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Hernias exposed

Born two months premature with twin brother Tyler, Hunter Molway was discharged from Brigham and Women's Hospital (BWH) after spending four weeks in the NICU. Just days after arriving home, however, Hunter's parents noticed a change in his behavior.

"He seemed really fussy, was vomiting and wasn't eating much," says his father, David, a nurse at BWH.

After a visit to their pediatrician, the Molways ended up in Children's Hospital Boston's emergency room where doctors confirmed a diagnosis of an inguinal hernia, a congenital condition in which part of the intestine protrudes through an opening near the groin.

Inguinal hernias are relatively common in premature newborns, with an incidence rate of 16 to 25 percent. They are more common in boys and may occur on either side, though hernias on the right side occur more frequently. This was the case with Hunter who also had a hydrocele, a buildup of fluid around the testicle, on his left side.

Inguinal hernias and hydroceles occur most often when the patient's processus vaginalis, an opening that connects the abdomen and the scrotum, fails to close securely at birth. When this happens, the abdominal contents or hydrocele fluid can pass through the opening and end up in the scrotum.

Hydroceles may cause the scrotum to swell, but are harmless and in most cases spontaneously resolve. And hernias are often reducible. However, if the abdominal contents become trapped within the narrow processus vaginalis and cannot be reduced, this condition, called an incarcerated hernia, requires immediate attention. Fortunately, Hunter's hernia was not incarcerated, and surgery was scheduled for a few weeks away.

Though hernia operations are quite common—five to 10 are performed each day at Children's—Hunter's case was not. "The surgery itself was not unusual," says pediatric surgeon Catherine Chen, MD, MPH. "It was the days leading up to surgery that made his case so unique. We did a number of workups on him that revealed high levels of potassium in his blood. This was a concern because it can cause heart arrhythmias."

Doctors did not want to operate until Hunter's blood tests were normal. But after consulting with specialists in Nephrology, Cardiology and Metabolics (which looked at possible genetic causes), they still couldn't figure out why his potassium levels were so high.

"We finally asked the parents about Hunter's diet, hoping to uncover a clue there," says Dr. Chen. "Sure enough, he was drinking a lot of prune juice, which is very high in potassium. Once he cut that from his diet, his levels went back to normal."

On October 31, Hunter had surgery to repair the right-sided hernia and the left-sided hydrocele. Even though the procedure is the most common operation at Children's, there are associated risks, including bleeding, wound infection, reoccurrence of the hernia, and injury to the vas deferens and/or testicle.

While the procedure is typically carried out as a day surgery, because of Hunter's age, he remained in the hospital overnight for monitoring of his heart and lung function.

Like most babies, Hunter handled the surgery well. "There were a couple days of discomfort, but within 48 hours he was back to normal," says David. "It's true, kids are very resilient."

As for Dr. Chen, she was happy to repair the hernia before it became incarcerated. She says that pediatricians should refer a child to a specialist if they suspect any inguinal hernia. An incarcerated inguinal hernia, often characterized by irritability, vomiting, and a groin that is firm and red with a lump that cannot be pushed away, should be referred urgently.

For more information or to request an appointment,
visit www.childrenshospital.org/surgery or call (617) 355-7800.

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