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Umbilical Hernia Umbilical herniae may be subdivided into exomphalos, and into congenital and acquired herniae. An omphalocoele is a protrusion at birth of part of the intestine through a defect in the abdominal wall at the umbilicus, occuring once in every 5,000 births. It is due to failure of the intestine to return to the abdomen during early fetal life. Sometimes a large sac ruptures during birth causing peritonitis and often death. In other cases, the sac remains unruptured. It is semi-translucent and very thin. It comprises three layers - amniotic membrane on the outside, Wharton's jelly in the middle and inner peritoneum. There are two varieties: exomphalos minor - the sac is relatively small with the umbilicus attached to its summit exomphalos major - the sac is larger and the umbilicus is attached to its inferior aspect. It contains small and large bowel, and almost certainly, a portion of the liver. Intra-uterine epitheliasation of a small exomphalos may present a fully formed umbilical hernia at birth. Frequently, an omphalocoele occurs in association with other conditions - 50% have serious defects involving the alimentary tract, and cardiovascular, genitourinary, musculoskeletal, and central nervous systems. Specific associated conditions include: Beckwith Wiedemann syndrome chromosomal abnormalities - especially trisomies 13 and 18 exstrophy of the bladder or cloaca pentalogy of Cantrell Congenital Umbilical Hernia A congenital umbilical hernia occurs through a weak umbilical scar, usually the result of neonatal sepsis. It occurs in children and infants, especially in black children. Males are affected twice as frequently as females. The patient may be asymptomatic but as the hernia increases in size, there may be pain, and crying. The hernia is originally spherical. It becomes increasingly conical as it grows. Below the age of three years, obstruction or strangulation is uncommon. Many close spontaneously during the first year of life. Non-intervention is successful in 93% of cases of umbilical herniae. For asymptomatic patients, reassurance may be all that is necessary. A high percentage of cases will resolve spontaneously within the first few months of life. The healing process may be hastened by pulling the skin and abdominal musculature together using adhesive strapping placed across the abdomen. Surgery should not be performed before the age of 2 years. The herniorrhaphy is performed by making a small curved incision immediately below the umbilicus. The skin cicatrix is dissected upwards and the neck of the sac isolated. After emptying the sac, it is inverted into the abdomen or ligated by transfixion and excision. The defect in the linea alba is closed with two unabsorbable sutures. Acquired Paraumbilical hernis occur just above, or less commonly below, the umbilicus. They result from weakness in the linea alba and are more common in women than in men by a factor of five fold. They rarely occur in children and are most common in adults between 35 and 50 years. Often, the hernial sac has multiple loculations containing omentum and occasionally small and large bowel. The hernial neck is narrow compared to the size of the fundus predisposing to incarceration and strangulation. The predisposing factors for an acquired umbilical hernia include: multiple pregnancy ascites obesity large intra-abdominal tumours The clinical features of an acquired umbilical hernia include: five times more common in women than in men more common in middle age - especially the ages 35-50 sharp pain on coughing or straining dragging or aching sensation - especially large hernias gastro-intestinal symptoms due to traction on stomach or transverse colon transient intestinal colic caused by subacute intestinal obstruction steady increase in size hernia soon becomes irreducible as a result of omental adhesions within the sac skin changes with large hernias: o intertrigo o necrosis strangulation is common in adults but not children An umbilical hernia should be repaired to avoid incarceration and strangulation. Surgical indications and contraindications are detailed in the submenu. If there is significant ascites, this should first be controlled medically or by peritoneovenous shunt since it is associated with high morbidity and recurrence. The indications for surgery on a paraumbilical hernia are: obstruction strangulation pain or discomfort at the umbilicus irreducibility with skin changes at site e.g. necrosis The contraindications to surgery on a paraumbilical hernia are: obesity chronic disease: o cardiovascular o respiratory ascites Most of these are relative contraindications and full anaesthetic assessment is mandatory.
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