Abdominal Wall Hernia in Pediatrics

Yu Qiang Ng, MD and Feng Na Zheng, MD
The Operative Review of Surgery. 2023; 1:224-227.

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Table of Contents

Umbilical Hernia
Inguinal Hernia

References

Umbilical Hernia

Natural History

  • All Infants Have a Fascial Defect at Birth from Placental Vessels
  • 10-30% Have a Hernia at Birth 1
  • Most (90%) Close Spontaneously by 4-5 Years Old 2

Risk Factors 3-5

  • Black Race
  • Premature or Low Birth Weight
  • Ehlers-Danlos
  • Beckwith-Wiedemann Syndrome
  • Down Syndrome
  • Trisomy 18
  • Mucopolysaccharidoses
  • Hypothyroidism

Presentation

  • Bulge at the Umbilicus
  • The Vast Majority are Asymptomatic
  • Can Interfere with Feeding
  • Incarceration is Rare in Pediatrics (0.07-0.3%) 4,6,7

Diagnosis

  • Clinical Diagnosis
  • Consider Abdominal US if Uncertain

Treatment

  • General Treatment: Delay Surgical Repair Until 4-5 Years Old (Before Entering School) 8
    • *Do Not Use Mesh
  • Indications for Early Repair:
    • Symptomatic
    • Large Defects > 2 cm (Tend to Enlarge with Risk for Developing a Large Proboscoid Hernia with Poor Cosmetic Outcome) 9
    • Emergent Indications – Acute Incarceration or Strangulation

Umbilical Hernia in Adults

Proboscoid Umbilical Hernia 10

Inguinal Hernia

Incidence and Epidemiology

  • 3-5% in Term Infants 11,12
  • 9-13% in Premature Infants 11,12
  • Most Common in Boys (6:1) 13
  • More Common on the Right – Later Descent of the Testicle and Obliteration of the Processus Vaginalis on the Right 14
    • 60% are on the Right
    • 30% on the Left
    • 10% are Bilateral
  • Almost All are Indirect Due to a Persistent Processus Vaginalis

Presentation

  • Intermittent Bulge
  • Most are Asymptomatic
  • Higher Risk of Incarceration (14-31%) 4,15

Diagnosis

  • Often a Clinical Diagnosis
    • Inguinal Mass is Frequently Not Present on Examination 5
    • May or May Not Transilluminate
    • “Silk Glove Sign” – Palpation of the Cord Resembles the Friction of Rubbing Pieces of Silk Together from the Opposing Peritoneal Membranes of the Empty Hernia Sac 16
  • Consider Scrotal US if Uncertain

Treatment

  • Treatment: Reduce First, Then Surgical Repair 17
    • Reducible: Elective Repair in 1-3 Days (Allow Edema Dissipation)
    • Incarcerated: Emergent Repair
  • Surgical Repair: High Ligation and Excision of the Hernia Sac/Processus Vaginalis
    • Laparoscopic Repair is Being Increasingly Used 18
    • Consider Contralateral Exploration at the Same Time (Debated) 19
    • *Do Not Use Mesh
  • Sex Considerations:
    • Males: Examine the Scrotum and Palpate at the End of the Procedure – High Ligation Risks Pulling the Testicle into the Inguinal Canal
    • Females: Inspect the Proximal Sac for Sliding Contents – May Contain Fallopian Tube, Ovary, Uterus, Bowel, or Bladder 20

Inguinal Hernia in Adults

References

  1. Burcharth J, Pedersen MS, Pommergaard HC, Bisgaard T, Pedersen CB, Rosenberg J. The prevalence of umbilical and epigastric hernia repair: a nationwide epidemiologic study. 2015 Oct;19(5):815-9.
  2. Laje P. Umbilical Hernia. Children’s Hospital of Philadelphia.
  3. Evans AG. The Comparative Incidence of Umbilical Hernias in Colored and White Infants. J Natl Med Assoc. 1941 Jul;33(4):158-60.
  4. Abdulhai SA, Glenn IC, Ponsky TA. Incarcerated Pediatric Hernias. Surg Clin North Am. 2017 Feb;97(1):129-145.
  5. Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann. 2001 Dec;30(12):729-35.
  6. Papagrigoriadis S, Browse DJ, Howard ER. Incarceration of umbilical hernias in children: a rare but important complication. Pediatr Surg Int. 1998 Dec;14(3):231-2.
  7. Okada T, Yoshida H, Iwai J, Matsunaga T, Ohtsuka Y, Kouchi K, Ohnuma N. Strangulated umbilical hernia in a child: report of a case. Surg Today. 2001;31(6):546-9.
  8. Zens T, Nichol PF, Cartmill R, Kohler JE. Management of asymptomatic pediatric umbilical hernias: a systematic review. J Pediatr Surg. 2017 Nov;52(11):1723-1731.
  9. Bowling K, Hart N, Cox P, Srinivas G. Management of paediatric hernia. 2017 Oct 19;359:j4484.
  10. Ashu EE, Leroy GM, Aristide BG, Joss BM, Bonaventure J, Patrick SE, Myriam FG. Double half-cone flap umbilicoplasty for proboscoid umbilical hernia in a 2 years old child with satisfactory results 2 years later. Pan Afr Med J. 2015 Sep 17;22:44. (License: CC BY 2.0)
  11. Kasper S. Wang, COMMITTEE ON FETUS AND NEWBORN, SECTION ON SURGERY, Lu-Ann Papile, Jill E. Baley, William Benitz, James Cummings, Waldemar A. Carlo, Praveen Kumar, Richard A. Polin, Rosemarie C. Tan, Kristi L. Watterberg, Mary L. Brandt, Robert C. Shamberger, Michael G. Caty, Kurt F. Heiss, George W. Holcomb, Rebecka L. Meyers,  Lawrence Moss, Frederick J. Rescorla; Assessment and Management of Inguinal Hernia in Infants. PediatricsOctober 2012; 130 (4): 768–773.
  12. Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J Surg. 1989 Sep-Oct;13(5):506-15.
  13. Chang SJ, Chen JY, Hsu CK, Chuang FC, Yang SS. The incidence of inguinal hernia and associated risk factors of incarceration in pediatric inguinal hernia: a nation-wide longitudinal population-based study. Hernia. 2016 Aug;20(4):559-63.
  14. Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review. J Pediatr Surg. 2006 May;41(5):980-6.
  15. Zamakhshary M, To T, Guan J, Langer JC. Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery. CMAJ. 2008 Nov 4;179(10):1001-5.
  16. Aneiros Castro B, Cano Novillo I, García Vázquez A. The Accuracy of Silk Glove Sign Compared with Inguinal Bulge in the Diagnosis of Indirect Inguinal Hernia in Children. J Laparoendosc Adv Surg Tech A. 2019 Oct;29(10):1349-1351.
  17. Yeap E, Pacilli M, Nataraja RM. Inguinal hernias in children. Aust J Gen Pract. 2020 Jan-Feb;49(1-2):38-43.
  18. Esposito C, Escolino M, Turrà F, Roberti A, Cerulo M, Farina A, Caiazzo S, Cortese G, Servillo G, Settimi A. Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era. Semin Pediatr Surg. 2016 Aug;25(4):232-40.
  19. Wang KS; Committee on Fetus and Newborn, American Academy of Pediatrics; Section on Surgery, American Academy of Pediatrics. Assessment and management of inguinal hernia in infants. Pediatrics. 2012 Oct;130(4):768-73.
  20. Ohkura T, Kumori K, Kawamura T, Manako J, Ishibashi S, Funabashi N, Tajima Y. Association of pediatric inguinal hernia contents with patient age and sex. Pediatr Int. 2022 Jan;64(1):e15193.