Inguinal code according to ICD 10. Inguinal hernia in children

The protrusion of the elements of the abdominal organs through the inguinal canal is characterized as an inguinal-scrotal hernia. This condition can be congenital or appear simultaneously with age-related changes, and in the male part of the population it is observed much more often than in women.

Pathology responds well to treatment, especially timely. The neglected cases can threaten the infringement of the hernial sac and necrosis of the restrained organs.

ICD Code 10:

• K 40 - inguinal hernia.
• K 40.0 - bilateral inguinal hernia with obstruction symptoms.
• K 40.1 - bilateral inguinal hernia with gangrenous complications.
• K 40.2 - uncomplicated bilateral inguinal hernia.
• K 40.3 - unilateral or without clarification, with signs of obstruction.
• K 40.4 - unilateral or without specification with gangrenous complications.
• K 40.9 - one-sided or without clarifications, uncomplicated.

Causes of the groin-scrotal hernia

The factors that determine a person's predisposition to the occurrence of an inguinal-scrotal hernia are:

• heredity;
• age after 50 years;
• neurological pathologies affecting the nervous innervation abdominal wall;
• obesity, the presence of extra pounds.

The functional factors that can lead to the appearance of pathology include the following:

• excessive physical exertion on the abdominal area;
• chronic difficulty in defecation, constipation;
• adenoma of the prostate, proceeding with impaired urination;
• chronic bouts of coughing.

Pathogenesis of the disease

The main causes of this disease are closely related to the structural features of the musculo-ligamentous apparatus of the abdominal and inguinal zone of a particular patient. The most important point is the condition of the inguinal canal itself and the inguinal ring. The weakness of these organs predisposes to the appearance of a hernia.

Inguinal scrotal hernia is divided into the following types:

• By location:
  • one side;
  • on both sides.
• Typical:
  • direct hernia;
  • oblique hernia.
• By variant of occurrence:
  • congenital type;
  • acquired type.
• By the degree of development:
  • initial form;
  • inguinal canal form;
  • complete oblique inguinal hernia;
  • inguinal scrotal hernia;
  • giant shape.
• By the nature of the course:
  • without complications (with and without reduction);
  • with complications (with infringement, with coprostasis, with inflammation, etc.).
• By severity:
  • simple hernia;
  • transitional form;
  • complex hernia.

Inguinal-scrotal hernia symptoms

An oblique inguinal-scrotal hernia is more common than a straight one. Direct hernia occurs in only 5-10% of cases, and even then mainly in the elderly. In most cases, such a protrusion is bilateral. An oblique hernia usually appears in adolescent to middle-aged patients, more often on one side.

One of the most characteristic symptoms of hernial pathology is a tubercle in the form of edema in the groin area. An oblique inguinal-scrotal hernia has an oblong shape, it is located along the inguinal canal and is often descended into the scrotum. If the protrusion is large, then part of the scrotum can be markedly enlarged, the skin on it is stretched, there is a visible deviation of the penis to the opposite side. With a giant hernial form, the penis can sink into the skin folds.

Direct inguinal-scrotal hernia has a relatively round shape, located in the middle section of the inguinal ligament.

In situations where the hernial defect is located above the expected exit of the opening of the inguinal canal, it is necessary to exclude peri-groin or interstitial pathology.

Inguinal-scrotal hernia in men manifests itself as strong painful sensations. The pain may appear when feeling the place of the protrusion, after exercise, but at rest the pain subsides. Symptoms such as general weakness and discomfort, dyspeptic symptoms (bouts of nausea, vomiting).

Inguinal-scrotal hernia in children can form at any age, more often on the right side. The first signs can be seen with the naked eye:

• with tension of the abdomen, during laughter, sneezing, coughing, a tubercle with soft contents appears in the groin area;
• the tubercle disappears at rest or hides when pressed.

Sometimes there may be discomfort, slight pain, mainly after physical exertion.

Inguinal-scrotal hernia in newborns has an innate character and is formed even inside the womb. The pathology can be determined already in the first months of the baby's life: a tubercle in the groin appears and becomes larger during the cry and anxiety of the child and disappears when the baby calms down. The tubercle is painless to the touch, has a round or oval shape, and can be easily adjusted.

A strangulated inguinal-scrotal hernia is a dangerous condition and requires urgent medical attention. How to recognize such a complication?

• The skin at the site of the protrusion becomes purple or bluish.
• Arises strong pain, nausea, or vomiting.
• Stool disorder, flatulence appear, appetite disappears.

When pinched, the tubercle becomes very painful when felt. It is no longer possible to straighten it back, while an unrestrained inguinal-scrotal hernia is easily hidden when pressed with a finger.

Constipation with inguinal-scrotal hernia occurs when the intestinal loop is pinched - a condition occurs that fully corresponds to the characteristics of intestinal obstruction. Constipation can be accompanied by a significant deterioration in well-being, bloating, belching, heartburn, and vomiting. It is pointless to wait for relief in such a state - it is necessary to urgently call an "emergency aid".

Effects

Complications of an inguinal-scrotal hernia develop in the absence of timely treatment:

• infringement of the hernial tubercle is the most common consequence, which is eliminated only by surgical methods;
• necrosis of organs trapped in the pinched hernial sac - intestinal loops, areas of the omentum, bladder;
• peritonitis is a dangerous inflammatory reaction that spreads throughout abdominal cavity (can also appear as a result of infringement);
• acute attack of appendicitis - inflammation of the tissues in the appendix, which occurs as a result of the compression of the vessels of the appendix by the inguinal ring;
• the clinical consequences of an inguinal hernia can be disorders of the digestive process, disturbances in the functioning of the intestines, bloating, etc.

The most formidable complication is the infringement of the hernia - this situation requires urgent medical attention, with hospitalization in a hospital and an emergency surgery.

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Diagnostics of the inguinal-scrotal hernia

The doctor makes a diagnosis based on the patient's complaints, as well as on the results of an external examination. Feeling is carried out with the index finger: with an inguinal-scrotal hernia, the tubercle is palpable easily, and with a femoral hernia it is quite difficult to feel it.

In children, the doctor simultaneously determines the prolapse of the testicles into the scrotum, their size and shape, and the absence of varicocele. The condition of the lymph nodes in the groin area is checked without fail.

The condition of the hernial defect is checked in the horizontal and vertical position of the patient.

• an ultrasound scan of the scrotum, which helps determine the contents of the hernial sac (for example, part of the bladder or part of the intestine). Additionally, using ultrasound, you can distinguish a hernia from a dropsy of the testicle;
• the diaphanoscopy method is a light transmission of the scrotum - an uncomplicated and inexpensive diagnostic method. If the contents of the bag are liquid, then the rays are illuminated through the tubercle without problems. The denser structure will keep out the rays and the light will look dull or uneven.

Inguinal-scrotal hernia treatment

Drug therapy for inguinal-scrotal hernia disease is ineffective, and therefore this pathology can be cured only by surgery. The operation can be performed from the age of 6 months (it is undesirable for newborns to carry out the intervention due to the use of general anesthesia).

Anesthesia is usually combined with tranquilizers and local anesthetic drugs to prevent severe pain in the postoperative period.

Surgery for an inguinal-scrotal hernia is called hernia repair:

• the doctor makes an incision in the area of \u200b\u200bthe inguinal canal;
• cuts off and sutures a hernial formation;
• the elements of the organs, which turned out to be restrained, are adjusted to their physiological place - the normal anatomical structure of the inguinal and abdominal regions is restored.

During the operation, the surgeon makes sure that the spermatic cord and excretory duct are not damaged.

As a rule, hernia repair operation is not a complicated one - the procedure itself lasts no more than half an hour. Most often, the patient is discharged the next day, but bed rest is recommended for another three days. If the doctor applied ordinary stitches, then they are removed after 7-8 days.

Alternative treatment of hernia - the imposition of tight bandages, the application of coins, lotions, magnets, compresses - a useless exercise. Engaging in such treatment, the patient is only wasting time, which can lead to complications in the form of hernia infringement, which will require urgent surgical intervention. If the patient was operated on for 2 or 3 hours after the hernia was strangulated, then such an operation in most cases is successful. Delay in intervention can lead to serious complications, and in some situations, even lethal consequences are possible.

Bandage for scrotal-inguinal hernia

There is only one conservative technique that is used in the treatment regimen for inguinal-scrotal hernia pathologies - this is a bandage.

In what cases the doctor may prescribe wearing a bandage:

• large hernial formations, if it is impossible for one reason or another to carry out the operation;
• reappearance of pathology after surgical treatment;
• the presence of contraindications to surgical intervention (age restrictions, cardiovascular pathologies, problems with blood coagulation, etc.);
• childhood diseases in which the operation is postponed indefinitely.

At the same time, the bandage does not cure the disease radically. Its purpose is to alleviate the patient's condition, stop the increase in hernial protrusion and prevent infringement. However, if the patient stops using the bandage, then all signs of pathology return.

So, what does wearing a bandage give:

• the degree of discomfort decreases;
• ability to work returns to the patient;
• the hernia loses its tendency to aggravate and restrict.

The bandage is put on every morning, on the naked body, being in a horizontal position. At first, wearing it may be a little uncomfortable, but after a few days the patient gets used to it and does not notice any discomfort. Of course, a competent choice of a bandage is important: a medical specialist in a polyclinic or in a pharmacy can help with this.

The brace can be removed before going to bed, but if the patient has coughing fits at night, it is not necessary to remove the support.

As practice shows, wearing a bandage is a temporary phenomenon, and sooner or later the patient still has to decide on an operation.

When internal organs prolapse into the scrotum, we are talking about the development of an inguinal-scrotal hernia. This can happen due to the failure of the connective tissues of the inguinal rings, which serve as a natural opening of the abdominal wall. It is difficult to name the causes of this disease more precisely. There are many factors that can, to a greater or lesser extent, affect the tone of the rings and contribute to the prolapse of organs into the fold of the peritoneum called the scrotum.

What is an inguinal scrotal hernia?

It is a non-communicable disease that can affect older men and young boys. In the stronger sex, hernia most often develops after 50 years. At this age, the natural elasticity of the connective tissues decreases, and any physical activity creates additional pressure in the abdominal cavity, provoking organ prolapse.

Overweight can be a similar "burden" for the body. In advanced cases, infringement of the hernial sac may occur. This causes necrosis of the strangulated organs. In accordance with the international classification of the disease, the ICD-10 code is assigned: K40.

The development of the seal takes place in 5 stages:

1. The initial form, in which there are no external manifestations of a hernia, and the seal can be palpated when straining. In this case, the pouch does not go beyond the inguinal canal.
2. Inguinal canal stage. At this stage, the bottom of the hernia sac reaches the outer opening in the inguinal canal.
3. Rope hernia. The neoplasm in this stage comes out of the inguinal canal and descends along the spermatic cord.
4. An inguinal-scrotal hernia is diagnosed at the moment when the sac has already descended into the scrotum. There he is able to reach the testicle and sit around it.
5. Giant shape. The size of the seal has reached such a size that new skin folds are formed. In them, as the hernia continues to grow, the genital organ begins to "sink".

Any form can occur with or without developing complications. With a large protrusion of the scrotum, a noticeable deviation of the male genital organ in the opposite direction to the protrusion may occur.

Types of seals

At the site of localization, an inguinal-scrotal hernia can be a cord (hernial sac descends to the spermatic cord) or testicular (prolapse occurs along the line of the testicles). By its nature, education can be direct or oblique. In the first case, the hernia enters the inguinal canal through the peritoneal wall, bypassing the internal opening, and is located closer to the midline. With an oblique type of compaction, the contents of the sac passes through the entire canal, affecting not only the spermatic cord, but also the vas deferens with vessels. An oblique hernia can be both congenital and acquired. Direct - exclusively acquired.

Depending on the causes of the disease, it can be:

1. Congenital;
2. Acquired.

The seal can be located on one or both sides at once. An inguinal hernia is often diagnosed. Infringements in it can be elastic or fecal. In the first case, infringement occurs with a significant and sudden increase in intra-abdominal pressure. As a rule, this is coughing, sneezing, a sharp change in body position, straining during acts of defecation.In this case, more than usual contents can fit into the hernial sac. Oxygen starvation is noted in the organs that have fallen out, which can lead to tissue necrosis if medical care is not provided in a timely manner. With fecal infringement, the outflow of blood in the intestinal loops, which are located inside the hernial sac, is disturbed. The violation is caused by problems with the motor function of the gastrointestinal tract and the fusion of the connective tissues of the peritoneal cavity.

Conservative therapy in treatment rarely gives positive results. Therefore, it is important to diagnose a hernia in the early stages and accurately determine all of its characteristics.

Organ prolapse occurs due to excessive weakness of the muscles and ligaments outside the spermatic cord. There are times when there are several seals in the scrotum at once. This type of disease is called combined. Hernias are not interconnected and may differ in characteristics. So each seal has its own hernial gate.

In the photo there is an inguinal-scrotal hernia

The reasons

In addition to increased pressure in the abdomen caused by physical exertion or the presence of excess weight there are other reasons that can provoke the development of an inguinal-scrotal hernia.

Such factors include:

• Genetic predisposition;
• Patient's maturity (men over 50);
• Abdominal wall abnormalities;
• Congestion of the pelvic organs;
• Inactivity;
• Chronic constipation
• Neurological pathology.

The doctor should establish the cause of the appearance of the seal in the scrotum and eliminate the influence of factors contributing to its growth. In children, this pathology is most often associated with problems of intrauterine development, in which the vaginal peritoneal process did not become overgrown.

Frequent crying and coughing in a child can provoke the appearance of an inguinal-scrotal hernia in childhood. Processes of this kind cause a sharp change in intra-abdominal pressure.

Symptomatic manifestation

The primary reason for which men turn to a specialist is the appearance of a seal in the groin area. If the abdomen is straining from laughing, coughing or sneezing, it is palpable. The soft contents can be identified by touching the lump. At rest or when pressed, the seal is hidden. The pain syndrome accompanies the disease only if the infringement has occurred. Otherwise, the hernia grows painlessly.

Other symptoms of the disease are:

1. Change in skin color over the site of the tumor to purple or cyanotic.
2. An increase in the size of the scrotum (as a rule, disproportionate - on one side).
3. Pain when moving or urinating.

How much the size of the peritoneal fold can change is difficult to say. During the development of the disease, not only the hernial sac, but also the intestine can fall into it. But it is not worth starting a disease before such a thing. The resulting tumor increases in size when you cough.

Symptoms of the disease may differ depending on the age of the patient, characteristics of the formation and individual characteristics of the organism.

If the intestine is pinched, nausea and vomiting may be added to the main signs of the disease. If you suspect an inguinal-scrotal hernia, you should consult a urologist or surgeon.

Diagnostic measures

The main technique for determining the infringement of the ring with a hernia is "cough push". The doctor leaves his hand on the bag and asks the patient to clear his throat. If at the same time the shocks are directed to the sealing area, then there is no infringement. If these shocks are absent, then an infringement has occurred.

Hernia can be difficult to palpate if it is small. Then an ultrasound scan is performed to confirm or refute the diagnosis. This is the most accurate and safest way to diagnose an inguinal scrotal hernia. With the help of an X-ray, the presence of loops of a thick or small intestine in the area of \u200b\u200bthe bag.

Another diagnostic method is diaphanoscopy. With it, the scrotum is seen through: in the absence of pathologies, the liquid inside passes the directed rays of light without problems. The presence of denser structures in the fold will make it dull and uneven.

In boys, the doctor should also check for prolapse of the testicles, their size, and shape. And also determine the possible presence or absence of varicocele. The lymph nodes of the groin area are subject to compulsory research.

When the question is that the presence of a cyst is possible in the spermatic cord, it is imperative to take the hernial contents for examination by puncture. She can often mimic the development of a hernia in terms of symptoms.
In the video, an inguinal-scrotal hernia on ultrasound:

Treatment method

There are cases in which it is possible to treat a scrotal hernia without surgery. As a rule, this is done at the stage of early development of the seal.

Surgical intervention is contraindicated for:

• Severe health condition of the patient;
• Intolerance to anesthesia;
• Anemia
• Acute infectious and inflammatory processes.

In these cases, doctors direct all their efforts to conservative treatment of the patient, since the operation may not be tolerated. There are cases in practice when the patient himself refuses to carry out any surgical procedures.

Non-surgical treatment also involves wearing a special bandage. With its help, organs are held. Outwardly, it looks like swimming trunks. Strengthening the abdominal muscles is allowed through the lungs exercise. To relieve pain and inflammation, pain relievers and anti-inflammatory medications are prescribed.

Surgical intervention

In the case when the reception medicines does not give positive dynamics or the disease is at a stage when the drugs no longer help, surgical intervention is required. The operation is performed under local anesthesia and takes about half an hour.

The patient is made an incision through which the hernia is accessed. The pouch with it must be removed, and the fallen organs must be repositioned. Plastic is done on the inguinal canal damaged during the operation.

Suturing of wound layers occurs sequentially with the installation of drainage. In the postoperative period, there is a risk of a ligature fistula.

Rehabilitation after surgery

After about 3 asa after the operation, the patient can begin to move. A bandage is attached at the incision site, on which purulent discharge can accumulate. Nothing wrong with no. After the manipulation, this is the norm. The stitches are removed after 1-1.5 weeks. For the first 20 days thereafter, heavy lifting is prohibited. It is better to give up physical activity for six months from the date of the operation.

The healing process will go faster if the patient follows the medical recommendations of the rehabilitation period. These include:

1. Wearing a compression bandage;
2. Refusal of increased physical activity;
3. Taking antibacterial drugs.

If these conditions are met, the prognosis of recovery is very favorable. Subsequently, a man or boy can return to their usual way of life. But the influence of factors provoking the appearance of an inguinal-scrotal hernia should be controlled.

Self-medication or lack of therapy can cause serious complications or even death against the background of general intoxication of the body. The patient only loses precious time, which can cost him his health or even his life.
In the video about rehabilitation after surgical removal of an inguinal hernia:

The hip joint provides the connection of the largest bones of the human body, so it has mobility and is able to withstand increased loads. This is achieved by connecting the femoral head to the acetabular pelvic cavity using four ligaments.

In newborns, dysplasia of the hip joint (TPA) is manifested by the abnormal formation of one of its sections, while the ability to keep the femoral head in a physiological position is lost.

• Deviations in the development of this area are recorded in infants quite often. On average, these figures reach 2–3% among children. In Scandinavian countries, hip dysplasia is recorded somewhat more often, while in southern Chinese and Africans it is rare.
• Pathology often affects girls. They account for 80% of patients diagnosed with hip dysplasia.
• The facts of hereditary predisposition are indicated by the fact that family cases of the disease are recorded in one third of patients.
• In 60% of cases, dysplasia of the left hip joint is diagnosed, the share of damage to the right joint or both at the same time accounts for 20%.
• The relationship between the traditions of tight swaddling and increased incidence rates was noted. In countries where it is not customary to artificially restrict the mobility of children, cases of hip dysplasia are rare.

Asymmetrical groin and gluteal folds

If you put the baby on his tummy, three folds are visible under the buttocks on both straightened legs, which healthy baby continue each other. With dysplasia on the side of the affected joint, the folds are located higher, sometimes an additional fold is formed on the thigh.

Komarovsky notes that asymmetry also occurs in healthy children, so it cannot be included in the symptoms that are mandatory for the disease. The folds will be symmetrical in the newborn and in bilateral dysplasia of the hip joints.

Causes of the disease

Dysplasia of the hip joint can appear under the influence of the following reasons:

• Heredity. The infant whose mother has had this condition is more likely to be injured.
• Bad habits and poor nutrition of a pregnant woman.

• Poor environmental situation, which leads to malformations of the baby.
• Age and some diseases of the woman in labor. The later the pregnancy occurs (especially the first), the higher the risk of abnormalities.
• Early or late toxicosis during pregnancy. This condition suggests that the mother's body considers the fetus to be a foreign body, and tries to fight it at the biochemical level. Therefore, some changes in exchange can lead to incorrect formation of the skeleton.
• Serious somatic pathology of a woman in labor.
• Breech presentation of the baby. With the wrong and inconsistent work of doctors, the likelihood of dislocation becomes very high.
• Violation of the balance of water-salt metabolism of the fetus.
• The baby is entwined with the umbilical cord.

• Taking some medications, prematurity of the child. Naturally, the baby's bones are still very soft, so you can damage them with any careless finger press. Premature babies are a “crystal vase”.
• Incompetence of medical staff. Hip dysplasia, and especially dislocation, can occur due to trauma to the baby during childbirth due to the carelessness of obstetricians.

These reasons may not be the only ones, however, they are the most common.

It is at this time that the intrauterine structure of all the elements of the musculoskeletal system of the child passes.

The most common causes of the disease include:

• Genetics. Usually in families where there have been cases of this disease, the probability of a baby with pathologies of large joints grows by 40%. At the same time, girls have a higher risk of getting sick.
• Exposure to toxic chemical substances during pregnancy. This situation is most dangerous in the first trimester, when intrauterine laying of the organs of the musculoskeletal system occurs.
• Bad environmental situation. Harmful environmental factors have a negative effect on the development of the unborn child. Insufficient oxygen and a high concentration of carbon dioxide can cause intrauterine hypoxia of the fetus and lead to a violation of the structure of the joints.
• Expectant mother is over 35 years old.
• The mass of the child is more than 4 kilograms during childbirth.
• Birth of a baby ahead of schedule.
• Gluteal presentation.

• Bearing a large fetus with initially small sizes of the uterus. In this case, the baby is physically not enough enough space for active movements. Such forced passivity during fetal development can lead to limited mobility or congenital dislocation after birth.
• Infection with various infections of the expectant mother. During pregnancy, any viruses or bacteria easily pass through the placenta. Such infection in the early stages of the development of the baby can lead to birth defects in the structure of large joints and ligaments.
• Poor nutrition, lack of vital essential vitaminsthat are needed for the full development of cartilage and ossification - formation bone tissue.
• Excessive and very dense swaddling. Excessive pressing of the child's legs to the body can lead to the development of diverse variants of dysplasia.

Dysplasia in orthopedics is called a violation of the correct location of large trochanteric femurs. This causes improper breeding of the legs, which leads to problems: children can’t practically stand, have problems walking at an older age.

1. Violations during gestation. Excessive synthesis of relaxin leads to a strong softening of the femoral-sacral joints not only in the expectant mother, but also in the baby. As a result, deformation occurs; congenital dysplasia of the hip joints.
2. A large body mass of the baby. Obstetricians claim that high risk of developing hip dysplasia is observed in infants weighing more than 3.5 kg.
3. Gluteal presentation. In this case, the child is born booty forward, which increases the risk of deformation of the hip joints. The head leaves the acetabulum of the pelvic bone and is not able to return to its place on its own. To prevent the development of hip dysplasia in the baby in this case, doctors resort to cesarean section.
4. Genetic predisposition. Women with a similar pathology have a higher risk of having a baby with dysplasia.
5. Tight, wrong swaddling. In this case, there is excessive pressure on the hip joint, which increases the risk of deformation.
6. Adverse environmental conditions. It has been established that in children living in disadvantaged areas near the industrial zone, hip dysplasia occurs more often.

My terrible story and a happy ending

I have long suffered from joint pain. Aching, twisting and not giving sleep.

Doctors said it was time to do the operation, but I was afraid, and decided to try this tool ...

Elements of the musculoskeletal system are laid at 4-6 weeks of pregnancy. The final formation of joints is completed after the child begins to walk independently.

In medicine, there are three main reasons for the development of the considered pathology of the hip joint:

• genetic predisposition;
• tissue formation disorders during fetal development;
• hormonal effects.

Heredity

Quite often, the disease in question is diagnosed simultaneously with myelodysplasia - disorders in the process of the formation of blood cells in the red bone marrow.

Doctors attribute this disorder directly to hip dysplasia.

We are talking about an unstable hormonal background of a pregnant woman - the body notes high level progesterone. This hormone has a relaxing effect on ligaments, joints and cartilage - this is necessary for patrimonial activity and safe delivery.

Please note: this negative effect of the hormone progesterone is of particular intensity in case of incorrect position of the fetus or childbirth in the buttock presentation.

The embryo of the hip joint is observed already at the 6-week-old age of the fetus, the first child makes its first movements at the 10th week of its intrauterine development. And if at these stages negative / harmful factors will influence the pregnant woman (and therefore the fetus), then the likelihood of developing hip dysplasia increases significantly. Such harmful factors may include:

• various chemicals, certain medications;
• unfavorable environmental conditions;
• radioactive exposure.

Please note: the largest role in the formation of tissues in the fetus is played by viral diseases - if a woman is ill with this at the first trimester of pregnancy, then the risk of having a baby with hip dysplasia increases dramatically.

In addition, the disease in question is diagnosed in the following cases:

• the fruit is too large;
• the mother is diagnosed with oligohydramnios;
• pelvic presentation of the fetus;
• gynecological diseases of the mother - for example, myoma, adhesions and others.

The most common cause of disorders that occur during fetal development are genetic abnormalities (25-30% of cases), which are transmitted through the maternal line. But other factors are also able to adversely affect these processes.

• A large fetus is subject to anatomical displacement of bones when it is abnormally located inside the uterus.
• The effect on the fetus of physical factors and chemicals (radiation, pesticides, drugs).
• Malposition. First of all, we are talking about the gluteal presentation, in which the fetus abuts the lower part of the uterus not with the head, as it should be normal, but with the pelvis.
• Kidney disease in the unborn child.
• Genetic predisposition in case of the presence of the same problems in parents in childhood.
• Severe toxicosis at the initial stage of gestation.
• The tone of the uterus during the bearing of the child.
• Diseases of the mother - diseases of the heart and blood vessels, liver, kidneys, as well as vitamin deficiency, anemia and metabolic disorders.
• Viral infections during pregnancy.
• The effect of an increased concentration of progesterone in the last weeks of pregnancy can weaken the ligaments of the unborn baby.
• Bad habits and unhealthy nutrition of the expectant mother, in which there is a deficiency of trace elements, vitamins B and E.
• The poor environment in the region where the parents live causes frequent (with a 6-fold excess) cases of hip dysplasia.
• The tradition of tight swaddling.

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There are several factors that cause dysplasia in children under one year of age:

1. The longitudinal location of the fetus and complications during childbirth cause hip dysplasia in children. Features of the intrauterine location of the child often cause signs of joint deformation on the left side;
2. The disease can be transmitted by maternal inheritance in almost a third of cases. In newborn girls, it occurs several times more often;
3. A child’s lack of B vitamins, calcium, iodine, iron, phosphorus, and vitamin E minerals provokes the development of dysplasia. The formation of musculoskeletal tissue in children begins after a month of fetal development. A significant part of babies with joint damage are born in the winter, due to the spring deficiency of vitamins in the diet of a pregnant woman and vitamin deficiency in a child;
4. Imbalance in metabolism and water-salt balance impedes the normal formation of tissues;
5. Diseases endocrine system and infectious during pregnancy, the use of drugs can cause complications in the child;
6. Hormonal disorders. Before giving birth, the female body produces more progesterone to relax the ligaments, muscles for the baby to pass through the birth canal. In excess, the hormone enters the baby's body, contributing to the weakness and deformation of the ligaments. In a newborn, the level of progesterone is normalized in the first days of life, the elasticity of the ligaments is restored and the dislocation can itself be corrected;
7. A violation of the development of the spinal cord is one of the common causes of the diagnosis of dysplasia in children up to a year;
8. Restriction of fetal movement during pregnancy due to increased muscle tone of the uterus or a small amount of amniotic fluid. Lack of activity prevents the normal formation of the musculoskeletal system;
9. The unfavorable environmental situation in some areas causes an increase in the incidence rate of newborns by 3-4 times compared with those who live in favorable conditions;
10. Tight swaddling up to a year contributes to the development of acquired dysplasia, especially in children with weak ligaments. As a result of a study of incidence in African countries, where children are almost not swaddled, Japan switched to swaddling or abandoned it. This allowed to reduce the level of the disease by almost 10 times.

Limited leg movement

The baby must be put on his back, bent his legs at the knees and spread in different directions, as in the photo, to get the pose of the "frog". At healthy baby this will not cause inconvenience, the knees almost touch the surface on which it lies.

This method of identifying deviations in the development of the hip joints in the baby gives more accurate results and is an important reason to see a doctor.

Bending the baby's leg or moving it to the side causes a clicking sound, which is caused by the reduction of the joint dislocation. In the reverse movement, the click is repeated.

This method is most reliable for the diagnosis of hip dysplasia in children up to a year. It allows you to identify the disease in the baby at an early stage, but with a mild illness, the symptoms disappear on the 8th day after birth. The presence of extraneous sounds, crunch during flexion-extension of the joint should alert parents.

If you bend your legs and put your feet on the surface where the baby is, the knees should be on the same level. On the affected joint side, one knee will be lower than the other. On this basis, it is difficult to identify bilateral dysplasia.

At the slightest suspicion, you need to see a doctor to rule out the symptoms of the disease, or start urgent treatment when confirming the ailment. To diagnose the disease, they often use x-ray or ultrasound.

If the diagnosis is not made at an early stage and treatment is not prescribed, other signs appear:

• Limping. Up to a year, most babies begin to walk, because of lameness a "duck gait" is formed.
• Pain in a deformed joint, especially when moving, which may be accompanied by crying, whims, and a clear unwillingness of the child to move.
• Deformation of the pelvic bones, which in severe cases leads to problems with internal organs.

CLASSIFICATION

• Acetabular dysplasia - deviations in the structure of the acetabulum. The cartilage of the limbus located at its edges is affected. The pressure of the femoral head causes its deformation, displacement and inversion in the joint. The capsule is stretched, cartilage is ossified and the femoral head is moved.
• Epiphyseal. This dysplasia of the hip joints in newborns is determined with joint stiffness, limb deformity, and pain. It is possible to change the diaphyseal angle in the direction of increase or decrease.
• Rotational dysplasia. The placement of the bones when viewed in the horizontal plane is incorrect, manifested with clubfoot.

• I degree - anticipation. Deviation of development, in which the muscles and ligaments are not changed, the head is inside the beveled cavity of the joint.
• II degree - subluxation. Inside the joint cavity is only part of the femoral head, as it is moving up. Ligaments are stretched and lose tension.
• III degree - dislocation. The femoral head is completely out of the cavity and is located higher. The ligaments are tensioned and stretched, and the cartilaginous rim enters the joint.

The classification of dysplasia is based on a violation of the development of a particular department of the hip joint. With acetabular pathology, the acetabulum is incorrectly formed - its size is reduced, and the cartilaginous rim is underdeveloped.

Also, children's orthopedists classify dysplasia of newborns depending on the severity of TBS underdevelopment. The degree of pathology always becomes a determining factor when choosing treatment methods.

SYMPTOMS

Each degree of TPA has its own characteristic features, by which it is possible to identify the presence of pathological changes in the composition of the hip joint.

photo Check for dyspalasia

I degree of TPA does not have pronounced symptoms - folds on skin integument in the region of the lower extremities are located symmetrically, both legs have the same length.

In case of DTS of the first degree, a characteristic click is observed in children during the breeding of the legs, indicating the entry of a wide part of the femur (head) into the acetabulum.

photo in a child 2 degree of dysplasia

II degree of TPA has the most pronounced symptomatic picture. Breeding the baby's legs to the side presents some difficulties - they cannot be completely bred. Normally, the baby's feet should touch the surface. A characteristic click is also heard when breeding and mixing the legs.

In addition to all this, an asymmetric arrangement of the folds on the skin surfaces of the lower extremities is observed, while on the thigh, where pathology is observed, the folds are located slightly higher and deeper.

A child may experience a difference in the length of the lower extremities - the leg, from which there is a pathology, is slightly shorter than the other. A characteristic sign of TPA of the II degree is also the unnatural position of the foot during sleep.

photo different leg length

When breeding the legs in different directions, an obstacle is felt that does not allow to separate them in different directions, while the click becomes loud. There is a jerking of the leg from the pathology during the breeding of the limbs.

The first signs of hip dysplasia in infants may appear when they reach the age of 2-3 months, but they need to be diagnosed even in a maternity hospital.

The main symptoms are:

Identification of at least one of the listed signs is a reason for contacting a pediatric orthopedist.

• violation of the search and sucking reflex;
• Muscle atrophy in the affected area;
• reduced pulsation of the femoral artery from the side of the altered joint;
• signs of torticollis.

Almost every 20 newborn children have a very serious pathology, which can cause disability in case of untimely diagnosis and the absence of appropriate treatment. And this pathology is called dysplasia of the hip joint (hereinafter TPA)

READ ALSO: Rehabilitation period after hip replacement

Signs of hip dysplasia can be divided into two large groups:

• characteristic clinical picture in children of the first year of life;
• symptoms inherent in children over the age of 12 months.

Grades 1 and 2 of hip dysplasia are very difficult to diagnose - there are no obvious signs, a pediatrician or orthopedist can pay attention to the manifestations during a routine examination.

But parents themselves must carefully monitor the appearance and behavior of the newborn. The following factors should alert :.

• asymmetric arrangement of folds on the buttocks and popliteal hollows;
• to part the legs bent at the knees is problematic;
• the child shows obvious discontent, cries loudly when breeding legs with bent knees.

In some cases, it is advisable to conduct an X-ray examination - the image will clearly show the slanting of the outer edge of the acetabulum and the flattening of its roof.

Hip dysplasia is manifested much more intensively in the 3rd degree of the course and with dislocation. In these cases, the following characteristic features will be present:

1. The symptom of the “click”. This sound is heard when the doctor or parent begins to raise legs bent at the knees, to the sides - the head of the femur at that moment begins to enter the articular cavity and does this with a characteristic click. During the reverse movement, the same sound is heard - the head of the femur again goes beyond the articular cavity.
2. Skin fold asymmetry. This symptom is checked in a child lying on his stomach and lying on his back. Pay attention not to the number of folds (it varies even among healthy children), but to their depth and height.

1. Breeding the legs to the side is limited. It is this symptom that allows you to diagnose hip dysplasia in newborns in the first 5-7 days of life with a confidence of 100%. Adhere to the following indicator: if the limitation reaches 50%, then the disease in question is definitely present.
2. Shortening of the relative leg. This symptom is checked as follows: they put the baby on the back, bend the legs in the knees and set them in feet to the table / sofa. In a healthy child, the knees will be on the same level, but if one knee is clearly higher than the other, this means the presence of a shortened leg.
3. Symptom Erlacher. His doctors determine by bringing the straightened leg of the newborn to another leg, then try to get the test limb behind the other (fold the legs crosswise). In a healthy newborn, the intersection of the legs occurs in the middle or lower thigh, with dysplasia of the hip joint this phenomenon is observed in the upper third of the thigh.

It is very easy to identify the disease in question for children older than 1 year of age - a characteristic feature is gait disturbance: the child limps on one leg if hip dysplasia develops on one side, or has a “duck” gait in case of pathology on both sides.

In addition, small forms of the gluteal muscles from the affected side will be noted, and if you press on the calcaneus, mobility will be noticeable from the foot to the femur (the child should lie on his back with legs straightened).

A more obvious sign of dysplasia is a symptom of slipping or clicking of Marx-Ortolani. For diagnosis, the child needs to be laid on the back.

In healthy babies, both knees touch the surface of the table. If there is a dislocation, then the head during the breeding of the legs will slip into the acetabulum.

In this case, the doctor will feel a push. If you let go of the divorced thigh, it will immediately begin to move in the opposite direction.

The symptom of slipping is not an unambiguous indicator of the disease, since it does not always occur.

If there is a dislocation, the amplitude of the abduction of the legs of the baby to the sides will be limited.

• In a healthy newborn, the bent leg can be taken to the side at an angle of 80-90 degrees.
• Accordingly, both divorced legs form an angle of almost 180 degrees.
• If the legs are divorced no more than 40-50 degrees each, then the doctor will suspect a congenital dislocation of the hip. The presence of a defect is also indicated by the incomplete abduction of one or both legs.
• A clear sign of dislocation is the marked difference between the length of the femur of the infant. If you bend the baby's legs at the knees and connect them together, one knee will be higher than the other. The hip joint defect will be on the side where the knee is lower.
• The sooner dysplasia is detected, the easier it is to cure it. Doctors examine a newborn right after birth in the hospital.

The main symptoms are:

• Restriction during the removal of an unhealthy thigh is characteristic for the II and III degrees of dysplasia. In healthy children, legs bent at the knees are easily bent to the sides at an angle of 80–90 degrees. Pathological changes prevent this, and they can be bred no more than 60 degrees.
• Asymmetry of the folds under the knees, buttocks and groin. Normally, they are symmetrical and of the same depth. Attention should be paid if, in the supine position, the folds on one side are deeper and higher. This symptom is not considered objective, since it cannot indicate a problem with bilateral dysplasia. For many children, the pattern of folds is aligned by three months.
• Symptom of slipping, or clicking. The femoral head slides when moving, this is accompanied by a characteristic click when breeding or bringing legs. Such a sign is reliable symptom deviations 2-3 weeks after the birth of the baby. When examining children of a different age, this method is not informative.
• Shortening of one leg is a reliable sign of dysplasia and is detected when the kneecaps are combined in the supine position. This symptom may indicate a formed hip dislocation.
• Late standing, improper walking can be observed already in the last stages of hip dysplasia.

Diagnostics

It is customary to distinguish three stages of a child's dysplasia - a subluxation, a subluxation of the hip joint and a dislocation of the hip joint. The first stages are more or less painless for the baby, but they lead to a dislocation, which provokes pain in children when walking and a pathological change in gait and posture.

We describe the main symptoms and the treatment used at different stages of the dysplasia of the newborn.

A newborn with an early stage of dysplasia is almost indistinguishable from a healthy child. Symptoms are not very pronounced: there is no asymmetry of the skin folds on the legs and buttocks. The legs of the newborn are the same in size.

Diagnostics initial stage Dysplasia is not difficult, and it can be done by the parents themselves at home: if you put the baby face up and legs apart slightly on the sides, manifestations of the femoral head entering the acetabulum will begin - a slight obstacle will be felt and a slight crunch will occur.

If dysplasia is detected at the stage of pre-dislocation - this is very good, as it is easily fixable. You can cure with the simplest measures:

1. Massotherapy.
2. Improving gymnastics.
3. Electrophoresis
4. Wide swaddling baby.

If dysplasia is in the stage of dislocation, then you can get by with therapeutic massage

The next stage of dysplasia of an infant and an older child is a subluxation of the hip joint. At this stage appear:

1. The asymmetry of the folds on the skin of the legs and buttocks baby.
2. The legs of the newborn are divorced with difficulty.
3. Legs visually seem different.
4. During leg breeding, a click appears.
5. The child shows signs of discomfort while kicking.

If there are suspicions of a subluxation during a physical examination, then it will be necessary to do an ultrasound or ultrasonography - this will confirm the diagnosis. As for the treatment, with pelvic displacement of the second stage, massage, gymnastics, electrophoresis, the use of orthopedic devices to fix the desired position of the joint are used (Freyk pillow, Becker corset, Pavlik stirrups, Volkov bus and other devices).

The third, complicated stage of dysplasia is a dislocation of the hip composition. Symptoms of dislocation are exactly the same as the above symptoms of subluxation, only much more pronounced. To them is added pain when moving.

For the treatment of dislocation, hip reduction and subsequent fixation with orthopedic devices are used. Quite often, an operation is prescribed. After the dislocation is repaired (when the orthopedist puts the hip joint in place), it is necessary to undergo a course of rehabilitation procedures - this can be electrophoresis, massage, gymnastics.

Please note that the listed methods of treatment are conditional. In each case, depending on the degree of dysplasia, the treatment program is determined only by the doctor (it is dangerous for the parents to take any action without consulting a specialist).

In a baby, signs of hip dysplasia in the form of a dislocation can be diagnosed in the maternity hospital. A neonatologist should carefully examine the child for such abnormalities in certain pregnancy complications.

The risk group includes children who belong to the category of large, toddlers with deformed feet and heredity burdened by this criterion. In addition, attention is paid to toxicosis of pregnancy in the mother and gender of the child. Newborn girls are subject to mandatory examination.

• External examination and palpation is performed to identify characteristic symptoms of the disease. In infants, hip dysplasia has signs of both dislocation and subluxation, which are clinically difficult to detect. Any symptoms of deviations require a more detailed instrumental examination.
• Ultrasound diagnostics is an effective method for detecting deviations in the structure of joints in children in the first three months of life. Ultrasound can be performed repeatedly and is allowed during the examination of newborns. The specialist pays attention to the condition of the cartilage, bones, joints, calculates the angle of the deepening of the hip joint.
• The x-ray is not inferior in reliability ultrasound diagnosisbut has a number of significant limitations. The hip joint in children under seven months of age is poorly visible due to the low level of ossification of these tissues. Children in the first year of life are not recommended for radiation. In addition, it is problematic to lay a rolling baby under the apparatus in compliance with symmetry standards.
• CT and MRI provides a complete picture of pathological changes in the joints in various projections. The need for such an examination appears when planning an surgical intervention.
• Arthroscopy, arthrography are performed in severe, advanced cases of dysplasia. These invasive methods require general anesthesia to obtain detailed information about the joint.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Bilateral inguinal hernia without obstruction or gangrene (K40.2), Unilateral or unspecified inguinal hernia without obstruction or gangrene (K40.9)

Gastroenterology for children, Pediatrics, Surgery for children

general information

Short description

Approved
Joint Quality Commission medical services
Ministry of Health of the Republic of Kazakhstan
dated June 29, 2017
Protocol No. 24

Inguinal hernia- This is a pathological protrusion of the hernial sac (vaginal process of the peritoneum) together with the hernial contents (loop of the intestine, lock of omentum or ovary) in the inguinal region.

Congenital inguinal hernias in children are a local manifestation of mesenchymal insufficiency syndrome. Inguinal hernias in childhood are usually oblique, that is, they pass through the inguinal canal through its internal and external openings. Structural anatomy of a hernia includes: hernial gates - defects of the abdominal wall of congenital or post-traumatic genesis; hernial sac - a stretched sheet of parietal peritoneum; hernial contents - abdominal organs displaced into the hernial sac. The hernial sac is a partially or completely non-obliterated vaginal process of the peritoneum.

INTRODUCTION

ICD-10 code (s):

Protocol development / revision date:2017 year.

Abbreviations used in the protocol:

ALT	alanine aminotransferase
AST	aspartate aminotransferase
APTTV	activated partial thromboplastin time
HIV	aIDS virus
UPU	congenital heart disease
INR	international normalized attitude
ICD	international classification of diseases
Jab	general analysis blood
OAM	general urine analysis
Ultrasound scan	ultrasound procedure
ECG	electrocardiography
ECHOKG	echocardiography

Protocol Users: pediatric surgeons, general practitioners.

Evidence Scale:

AND	High-quality meta-analysis, systematic review of RCTs or large-scale RCTs with a very low probability (++) of systematic error, the results of which can be disseminated to the corresponding population.
IN	A high-quality (++) systematic review of cohort or case-control studies or a high-quality (++) cohort or case-control studies with a very low risk of systematic error or RCTs with a low (+) risk of systematic error, the results of which can be disseminated to the corresponding population .
FROM	A cohort or case-control study or a controlled study without randomization with a low risk of systematic error (+), the results of which can be distributed to the corresponding population or RCTs with a very low or low risk of systematic error (++ or +), the results of which cannot be directly distributed to the relevant population.
D	A description of a series of cases or an uncontrolled study or expert opinion.
GPP	Best clinical practice

Classification

Classification:

I. By etiology:

1) Congenital inguinal hernia;
2) Acquired inguinal hernia.

II. In relation to the inguinal ring:
1) Oblique inguinal hernia;
2) Direct inguinal hernia.

III. Depending on the level of obliteration of the vaginal process of the peritoneum and the projection of the hernial sac:
1) inguinal;
2) inguinal and scrotal;
a) rope;
b) testicular.

IV. By localization:
1) Right;
2) Left-handed;
3) Two-way.

V. Recurrent.
Also, hernias that are corrected (when the contents of the hernial sac are freely inserted into the abdominal cavity), irreducible and restrained are also distinguished. Irreversible inguinal hernias do not cause acute clinical manifestations and are rarely found, more often in girls with fixation of the ovary to the wall of the hernial sac. Injured inguinal hernias due to compression in the aponeurotic ring of the contents of the hernial sac and disturbances in the blood supply to the restrained organ are manifested by an acute symptom complex.
Depending on the structure of the hernial sac, a sliding inguinal hernia can be distinguished. In this case, the organ wall (for example, the bladder, the ascending colon) becomes one of the walls of the hernial sac.
Congenital inguinal hernia is predominantly one-sided, and on the right 3 times more often and is observed mainly in boys. Among the inguinal-scrotal hernia, the most common are hernia (90%), with the vaginal process not obliterated in the upper and middle parts, but separated from the lower which formed the testicular membrane itself. With testicular hernia, observed in 10% of cases, the peritoneal process remains non-obliterated throughout, therefore it is sometimes mistakenly believed that the testicle lies in the hernial sac. In fact, it is separated from it by serous membranes and only extends into its lumen.
Acquired inguinal hernias in children are extremely rare, usually in boys over 10 years old with increased physical exertion and severe weakness of the anterior abdominal wall.
Direct inguinal hernias in children are formed extremely rarely and in the vast majority of cases are associated with congenital or iatrogenic pathology of the anterior abdominal wall.

Diagnostics

DIAGNOSTIC AND TREATMENT METHODS, APPROACHES AND PROCEDURES

Diagnostic criteria

Complaints:on tumor-like protrusion in the inguinal, inguinal and scrotal region.

Medical history:the reason for the examination is a dispensary examination of children or complaints of parents about the periodic appearance of a tumor-like formation in the inguinal region or an increase in the size of the scrotum.

Physical examinations:
On examination: the clinical picture of an uncomplicated inguinal hernia is manifested by the presence of a tumor-like formation in the inguinal region, increasing with screaming and anxiety and decreasing or disappearing in a calm state. The protrusion has a rounded (with inguinal) or oval (with inguinal-scrotal hernia) shape.
On palpation elastic consistency, painless, hernial protrusion disappears on its own when the patient moves to a horizontal position, or as a result of finger pressure. At the same time, a distinctive rumbling is clearly audible. After the hernia contents are repositioned, the expanded external inguinal ring is palpated.

In girls, the protrusion in an inguinal hernia has a rounded shape and is determined by the external inguinal ring. With a large hernia, the protrusion can fall into the labia majora.
Older children are examined in a standing position, with tension of the abdominal muscles, coughing.

Laboratory research:not.

Instrumental research (UD - V):
· Ultrasound procedure inguinal, scrotum.

The list of necessary studies for planned hospitalization:
· general blood analysis;
· general urine analysis;
· biochemical analysis blood (total protein and its fractions, urea, creatinine, ALT, AST, glucose, total bilirubin and its fractions, amylase, potassium, sodium, chlorine, calcium);
Coagulogram (prothrombin time, fibrinogen, thrombin time, INR, APTT);
· Blood test for hepatitis B, C;
Blood test for HIV;
Feces on worm eggs
· ECG - to exclude heart pathology before the upcoming operation;
· ECHOCG - if there is a suspicion of an CHD
· Consultation of narrow specialists - according to indications (anemia-hematologist, pathology of the heart-cardiologist, etc.).

Indications for expert advice:
· Consultation of narrow specialists - according to indications.

Diagnostic Algorithm:

Differential diagnosis

Differential diagnosis and justification of additional studies:

Diagnosis	The rationale for differential diagnosis	Surveys	Diagnosis exclusion criteria
Unstressed (uncomplicated) inguinal hernia		Physical examination. Diaphanoscopy Ultrasound of the inguinal region	A tumor-like protrusion that increases with screaming and anxiety and decreases or disappears when calm. "Rumbling" with a finger board. Elastic consistency. The external inguinal ring is expanded. Diaphanoscopy is negative. Ultrasound - intestinal loops, enlarged inguinal ring.
Dropsy of testicular membranes	The presence of tumor-like protrusion in the inguinal, inguinal and scrotal region	Physical examination. Symptom of diaphanoscopy. Ultrasound of the inguinal region	Tight-elastic consistency, cystic nature. In the morning, smaller, flabby in the evening increases, it becomes tense. Diaphanoscopy is positive. Ultrasound - liquid contents, the external inguinal ring is not expanded.

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Treatment

Treatment (outpatient clinic)

Outpatient treatment tactics : these patients are treated only at the inpatient level. Before surgery, at the stage of preparation for surgical treatment - wearing a special bandage, for older children it is recommended to avoid physical exertion, the exclusion of factors that increase intra-abdominal pressure (prevention of cough, constipation).

Non-drug treatment:not.

Mdrug treatment: in the absence of complications, drug therapy is not indicated.

List of essential and complementary medicines: not.

Surgical intervention:not.

Further maintenance:
· Referral of children to a surgical hospital for elective surgery.

not.

Treatment (hospital)

STATIONARY TREATMENT TACTICS : the only radical method for treating inguinal hernia is surgical.

Non-drug treatment:
· Mode ward, in the early postoperative period - bed.
· Age Diet: breastfeeding, table No. 16, 15.

Mdrug treatment (see table 1 below):
Anesthetic therapy
Symptomatic therapy.

Essential Medicines List:
· Analgesia by non-narcotic analgesics - for adequate pain relief in the postoperative period.

Surgical intervention:
· Hernia repair.
Indications:
· Clinical and instrumental confirmation of the diagnosis of inguinal hernia.
Contraindications:
Acute inflammation of the upper respiratory tract;
Sharp infectious diseases;
Severe hypotrophy, rickets;
Hyperthermia of unknown etiology;
Purulent and inflammatory changes in the skin;
absolute contraindications from the cardiovascular system.

Further maintenance:
School children after discharge home are exempted from classes for 7-10 days and from physical activity for 2 months. Subsequently, the follow-up of the surgeon is necessary for the child, since in 3.8% of cases there are relapses of the hernia, requiring repeated surgery.

Indicators of treatment effectiveness:
· Disappearance after surgery of the manifestation of hernia;
Healing postoperative wounds primary intention;
· The absence of ligature fistulas in the long-term postoperative period and the manifestation of hernia recurrence.

Table 1.Comparison chart of drugs:

№ p / p	Name of the drug	Route of administration	Dose and frequency of use (number of times per day)	UD, link
1	Paracetamol	v / m, iv, peros, rectally	Inside.Premature births at the 28-32th non-gestation - 20 mg / kg as a single dose, then 10-15 mg / kg every 8-12 hours as needed; maximum 30 mg / kg daily, divided into several doses. - 20 mg / kg in a single dose, then 10-15 mg / kg every 6-8 hours as needed; maximum - 60 mg / kg daily, divided into several doses. 1-3 months - 30-60 mg every 8 hours as needed; with serious symptoms - 20 mg / kg as a single dose, then 15-20 mg / kg every 6-8 hours; maximum - 60 mg / kg daily, divided into several doses. 3-12 months - 60-120 mg every 4-6 hours (maximum - 4 doses within 24 hours); with serious symptoms - 20 mg / kg every 6 hours (maximum 90 mg / kg daily, divided into several doses) for 48 hours (or longer if necessary; if adverse effects are excluded, then 15 mg / kg every 6 hours) . Rectally. Prematurity born on 28-32th non-gestation - 20 mg / kg in a single dose, then 15 mg / kg every 12 hours as needed; maximum - 30 mg / kg daily, divided into several doses. Newborns born on more than 32nd non-gestation - 30 mg / kg as a single dose, then 20 mg / kg every 8 hours as needed; maximum - 60 mg / kg daily, divided into several doses. 1-3 months - 30-60 mg every 8 hours as needed; with serious symptoms - 30 mg / kg as a single dose, then 20 mg / kg every 8 hours; maximum - 60 mg / kg daily, divided into several doses. 3-12 months - 60-120 mg every 4-6 hours (maximum - 4 doses within 24 hours); with serious symptoms - 40 mg / kg once, then 20 mg / kg every 4-6 hours (maximum 90 mg / kg daily, divided into several doses) for 48 hours (or longer if necessary; if adverse effects are excluded, then 15 mg / kg every 6 hours). 1-5 years - 120-250 mg every 4-6 hours as needed (maximum 4 doses over 24 hours); for serious symptoms - 40 mg once, then 20 mg / kg every 4-6 hours (maximum 90 mg / kg daily, divided into several doses) for 48 hours (or longer if necessary; if adverse effects are excluded, then 15 mg / kg every 6 hours). 5-12 years old - 250-500 mg every 4-6 hours as needed (maximum - 4 doses within 24 hours); with serious symptoms - 40 mg / kg (maximum 1 g) once, then 20 mg / kg every 6 hours (maximum 90 mg / kg daily, divided into several doses) for 48 hours (or longer if necessary; if adverse effects are excluded, then 15 mg / kg every 6 hours). 12-18 years old - 500 mg every 4-6 hours (maximum - 4 doses within 24 hours); with serious symptoms - 0.5-1.0 g every 4-6 hours (maximum - 4 doses per day in several doses). 1-5 years - 120-250 mg every 4-6 hours (maximum - 4 doses within 24 hours); with serious symptoms, 20 mg / kg every 6 hours (maximum 90 mg / kg daily, divided into several doses) for 48 hours (or longer if necessary; if adverse effects are excluded, then 15 mg / kg every 6 hours) . 6-12 years old - 250-500 mg every 4-6 hours (maximum - 4 doses within 24 hours); with serious symptoms - 20 mg / kg (maximum - 1 g) every 6 hours (maximum 90 mg / kg daily, divided into several doses, not more than 4 g per day) for 48 hours (or longer if necessary; if excluded adverse effects, then 15 mg / kg every 6 hours, maximum 4 g daily). 12-18 years - 500 mg every 4-6 hours (maximally - 4 doses within 24 hours); with serious symptoms - 0.5-1.0 g every 4-6 hours (maximum - 4 doses within 24 hours).	IN
2	Ibuprofen	v / m, iv, peros, rectally	. Children under 2 years of age are contraindicated drops for oral administration, up to 3 months - suspension for oral administration, up to 12 years - prolonged action capsules. . Pain syndrome of mild to moderate intensity, febrile syndrome; pain and inflammation in soft tissue lesions. ◊ Inside. 1-6 months, with a body weight of more than 7 kg: 5 mg / kg 3-4 times a day; the maximum daily dose is 30 mg / kg. 6-12 months: 5-10 mg / kg (average 50 mg) 3-4 times a day, in severe cases, 30 mg / kg × day is prescribed for 3-4 doses. 1-2 years: 50 mg 3 times a day, in severe cases, 30 mg / kg × day is prescribed for 3-4 doses. 2-7 years: 100 mg 3 times a day, in severe cases, 30 mg / kg × day is prescribed for 3-4 doses. Age 7-18 years: the initial dose is 150-300 mg 3 times a day (maximum daily dose - 1 g), then 100 mg 3 times a day; in severe cases, 30 mg / kg × day is prescribed for 3-4 doses. For fever with a body temperature above 39.2 ° C, 10 mg / kg × day is prescribed; at a body temperature below 39.2 ° C, 5 mg / kg × day.	IN

Hospitalization

INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF TYPE OF HOSPITALIZATION

Indications for planned hospitalization:
· Children with diagnosed inguinal hernia in the absence of absolute contraindications for surgery;
· The age of the child - modern methods of analgesia allow you to perform an operation at any age, starting from the neonatal period. According to relative contraindications (past diseases, malnutrition, rickets, etc.) in uncomplicated cases, the operation is transferred to an older age (6-12 months).

Indications for emergency hospitalization:
Clinic of a restrained inguinal hernia.

Information

Sources and literature

1. Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2017
   1. 1) Yu.F. Isakov, A.Yu. Razumovsky. Children's Surgery - Moscow, 2015 - S. 523-525 2) Pediatric Surgery: Diagnosis and Treatment Christopher P. Coppola, Alfred P. Kennedy, Jr., Ronald J. Scorpio. Springer, 2014; 207. 3) Daniel H Teitelbaum, Hock Lim Tan, Agostino Pierro. Operative pediatric surgery Seventh edition. CRCPress, 2013; 277-288 4) P. Puri, M. Golvart. Atlas of Pediatric Surgical Surgery. Translation from English edited by T.K. Nemilova. 2009, p. 153-159. 5) Edoscopic surgery in children. A.F. Dronov, I.V. Poddubny, V.I. Kotlobovsky. 2002 - S. 208-212. 6) K.U. Ashcraft, T.M. Holder "Pediatric Surgery" Hardford. St. Petersburg 1996. Translation from English edited by T.K. Nemilova. Page 251-260. 7) Yu.F. Isakov, A.F. Dronov Pediatric Surgery National Guide. Moscow 2009, pp. 685-690. 8) Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial. Gause CD, Casamassima MG, Yang J., etc. PediatrSurg Int. 2017 Mar; 33 (3): 367-376. 9) Chan KL, Hui WC, Tam PKH. Prospective, randomized, single-center, single-blind comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surgical Endoscopy 2005; 19: 927-32. 10) Melone JH, Schwartz MZ, Tyson DR et al. Outpatient inguinal herniorraphy in premature infants: is it safe? Journal of Pediatric Surgery 1992; 27: 203-8. 11) Niyogi A. Tahim AS, Sherwood WJ et al. A comparative stady e)