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Umbilical Hernia


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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

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.


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
      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

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