One of the rarest hernias seen in children is the direct inguinal hernia. Essentially all pediatric inguinal hernias are of the indirect variety (patent processus) and therefore high ligation is all that is necessary. It is very rare to discover that the floor of the inguinal canal is deficient either before or during an inguinal hernia repair. With the possible exception of a second recurrence or a child with a known connective tissue disorder, the use of an artificial material is not recommended for inguinal hernia repair in a child because of the uncertain long-term effects and the possibility of injury to adjacent structures. Rather, a traditional technique, such as the McVay Cooper ligament repair, is favored.
Spigelian hernias are frequently considered but rarely found. Patients will sometimes provide a history that is textbook, only to have intact fascia by physical examination, imaging studies, and even local exploration. It can be very frustrating for all involved. Although MRI and laparoscopy provide the best available techniques for confirmation of a hernia, no study or combination of studies is especially accurate.
The eponymous inguinal hernias are mostly of historical interest as they rarely cause true clinical mayhem – when performing an inguinal hernia repair, the surgeon must be prepared to deal with any number of surprises. The one exception is the Richter’s hernia, which can be easily missed when one assumes that incarcerated hernia has been ruled out because of the absence of obstructive symptoms. The consequences of this error, bowel necrosis and perforation, can be dire. Imaging studies can also be deceiving, reinforcing the adage that, when in doubt, the patient should be explored.
Diastasis recti is not a true hernia and should never be operated upon, but parents often need to be repeatedly reassured. Likewise, epigastric hernias (epiploceles) should only be repaired if they become large or symptomatic. Despite being true hernias, they are almost always tiny, allowing only a small amount of properitoneal fat to herniated, and are thus generally harmless. Finally, incisional hernias can occur whenever a surgical procedure has been performed and are usually easily confirmed on physical examination. The exception is the rare trocar site hernia, which can be difficult to diagnose. The combination of pain and a lump at a trocar site should usually prompt surgical exploration to rule out a hernia.