Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This condition is frequently seen in both girls & boys. This is noticed soon after birth when the umbilical cord falls off. There is a bulge in the region of the umbilicus with skin cover. The swelling increases when the child cries or strains, and may or may not be seen when the child is sleeping or lying quietly.
During the formation (embryology) , the fetus is formed by 4 folds which come together to meet at the future umbilicus. If, there is any delay or pause in the closure, there remains a gap through which the contents of the abdomen can come out. Thus when the child cries or increases the abdominal pressure – the intestines come out thru this gap or hole in the region of the umbilicus, and may go back inside when the pressure comes to normal.
Left to itself in the natural course of events, this gap may automatically narrow with passage of time and may ultimately close totally. In such cases there is no need for any surgical intervention. However there is no way to predict which ones will close and when. During the period when we are waiting for the natural process, there may be complications – like the intestines coming out thru the gap beneath the skin and then not being able to go back – irreducibility. This will give pain at first, then the obstruction to the contents within the intestines from progressing forward, leading to vomiting. If this continues for a longer period of time, then the intestines proximal to those that are obstructed start getting dilated . Still further the blood supply to the intestines which are stuck may gradually get squeezed between the edges of the gap in the muscle and this will lead to gangrene of the intestines and gross infection, at times perforation of the intestines. If the complication can be tided over by early diagnosis and manual reduction by a doctor then there is no harm done. If the obstructed hernia is not reducible then an emergency surgery needs to be done to reduce the hernia and then to repair the defect. Even after the complication is tided over by manual reduction, there is now no reason to wait any further and as soon as possible, the hernial defect must be closed at the earliest.
Umbilical & inguinal hernia
Umbilical hernias with a small ring diameter (< 1 cms) are more likely to close spontaneously and sooner than those with a larger diameter ( >1.5 ms). The diameter is more important than the length of the protrusion of the umbilical hernia. Thus, unless a complication occurs or the child is above 3 years and the defect is still patent, there is no hurry to surgically repair the hernia. There is NO ROLE for a coin, belt or truss over the umbilical defect to enhance the closure – this is very dangerous and could cause complications like a small piece of bowel gets pinched between the coin or belt and the skin and could lead to a perforation of the intestine.
Gap in the muscles seen –rounded edges
Surgery when required is usually a day care or maximum 2 day stay surgery. The child is brought to the hospital on the day of operation in the morning. The surgery is done preferably as the first case of the day so that fasting is minimum during waking period of the child. If all goes well, the child can be sent home the same night or may have to stay over at the hospital for the night and leave by next day afternoon. The surgery is done under general anesthesia so the child is totally not conscious of what is happening. A small subumbilical incision is taken and the sac of the hernia is isolated and separated till the muscle edges are seen on both sides. After reducing all the contents into the abdominal cavity, the 2 edges of the muscle are brought together in the midline with multiple non absorbable sutures. The skin is then closed to make the umbilicus look like before minus the protrusion. And looks cosmetically pleasing especially in girls and the scar of the operation is hardly visible in later years of life.
Gap seen on the right and after closing the muscles with sutures
Complications that can occur after the surgery are recurrence, wound infection. Recurrence can occur if the sutures give way partly or totally. Local infection in the wound can occur with or without formation of pus.
Last Updated: 27th January 2009