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192 A. Shalaby and J. Curry
analgesia. The latter is achieved with morphine. The dose is
0.1 mg/kg given intravenously to infants or 0.2 mg/kg as an
oral preparation for children over 6 months of age. The dose
should be reduced 0.025 mg/kg for the premature infant.
Midazolam 0.1 mg/kg may be added for the older child. The
respiration and pulse must be monitored. After allowing adequate time for the infant to settle, spontaneous reduction may
occur; if not, gentle bimanual compression is usually successful in reduction. Ipsilateral hip fl exion with external rotation aids in the ability to achieve reduction. The pressure
should be gentle and sustained: a gurgling sensation will
indicate emptying of the bowel and subsequent reduction.
An elective repair can then be scheduled in 24–48 h [
25 ] . This time allows some resolution of the edema, mini-
mizing the dif fi culty of the dissection and decreasing the risk
of complications.
Failure to reduce the hernia is an indication for an immediate operation. The operative approach is that for the elective procedure, but the external inguinal ring must be opened
to allow reduction of the contents of the hernia. Further operative management is determined by the viability of the intestine. If the incarcerated intestine is viable, it is reduced into
the abdominal cavity and a high ligation of the sac is performed. If, on the other hand, the intestine is no longer viable, it should be resected, either through the sac or through a
separate entry into the peritoneal cavity via the same skin
incision. An incarcerated hernia in an infant is technically
more dif fi cult and has a higher complication rate since the
hernial sac is typically edematous and fragile. The testicular
vessels and the vas deferens are particularly susceptible to
injury because of the edema and often-dif fi cult dissection.
These procedures are safest in the hands of experienced
surgeons.
The complication rate in patients with incarcerated hernia
has been reported to range from 11 to 31% [ 18 ] . Reducible
incarcerated hernias have a complication rate of 4.5%, compared to 33% for those that were irreducible and required an
emergency operation [
noted a slightly higher complication rate in very low-birthweight infants younger than 2 months of age at the time of
their operation.
9 ] . Rescorla and Grosfeld (1984) [ 9 ]
1, 18,
Incarcerated Ovary
The management of an asymptomatic irreducible ovary is
unclear. In a survey of the variability of technique in inguinal
hernia management and repair, Levitt et al. (2002) found that
management of an incarcerated non-tender ovary still varied
from repair at the fi rst available elective time (50%), repair
that week (28%), or repair that day as an emergency (10%)
[ 37 ] . The herniated ovary and fallopian tube are at a risk of
vascular compromise either due to incarceration or, more
likely, torsion. The reported incidence of strangulated irreducible ovaries is as high as 32% [
ion that the risk to the ovary is indeed signi fi cant and should
be managed as an emergency.
5 ] . It is therefore our opin-
Metachronous Hernia
If patients are observed after ipsilateral hernia repair, a
metachronous hernia will appear on the contralateral side
from 1 to 31% of the time [ 38 ] . Exploration of the asymp-
tomatic side was designed to detect a PPV or nonevident
clinical hernia. The goals of identifying these two entities are
to avoid a second anesthesia, minimize parental and patient
inconvenience, avoid the chance of incarceration, and reduce
costs. However, there is no current support for contralateral
exploration in any child with a unilateral inguinal hernia and
a clinically normal, asymptomatic contralateral groin [ 39,
40 ] . Furthermore, contralateral exploration is not done in
cases of incarceration [ 9 ] .
In 2007, a systematic review on the risk of developing a
metachronous contralateral inguinal hernia (MCIH) acknowledged that “the success of contralateral exploration cannot
be measured by how many PPVs are closed, but by how
many MCIHs are prevented” [ 41 ] . The results of the review
stated that the risk of MCIH for all children having open hernia repair is 7.2%. Overall, 14 contralateral explorations
would be required to prevent one metachronous hernia. In
boys younger than 2 years, the ratio is still high [ 41 ] .
Laparoscopy has offered the advantage of closing an incidentally found PPV. Interestingly, some cases in which the
contralateral side was deemed closed on laparoscopy were
noted to develop an inguinal hernia at a subsequent time
(authors’ experience).
Premature Infants
It is a well-established fact that premature infants have a
higher incidence of inguinal hernias and are likely to have a
bilateral presentation. It is known that the more premature
the infant, the higher the incidence of an inguinal hernia.
Premature infants also show an increased risk of postoperative life-threatening apnea after inguinal hernia repair [ 20,
42 ] . Unlike older children who may be treated on a day-case
basis, monitoring of these high-risk infants for 12–24 h after
operation is recommended [ 20 ] .
The optimal timing of surgical repair in these neonates is
controversial [ 25 ] . In a small premature infant, the operation
is technically more dif fi cult and associated with a higher
morbidity. Furthermore, the anesthetic risk is higher in a premature infant. For those already admitted to a neonatal intensive care unit, it has been suggested that they should have
19311 Inguinal Hernias in Children
their hernia repaired before discharge [ 1 ] , but this is a sim-
plistic proposal. Many factors such as gestational age, birth
weight, actual weight, comorbidities, pulmonary status, and
history of incarceration are all factors that should be taken
into consideration in order to formulate an individualized
approach to determine the optimal time for surgical repair
[
25 ] . For infants diagnosed after discharge from the hospital
and who are expected to require ventilatory support or experience episodes of apnea and/or bradycardia, elective repair
is usually delayed until 44–60 weeks of corrected conceptional age [ 17 ] .
Congenital Hydrocele
For infants with congenital hydrocele, the processus vaginalis will usually close and the hydrocele resolve during the
fi rst year of life. The recommended management of a hydrocele is therefore to avoid surgery during that period, unless a
hernia cannot be excluded. After 2 years of age, a hydrocele
is unlikely to resolve and should be operated upon. The recommended operation is high ligation of the processus vaginalis, as for inguinal hernia, with drainage of the distal sac.
Splitting, everting, or removal of the distal sac is not only
unnecessary, but may even cause a postoperative hematoma.
Fluid rarely reaccumulates the sac and if it does, it usually
resolves spontaneously.
There is no evidence that a hydrocele will become a hernia, although this is theoretically possible. Occasionally, a
previously unapparent hydrocele may present in an older
child as a scrotal swelling often presenting during a viral
illness.
Sliding Hernia
A number of structures could be involved in a sliding hernia
in children. In infants, the bladder may be pulled with the
hernia sac. Alternatively the cecum or appendix may share a
wall with a right-sided hernia sac. In girls, a fallopian tube or
mesosalpinx may share a wall with the sac.
Careful inspection of the neck of the hernia sac before
trans fi xion avoids injury to any of these structures. If, on the
other hand, there is any doubt of safety, the sac should be
opened and inspected from the inside and subsequently
closed with a purse-string suture.
Direct Inguinal Hernia
It occurs due to a defect in the transversalis fascia and
presents as a bulge medially in the groin. It is rarely
encountered in children and often misdiagnosed as an
indirect inguinal hernia. As is often the case, a direct hernia may not be obvious while the patient is anesthetized,
and they will return with what appears to be a recurrent
indirect inguinal hernia. If this is the case, it is repaired
using interrupted nonabsorbable sutures between the inguinal ligament and conjoined tendon. Occasionally a mesh
repair is required in the older child. Therefore, a direct hernia should be suspected if a typical PPV cannot be found
or in “recurrent” cases.
Operative Techniques
The Open Inguinal Approach (Fig. 11.5 )
An incision is made in the lowest inguinal crease. Scarpa’s
fascia is incised and the external oblique fascia along with the
external inguinal ring is identi fi ed. At this point the spermatic
cord may be accessed either at its exit from the external ring
or inside the inguinal canal by incising the external oblique. If
the latter approach is used, the ilioinguinal nerve should be
identi fi ed on the inner surface of the external oblique aponeurosis in order to avoid its entrapment in a suture.
The cremasteric fascia is opened to expose the cord structures (Fig. 11.5a ). Care is taken not to grasp either the vas
deferens or the vessels. Only loose connective tissue may be
handled until the hernia sac is identi fi ed. At this point, the
latter is grasped with a pair of non-toothed forceps and the
remaining cord structures pushed away bluntly (Fig. 11.5b ).
In boys, delivery of the testicle into the wound is usually
unnecessary.
Once free from the vas and vessels, the sac can be divided
between clamps and the proximal end dissected superiorly to
the level of the internal inguinal ring (Fig. 11.5c ). This is
identi fi ed by appearance of the preperitoneal fat. The contents of the sac are reduced and the sac twisted and trans fi xed
(Fig. 11.5d ). The distal end of the sac is left open. Further
dissection of this distal sac is discouraged.
In boys, the testicle should be con fi rmed to be in a normal
intrascrotal position at the end of the procedure. Unlike
adults, the infantile inguinal hernia does not need reinforcement. Exception is made for children with an underlying collagen disease [ 8 ] or perhaps a recurrent hernia.
The external oblique (if opened) and Scarpa’s fascia are
closed with interrupted absorbable sutures. The skin is closed
with a subcuticular absorbable suture.
In girls, the absence of vital cord structures makes repair
simpler. The surgical approach to the sac is the same.
However, it is important to routinely open the sac in girls
because as many as 21% [
to exclude CAIS (Fig.
the level of the internal ring, twisted, and ligated. The wound
is closed in a standard fashion (described above).
43 ] have a sliding component, and
11.6 ). The proximal sac is dissected to
194 A. Shalaby and J. Curry
Fig. 11.5 ( a – d ) Open inguinal herniotomy. ( a )The cremasteric fascia
is opened to expose the cord structures. ( b ) The sac is grasped with a
pair of non-toothed forceps and the remaining cord structures pushed
The High Scrotal “Bianchi” Approach
In 1989, Bianchi and Squire [ 43 ] hailed the use of their
scrotal approach for a palpable undescended testis as an
acceptable alternative to the groin incision. A high scrotal
crease incision exposes the cord structures. The hernia sac
is dissected in the usual manner. Upward traction allows
access to the neck of the hernia sac for trans fi xion. Age
may be a limiting factor to this approach. The older the
child, the more retraction becomes necessary to reach the
neck of the hernia sac. The published literature is not unencouraging [
44– 46 ] .
away bluntly. ( c ) The sac is divided between clamps and the proximal
end dissected superiorly to the level of the internal inguinal ring. ( d )
The contents of the sac are reduced and the sac twisted and trans fi xed
Laparoscopic Closure
Laparoscopy was fi rst applied to pediatric inguinal hernias to
evaluate the contralateral side for the presence of a PPV [ 37,
47– 49 ] and can be used to con fi rm a diagnosis of inguinal
hernia [ 47, 48 ] .
A 0° telescope is inserted via the umbilicus using an open
technique. An instrument is inserted in the right and left
lower quadrants. Ports are not necessary for these instruments. The internal ring is closed by a purse-string suture
that avoids the vas and vessels. Contrary to appearances, this
suture does not seem to affect testicular viability [
50 ] . Some
Fig. 11.6 Open inguinal
herniotomy in girls
19511 Inguinal Hernias in Children
authors incise the peritoneum laterally to reduce mechanical
tension, although the bene fi t of this step has been questioned
[ 47, 48 ] . Other groups have reported a needlescopic technique, using one or two lateral ports to assist with percutaneous, extraperitoneal ligation of the internal ring [ 49, 51 ] . The
choice of suture material (absorbable vs. nonabsorbable,
mono fi lament vs. braided) differs according to the surgeon
[ 47, 48 ] . Proponents of the laparoscopic approach cite a
comparable operative time to that of open surgery and a similar complication rate [ 25, 47 ] .
Improved cosmetic outcome aside, the laparoscopic
approach offers the surgeon the ability to easily examine the
contralateral groin and to repair any hernia found. Openings
no deeper than 2 mm (size of the needle driver shaft) are suggested to be unlikely to cause a hernia and are left open by
some authors [ 48 ] . Laparoscopy is also advantageous when
dealing with sliding components in the hernial sac.
Direct and femoral hernias, which are rare in children, are
more readily diagnosed and repaired laparoscopically [ 47,
48 ] . Laparoscopy is equally advantageous in cases of recurrent
inguinal hernias after open surgery [ 25 ] , allowing the surgeon
to avoid previously operated tissue planes and potentially lowering the risks of injury to the vas and/or vessels. The pneumoperitoneum may widen the internal ring and help in reduction
of incarcerated hernias [
52 ] , the viability of which can be eas-
ily assessed and addressed if needed. In addition, immediate
repair could avoid the tissue edema and complications arising
from delayed repair after incarceration [ 52 ] .
Laparoscopic repair, however, remains an intraperitoneal
procedure with increased costs, longer operating time
(reported by some to range from 25 to 74 min [ 49 ] ), and a
prolonged learning curve. Peritoneal thickening from chronic
irritation may hinder the identi fi cation of cord structures and
put them at risk of entrapment. Nerve entrapment is also a
possibility [ 53 ] . Finally, the effects of prolonged pneumoperitoneum have not been fully elucidated.
Variations in Laparoscopic Technique
Flip-Flap Closure
A fl ap of peritoneum is dissected laterally, fl ipped, and
anchored to cover the hernial opening [ 54 ] . Initial reports on
this technique are unsatisfactory due to intraoperative
complications (vas injury, fl ap avulsion) and high rate of
recurrence.
Laparoscopic Inversion Ligation
The hernial sac is inverted into the peritoneal cavity, and the
base tied with an endo-loop.
It is only applicable in girls, as the vas and vessels cannot
be excluded from the tie (Fig. 11.7 ). A series of 241 proce-
dures reported only two recurrences [
5, 55 ] .
196 A. Shalaby and J. Curry
Fig. 11.7 Laparoscopic inversion ligation (LIL). Hernia is identi fi ed ( a ), peritoneum inverted ( b ), twisted and double ligated ( c ), and then excised
( d ) (From Lipskar et al. [
53 ] , with permission)
The Reverdin* Needle Technique
Reverdin needle (RN) is a surgical needle with an eye that
can be opened and closed with a slide. It essentially modi fi es
the delivery of the suture material, creating extracorporeal
knot tying (Fig.
11.8 ). It markedly reduces both operative
time and technical dif fi culty [ 56 ] .
*Jaques L. Reverdin, Swiss surgeon, 1842–1929
Laparoscopic Percutaneous Extraperitoneal Closure
An Endoneedle [ 57 ] devised by the Department of Pediatric
Surgery of Saitama Municipal Hospital in Japan is a special
instrument that has a wire loop to hold the suture material at
Fig. 11.8 Both components of the Reverdin needle, seen here with
mounted suture (From Shalaby et al. [
56 ] , with permission)
19711 Inguinal Hernias in Children
Fig. 11.9 ( a – c ) Laparoscopic percutaneous extraperitoneal closure
(LPEC) of the internal ring (From Takehara et al. [
sion). ( a ) Half of the purse-string suturing is started extraperitoneally,
beginning at the anterior edge and proceeding to the posterior edge on
the lateral side of the internal inguinal ring using the LPEC needle. ( b )
58 ] ; with permis-
the top and can be used for purse-string suturing around the
internal inguinal ring, with extracorporeal knot tying [ 58 ]
(Fig. 11.9 ).
Percutaneous Internal Ring Suturing
A hollow needle with suture material inside is passed percutaneously under the peritoneum of each half of the internal
ring. It allows extracorporeal knot-tying by catching a loop
of the suture material and pulling it to the surface. Patkowski
et al. (2006) report some intraoperative and postoperative
Suturing of the medial side of the internal ring is placed extraperitoneally
using the same technique, and the suture material is held in the wire
loop inside the LPEC needle. ( c ) The LPEC needle is then removed
from the abdomen together with the suture material. The purse-string is
tied extracorporeally
complications, the most serious of which was bowel strangulation that required resection anastomosis. Recurrence was
in three cases out of 106 children [ 59 ] .
Subcutaneously Endoscopically Assisted
Ligation (Fig.
A swaged-on needle is inserted percutaneously and passes
extraperitoneally over half of the internal ring. A hollow
needle is also inserted percutaneously over the opposite half
of the internal ring. Mating of the two allows the suture
11.10 )
198 A. Shalaby and J. Curry
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Umbilical Hernia in Babies and Children
Anjili Khakar and Simon Clarke
Introduction
Umbilical hernia is a protrusion of intra-abdominal contents
through the umbilical ring, within a peritoneal sac, and is one
of the most common conditions managed by pediatric surgeons (Fig. 12.1 ). Debate exists regarding its natural history,
expectant management before surgery, and supposed infrequent incarceration rate.
History of Umbilical Hernia Management
Observations regarding the management of pediatric umbilical hernia date back to the fi rst century. Celsus described an
operation by “ligature” for umbilical hernia, whereas Soranus
(A.D. 98–117) suggested “doubling the cord over, rolling it in
wool and laying it gently against the middle of the navel” [ 1 ] .
In 1884 Erichsen declared that “these small umbilical hernias never strangulated, never caused death, and were rarely
seen over the age of ten” [ 2 ] . Woods observed that no case of
strangulation of an infantile umbilical hernia had ever been
recorded, and treatment by strapping may actually delay the
disappearance of the hernia or even increase its severity [ 1 ] .
Surgical closure is now the accepted treatment if spontaneous
resolution has not occurred or if complications arise. Recent
reports would suggest that incarceration with or without strangulation occur more commonly than was previously thought [ 3– 9 ] .
Umbilical Pathology in Children
1 2
The majority occur due to abnormal embryologic or
physiological processes. Umbilical hernia falls into the spectrum of congenital abdominal wall defects (see Table 12.1 )
Formation of the Anterior Abdominal Wall and Its Relation to Umbilical Hernia
During embryonic development the umbilical area is highly
complex. After birth however the normal umbilicus is a relatively simple structure. During fetal life anterior abdominal
wall development depends on differential growth of embryonic tissues. This occurs by a combination of cranial, caudal,
and lateral infolding of the head and tail folds as well as
acute ventral fl exion beginning in the 4th fetal week. Return
of the midgut and a reduction in the relative size of the body
stalk also play an important part [ 10 ] . The rectus muscles
approximate and become closed by the 12th week, except for
the umbilical ring. The connective tissue of the umbilical
cord originates from the primitive mesoderm, whereas the
rectus sheath, the linea alba, and the fascia of the anterior
abdominal wall are formed from intraembryonic mesoderm.
Fusion of these two types of mesoderm occurs at the embryonic rim which then becomes the umbilical ori fi ce.
Proliferation of lateral connective tissue plates is then responsible for closure of the umbilical ring; when this is incomplete, a patent ring is the result [ 1 ] .
There are also anatomical theories for predisposition to
development of umbilical hernia in addition to the embryonic theories (Table 12.2 ).
Umbilical disorders are common in pediatric surgical practice and usually present with umbilical discharge, pain, or mass.
A. Khakar • S. Clarke (*)
Department of Pediatric Surgery , Chelsea and Westminster Hospital ,
London , United Kingdom
e-mail: simon.clarke@chelwest.nhs.uk
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_12, © Springer Science+Business Media London 2013
Physiology/Natural History of the Umbilicus After Birth
Shortly after birth there is a natural clamping of the blood
fl ow through the umbilical cord, a physiological process triggered by the fall in temperature. Wharton’s jelly swells and
blood vessels within the cord collapse. After cord ligation,
201
202 A. Khakar and S. Clarke
Fig. 12.1 Umbilical hernia
Table 12.1 Congenital umbilical disorders
Delayed cord separation
Failure of normal physiology
Congenital Abdominal wall
defects
Others Dermoid cyst
Embryological
remnants
Vitelline duct
remnants
Urachal remnants Umbilical polyp
Table 12.2 Summary of the embryologic and anatomical theories
predisposing to development of umbilical hernia
Failure of the recti to approximate in the midline after return of the
midgut
Variability in the attachment of the ligamentum teres and median
umbilical ligament
Variability in coverage of the umbilical ring by umbilical (Richet’s)
fascia
Anatomical maturity of the umbilical fascia
Umbilical granuloma
Hernia of umbilical cord
Exomphalos/omphalocele
(gastroschisis)
Umbilical hernia
Vascular malformation
Umbilical polyp
Patent vitellointestinal duct
Meckel’s diverticulum/band/cyst
Patent urachus
Urachal sinus/cyst
the vessels thrombose and the cord dries and sloughs. This
leaves a granulating surface that heals by cicatrization and
becomes covered by epithelium.
Elastic fi bers that reinforce the umbilical ring, together
with proliferation of the lateral connective tissue plates, originally from the cord, are responsible. Atrophy and obliteration of the umbilical vessels continue the process with the
scar contracting resulting in a retracted umbilicus. Delay in
development during the latter stages results in umbilical
defects with minor degrees of herniation of the umbilicus
observed in many neonates [
11 ] .
Table 12.3 Conditions associated with umbilical hernia
Prematurity and low birth weight
Racial variation
Trisomy 21, 13, 18
Beckwith–Wiedemann syndrome
Congenital hypothyroidism
Malnutrition/rickets
Mucopolysaccharidosis type 1
Natural History of Congenital Umbilical Hernias
The expectant approach to management of pediatric umbilical hernias relates to their natural history and asymptomatic
nature. Umbilical hernias regress spontaneously in the
majority of children. Early reports demonstrated that up to
93% of children resolve automatically in the fi rst year of
1 ] . Recent series have established spontaneous closure
life [
occurring in most children by the age of 4 years [
12– 15 ] .
In Africa however some demonstrate resolution continuing
up to 14 years of age [ 16 ] .
If not repaired in childhood, 10% of umbilical hernias will
persist to adulthood [ 17 ] and have an increased risk of incar-
ceration compared to childhood hernias [ 18 ] . Emergency sur-
gery for an incarcerated umbilical hernia in adults has signi fi cant
morbidity and carries a mortality rate of up to 6% [ 19 ] .
Some authors have observed that the size of the fascial
defect, and even its sharpness, is indicative of its ability to
close naturally [ 12, 20, 21 ] . Walker demonstrated in a series
of 314 children that fascial rings measuring less than 1 cm in
diameter tend to close spontaneously, while those larger than
1.5 cm rarely do [ 21 ] . A hernia with a thicker, rounded fas-
cial edge is suggested by some as more likely to close than
one with a thin, sharper edge [ 20 ] .
Epidemiology of Umbilical Hernia
As the majority of umbilical hernias resolve naturally, their
exact incidence is unknown. A true fi gure could only be
obtained by large population-based studies. Incidence
fi gures in the literature vary, due to differing de fi nitions and
methods of patient selection. Incidence is also dependent on
factors such as the age and ethnicity of the patient group
(Table
12.3 ).
Age
One author found that 106 (19%) of 583 healthy infants below
the age of 6 months attending a welfare clinic had an umbilical
hernia. It was also found that in a group of 105 children at
nursery school, 10 children (9.5%), all age 2 years, had umbilical hernias. These all resolved by 5 years of age [
1 ] .