In adolescents, a {{c1::transscrotal hydrocelectomy}} is appropriate in the absence of signs of a PPV or tumor.
Published	11/02/2024	The incidence of incarceration in an inguinal hernia peaks in the {{c1::first year}} of life and ranges from {{c2::3–16%}}.
Published	11/02/2024	Increasing the wait time for elective hernia repair in infancy increases the risk of {{c1::incarceration}}.
Published	11/02/2024	Symptoms of incarceration include a fussy or inconsolable infant with intermittent {{c1::abdominal pain}} and {{c2::vomiting}}.
Published	11/02/2024	A tender and sometimes erythematous irreducible mass is noted in the {{c1::groin}} during incarceration.
Published	11/02/2024	The presence of peritonitis, hemodynamic instability, or septic shock is an absolute contraindication to attempted {{c1::reduction}}.
Published	11/02/2024	Successful reduction of an incarcerated hernia is usually confirmed by a sudden “{{c1::pop}}” of the contents back into the peritoneal cavity.
Published	11/02/2024	An urgent operation is necessary if reduction of the hernia contents is {{c1::unsuccessful}} or {{c2::incomplete}}.
Published	11/02/2024	The laparoscopic approach for incarcerated hernias is associated with fewer {{c1::complications}}.
Published	11/02/2024	Postoperative complications are significantly increased in incarcerated hernias compared with {{c1::elective repairs}}.
Published	11/02/2024	The risk of recurrence is significantly increased in the presence of {{c1::incarceration}}.
Published	11/02/2024	The incidence of testicular atrophy in boys with an incarcerated hernia is {{c1::2–3%}}.
Published	11/02/2024	In girls, the {{c1::ovary}} and/or {{c2::fallopian tube}} are more commonly involved in an incarcerated hernia than the intestine.
Published	11/02/2024	The presence of an inguinal hernia is an indication for {{c1::elective repair}}.
Published	11/02/2024	Prompt repair may decrease the risk of {{c1::incarceration}}, especially in the {{c2::very young}}.
Published	11/02/2024	A Canadian study found that children under {{c1::1 year}} of age had twice the risk of incarceration when repair was performed more than {{c2::2 weeks…
Published	11/02/2024	Inguinal hernias are common in the {{c1::neonatal intensive care unit (NICU)}}.
Published	11/02/2024	“Early” repair of an inguinal hernia shortly before neonatal discharge can be more technically demanding and has higher {{c1::recurrence}} and {{c2::c…
Published	11/02/2024	Early repair may prolong {{c1::mechanical ventilation}} and length of stay in the {{c2::NICU}}.
Published	11/02/2024	Early repair is associated with an increased risk of {{c1::apnea}} and {{c2::bradycardia}}.
Published	11/02/2024	“Late” repair (after {{c1::55 weeks}} postconceptual age) carries an increased risk of {{c2::incarceration}} (10–30%).
Published	11/02/2024	Late repair may result in more frequent {{c1::emergency department}} and clinic visits and {{c2::readmissions}}.
Published	11/02/2024	Concerns about long-term {{c1::neurodevelopmental}} risks of anesthesia in premature infants may favor the {{c2::late}} approach.
Published	11/02/2024	Approximately {{c1::40%}} of premature infants underwent early repair, but there was significant variability between {{c2::hospitals}}.
Published	11/02/2024	The open repair of an indirect inguinal hernia (OHR) in children centers on {{c1::high (internal inguinal ring) ligation}} of the hernia sac.
Published	11/02/2024	A transverse inguinal crease incision is used for the {{c1::open repair}}.
Published	11/02/2024	The {{c1::Scarpa fascia}} is opened, and the external oblique aponeurosis is identified and opened along the direction of its fibers.
Published	11/02/2024	Care is taken to identify and preserve the {{c1::ilioinguinal nerve}}, which supplies cutaneous sensation to the skin of the {{c2::anterior thigh}}.
Published	11/02/2024	In boys, the anteromedial hernia sac is carefully separated from the {{c1::cord structures}}.
Published	11/02/2024	In girls, the hernia sac is mobilized up to the {{c1::internal inguinal ring}}.
Published	11/02/2024	The sac may extend down into the {{c1::scrotum}} in boys and is clamped after ensuring the absence of the vas and testicular vessels.
Published	11/02/2024	The hernia sac is divided and followed proximally to the internal inguinal ring, where it is {{c1::doubly ligated}} with absorbable suture.
Published	11/02/2024	The distal sac should be widely opened but need not be {{c1::removed}}.
Published	11/02/2024	If a hydrocele is present, it is {{c1::evacuated}}, but excision of the hydrocele sac is not necessary.
Published	11/02/2024	Large or thick sacs may be everted behind the cord in the {{c1::Bottle procedure}}.
Published	11/02/2024	Historically, {{c1::contralateral open inguinal exploration}} was common for unilateral inguinal hernias.
Published	11/02/2024	Over the past 20 years, there have been reports describing the use of {{c1::laparoscopy}} to evaluate the contralateral inguinal ring at the time of o…
Published	11/02/2024	A small 70-degree scope can be inserted through a {{c1::2-mm port}} placed through the ipsilateral hernia sac to look for a contralateral PPV.
Published	11/02/2024	There is a small, but definite ({{c1::1–2%}}), incidence of developing a contralateral hernia even after a negative evaluation.
Published	11/02/2024	The indications for contralateral evaluation are controversial, but with the increasing use of {{c1::transumbilical laparoscopic repair}}, this may be…
Published	11/02/2024	More recent studies and meta-analyses suggest that contralateral evaluation may not be necessary, indicating it might be {{c1::overtreatment}}.
Published	11/02/2024	In one study, when given the options of unilateral repair alone versus unilateral repair with contralateral evaluation, parents overwhelmingly chose {…
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