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Newborn Inguinal Hernia - Leading to Strangulation and Perforation

#TIME TO REFORM THE COUNSELLING #

HERNIA: Protrusion of viscus or a part of it through an abnormal opening in its contained cavity( Peritoneal cavity)

PRESENTATION: Bulge in inguinal region / inguinoscrotal region/ Groin area/ Private Part.

INCIDENCE: 4 % TERM AND 33% PRETERM NEWBORNS.

SITE: Right : 60 - 70 %, Left :20 -30 %, BILATERAL : 10 %.

CAUSE

Mostly due to PATENT PROCESSUS VAGINALIS which is related to Testicular decent during in utero development. Failure to obliterate following the decent of testis causes a rent in peritoneal cavity leading to abnormal protrusion of viscus in the groin( Hernia) or collection of fluid around the scrotum ( hyrocele) depending on the size of the defect. Rarely Muscular Dystrophies, Connective tissue Disorders, Eagle Barret Syndome.

TIMING OF SURGERY

AS SOON AS DIAGNOSED unless the baby has cardiopulmonary issue which needs optimization first. Cut off weight is 2 kg still the waiting is advisable with Hawk's eye vision.

PROCEDURE

HERNIOTOMY, which is done under general anaesthesia and is considered 99 percent safe and successful in newborns in present era of evolution of anaesthesia and skillful approach with less than 1 percent risk of injury to vas and vessels.

COMPLICATION

  • Infants are more prone during incessant crying episodes
  • 30- 50 percent obstruction occurs in less than 6 months of age
  • OBSTRUCTION/ INCARCERATION / STRANGULATION
  • Leading to bowel gangrene and perforation and sometimes testicular gangrene

A DAY CARE SURGERY TURNING TO DISASTER # INCREASED MORBIDITY AND IN WORST SCENARIO MORTALITY # WHEN ALL WE NEED IS "TO BECOME MORE AWARE AND ACTIVE -RATHER THAN A CASUAL COUNSELLING."

TODAY'S TIME WHEN WE HAVE AVAILABILITY OF NEONATAL SURGEON AND ANAESTHESIA JUST A TIMELY DIAGNOSIS AND PROPER COUNSELLING CAN CHANGE THE COURSE.

HOW???

Right information to the parents about the diagnosis....Inguinal Hernia needs surgical treatment and it never never never resolves itself. Explaining them about the danger signs so that they get timely help rather than complicating things more, which goes out of way.

A COMPLICATED HERNIA IS TOO CHALLENGING FOR ANAESTHETIST TO HANDLE THE AIRWAY AND FOR SURGEON TO OPREATE BECAUSE OF LOSS OF ANATOMICAL PLANES AND THEREBY MORE RISK OF INJURY TO VAS AND VESSELS...AND THE SEPSIS CAUSES A TOPSY TURVY NICU STAY.

INDEX CASE

Term male born by uneventful normal vaginal delivery,less than 24 hours of life presented with inguinoscrotal swelling and abdominal distension. No significant history was coming from parents ...even a consolidated history of bulge in inguinal region was lacking as the baby was less than a day and perhaps too early for the parents to take note of the things.

  • Sent by primary physician suspecting hernia...
  • Examination
  • Grossly oedematous scrotum with erythema and induration.
  • Abdomen tense with dilated veins, gaurding , rigidity and absent bowel sound

Rest of the story comes from the pics...Seeing such a toxic newborn ...first ruled out any forceful vaginal delivery because of the look of scrotum...To rule out hematoma??

Confirmation

  • Done with X-ray Abdomen and pelvis erect
  • Usg whole abdomen and inguinoscrotal region suggestive of "Strangulated left inguinal hernia with Pneumoperitoneum. "

Strangulation leading to perforation was pointing towards intrauterine event????

Sharing it for everyones interest so that we become more vigilant in our counselling. "Decision is always in parents hand but doing our best with the best of our knowledge and skills is what we can offer."

The elaborate emphasis is coming out of the struggle while managing this case on table...baby presented at 7 pm...going through the reluctance phase and parental insistance on medical treatment finally was persuasive to them to take the risk... Risk for them and equally for us. The blood parameters were bad...preop optimization done with fluid, antibiotics, FFP ( INR: 2.9).
Finally my turn with my scalpel came at 2 am ...those crazy hours of patient preparation, anaesthestist and ot staff handling and the cleaning the dirt..( fecal peritonitis) There was gangrene in the sigmoid loop with perforation and the fecal matter was sweeping through the hernial ring to scrotum causing fecal peritonitis and "Angry SCROTUM " The distal sigmoid was sloughed along the posterior wall...did a mid sigmoid end colostomy and closed the distal sigmoid( Hartmann's Procedure) Still God is Great that the proximal bowel was secured and the surgical help turned fortuitous.
The baby recovered progressively and is being discharged at post op day 7.
I am thankful to all my team for this great save for the vigour they showed at the CHALLENGING hours of night as they all just got ready to be on the same page with me..and Almighty for being throughout paving my way for best decision.
Done at Sarvodaya Hospital, Sector -8 Faridabad