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What is an Umbilical Hernia?

Umbilical hernias are one of the more common disorders of the abdominal wall seen in children, occurring in approximately 1:6 children in some series. The umbilicus at birth is encircled by a fascial ring which represents a defect in the linea alba. This umbilical opening has the remnants of the umbilical arteries and urachus in an inferior direction as well as the umbilical vein in a superior direction. A layer of fascia derived from the transversalis fascia supports the base of the umbilicus. When the supporting fascia at the umbilicus is weak or absent, a direct hernia results in which the peritoneal sac is attached to the overlying skin and together protrude as a visible umbilical hernia. An umbilical hernia is differentiated from a hernia of the umbilical cord in which there is a defect in the peritoneum as well as an open fascial defect at the umbilicus. A hernia of the umbilical cord has intestine herniating into the substance of the umbilical cord and it is covered by amnion alone. A hernia of the umbilical cord is very similar in appearance to a very small omphalocele.

Umbilical hernias occur with equal frequency in boys and girls. Several reports have documented a high incidence in African and African American infants. The umbilical ring naturally is open during gestation and becomes progressively smaller towards the end of the gestational process. Most umbilical hernias are noted after cord separation in the first few weeks of life and almost all are noted by six months of age. Umbilical hernias are very commonly found in low birth weight infants and most of these (75%) will resolve spontaneously. Most umbilical hernias in both premature and term infants undergo spontaneous closure during the first three years of life. Umbilical hernias with a fascial ring less than 1 cm. are much more likely to close spontaneously than those with a fascial greater than 1.5 cm. (Figure 1) In addition, children with proboscis-type hernias are less likely to close. (Figure 2) Complications related to umbilical hernias in childhood are very unusual. Incarceration, although rare in childhood, is much more common in adulthood.

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A period of observation is indicated for most umbilical hernias and in otherwise healthy children we generally wait until 4-5 years of age before performing operative repair. Infants with giant proboscoid hernias, in which the umbilical ring does not narrow significantly may be considered for repair in the first two years of life. In addition, large defects > 1.5 cm. are less likely to close and may be considered for a slightly earlier operative closure. It is not unusual for parents to feel that the child has a symptomatic umbilical hernia since it often protrudes when the child has increased abdominal pressure and may be fussy due to other concerns. Although incarceration and strangulation are very rare in childhood these are absolute indications for surgical repair.

Surgical repair is generally an outpatient procedure in which an infraumbilical incision is utilized. The hernia sac is circled at the level of the fascia and amputated from the underside of the skin. The hernia sac is excised and a single layer closure, usually in the transverse direction is performed of the fascial defect. The underside of the umbilical skin is tacked down to the fascia and the infraumbilical incision is closed. During surgery local anesthesia is placed around the hernia repair to assist in post-operative pain relief. After surgery children are given liquid pain medicine by mouth for 1-2 days.

Epigastric hernias are located in the midline, usually between the umbilicus and the xiphoid process. They are generally about 1 cm in size. They also can sometimes occur just above the umbilicus as a separate defect from the umbilical ring. Epigastic hernias usually have extraperitoneal fat protruding through them and can be repaired through a very small transverse incision as an elective outpatient procedure.

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