INGUINAL HERNIA TYPE OF UMBILICAL HERNIA

HERNIA
OVERVIEW

Congenital umbilical hernia is a congenital

An inguinal hernia is a protrusion
malformation, especially common in infants
of abdominal-cavity contents through
the inguinal canal. They are very common
(lifetime risk 27% for men, 3% for women[1]),
and their repair is one of the most frequently
performed surgical operations.
There are two types of
inguinal hernia, direct and indirect, which are
defined by their relationship to the inferior
epigastric vessels. Direct inguinal hernias
occur medial to the inferior epigastric vessels
when abdominal contents herniate through
the external inguinal ring. Indirect inguinal
hernias occur when abdominal contents
protrude through the deep inguinal ring, lateral
to the inferior epigastric vessels; this may be
caused by failure of embryonic closure of
the processus vaginalis.
Origin
In men, indirect hernias follow the same route
as the descending testes, which migrate from
the abdomen into the scrotum during
thedevelopment of the urinary and
reproductive organs. The larger size of
of African descent. Among adults, it is three
times more common in women than in men;
among children, the ration is roughly equal. An
acquired umbilical hernia directly results from
increased intra-abdominal pressure and are
most commonly seen in obese individuals.
Presentation
A hernia is present at the site of
the umbilicus (commonly called a navel, or belly
button) in the newborn; although sometimes
quite large, these hernias tend to resolve
without any treatment by around the age of 5
years.[citation needed] Obstruction and strangulation of
the hernia is rare because the underlying defect
in the abdominal wall is larger than in
an inguinal hernia of the newborn. The size of
the base of the herniated tissued is inversely
correlated with risk of strangulation (i.e. narrow
base is more likely to strangulate).
Babies are prone to this malformation because
of the process during fetal development by
which the abdominal organs form outside the
abdominal cavity, later returning into it through
their inguinal canal, which transmitted the an opening which will become the umbilicus.
testicle and accommodates the structures of
the spermatic cord, might be one reason why
men are 25 times more likely to have an
inguinal hernia than women. Although several
mechanisms such as strength of the posterior
wall of the inguinal canal and shutter
mechanisms compensating for raised intra-
abdominal pressure prevent hernia formation
in normal individuals, the exact importance of
each factor is still under debate.
 Subtypes

Relation
Covered
ship
by inter
to inferi
Typ Descript nal Usual
or
e ion spermat onset
epigastr
ic
ic
fascia?
vessels

protrude
s
through
the
inguinal
ring and
is
ultimatel
y the
indir
result of
ect
the
ingui Congenita
failure of Lateral Yes
nal l
embryon
hern
ic
ia
closure
of the
internal
inguinal
ring after
the testic
le passes
through
it

enters
The cause of inguinal hernia in children can be CAUSES An umbilical hernia in an infant occurs when the
termed an abnormality of embryologic muscle through which blood vessels pass to feed
development of the fetus. However, some the developing fetus doesn't close completely.
children may present with an acquired form of
inguinal hernia, also called a direct inguinal Umbilical hernias are common in infants. They
hernia. In this type of hernia, weakness of the occur slightly more often in African Americans.
inguinal floor is present, which allows for Most umbilical hernias are not related to
protrusion of viscera from the abdominal disease. However, umbilical hernias can be
cavity. The hernia sac is composed of the associated with rare conditions such
peritoneal fold that contains the hernia. as mucopolysaccharide storage
diseases, Beckwith-Wiedemann syndrome,
Anatomically speaking, indirect and direct and Down syndrome.
inguinal hernias differ in that the direct hernia
bulges through the inguinal floor medial to the
inferior epigastric vessels and the indirect
hernia arises lateral to the inferior epigastric
vessels. Either hernia may cause fullness or a
palpable bulge in the inguinal region, and
distinguishing between the two types on the
basis of physical examination findings may be
difficult. The clinician may assume, until
proven otherwise, that the pediatric patient
with an inguinal hernia has indirect inguinal
hernia.

• The following are associated with an

increased risk of inguinal hernia:
o Prematurity and low birth weight
(Incidence approaches 50%.)
o Urologic conditions
 Cryptorchidism
 Hypospadias
  Epispadias
 Exstrophy of the bladder
 Ambiguous genitalia
o Patent processus vaginalis, which
may be present because of
increased abdominal pressure due
to ventriculoperitoneal shunts,
peritoneal dialysis, or ascites
o Abdominal wall defects
 Gastroschisis
 Omphalocele
o Family history
 Meconium peritonitis
 Cystic fibrosis
 Connective tissue disease
 Mucopolysaccharidosis
 Congenital dislocation of the
hip
 Ehlers-Danlos syndrome
 Marfan syndrome
 Cloacal exstrophy
 Fetal hydrops
 Liver disease with ascites
 Ventriculoperitoneal shunting
for hydrocephalus

CLINICAL A hernia can vary in width from less than 1

Hernias present as bulges in the groin area MANIFESTA centimeter to more than 5 centimeters.
that can become more prominent when TION
coughing, straining, or standing up. They are There is a soft swelling over the belly button
that often bulges when the baby sits up, cries, or
rarely painful, and the bulge commonly strains. The bulge may be flat when the infant
disappears on lying down. The inability to lies on the back and is quiet.
"reduce", or place the bulge back into the
abdomen usually means the hernia is
'incarcerated' which is a surgical emergency.

Significant pain is suggestive of strangulated

bowel (an incarcerated indirect inguinal
hernia).

As the hernia progresses, contents of the

abdominal cavity, such as the intestines, can
descend into the hernia and run the risk of
being pinched within the hernia, causing an
intestinal obstruction. If the blood supply of the
portion of the intestine caught in the hernia is
compromised, the hernia is deemed
"strangulated," and
gut ischemia and gangrene can result, with
potentially fatal consequences. The timing of
complications is not predictable; some hernias
remain static for years, others progress rapidly
from the time of onset. Provided there are no
serious co-existing medical problems, patients
are advised to get the hernia repaired
surgically at the earliest convenience after a
diagnosis is made. Emergency surgery for
complications such as incarceration and
strangulation carry much higher risk than
planned, "elective" procedures.

Laboratory Studies DIAGNOSTI

• No laboratory studies are needed in the
assessment of a patient with a suspected
inguinal hernia and/or hydrocele.
Imaging Studies
Imaging studies are generally not indicated to
assess for inguinal hernia. However,
ultrasonography can be helpful in the
assessment of selected patients.
C Importantly this type of hernia must be
EVALUATIO distinguished from a paraumbilical hernia, which
NS occurs in adults and involves a defect in the
midline near to the umbilicus, and
from omphalocele.
The doctor can find the hernia during a physical
exam.

• Ultrasonography: Some advocate the use

of ultrasonography to differentiate
between a hydrocele and an inguinal
hernia. Ultrasonography is capable of
finding a fluid-filled sac in the scrotum,
which would be compatible with a
diagnosis of hydrocele. However, if the
patient has an incarcerated inguinal
hernia, ultrasonography may not be
sensitive enough to differentiate
between the two conditions. Thus, this
study is rarely helpful in the treatment of
a pediatric patient with a suspected
 inguinal hernia. When presentation and
examination suggest a diagnosis other
than hernia or hydrocele, appropriate
imaging, including ultrasonography, may
be necessary. An enlarged inguinal
lymph node can mimic an incarcerated
inguinal hernia, and surgical exploration
may occasionally be necessary to
confirm the diagnosis.
• Peritoneography: Injection of contrast in
the peritoneal cavity has been used to
determine the presence of a patent
processus vaginalis. Although this test is
very sensitive, its use is limited. Because
of possible complications, including
bowel perforation and sepsis, injection of
contrast is rarely performed today.

Procedures

• Laparoscopy: Diagnostic laparoscopy is a

very effective method for determining
the presence of an inguinal hernia but is
used only selectively because it requires
anesthesia and surgery. Laparoscopy can
be useful to assess the contralateral side
(see Treatment) or to evaluate for
presence of a recurrent inguinal hernia in
patients with a history of operative
repair.

Surgical correction of inguinal hernias,
called a herniorrhaphy or hernioplasty, is
now often performed as outpatient
surgery. There are various surgical
strategies which may be considered in the
planning of inguinal hernia repair. These
include the consideration of mesh use,
type of open repair, use oflaparoscopy,
type of anesthesia, appropriateness of
bilateral repair, etc. During surgery
conducted under local anaesthesia, the
patient will be asked to cough and strain
during the procedure to help in
demonstrating that the repair is "tension
free" and sound.[3]
Non-surgical treatment
The hernia truss (medicine) is intended to
contain a reducible inguinal hernia within
the abdomen. This device fell out of favour
with the advent of hernia surgery. It is not
considered to provide a cure, and if the
pads are hard and intrude into the hernia
THERAPEUT
IC When the orifice is large (< 1 or 2 cm), 90%
MANAGEME close within 3 years (some sources state 85% of
NT all umbilical hernias, regardless of size), and if
these hernias are asymptomatic, reducible, and
don't enlarge, no surgery is needed (and in other
cases it must be considered). In some
communities mothers routinely push the small
bulge back in and tape a coin over the palpable
hernia hole until closure occurs. This practice is
not medically recommended as there is a small
risk of trapping a loop of bowel under part of the
coin resulting in a small area of ischemic bowel.
The use of bandages or other articles to
continuously reduce the hernia is not evidence-
based.
An umbilical hernia can be fixed 2 different
ways. The surgeon can opt to stitch the walls of
the abdominal or he/she can place mesh over
the opening and stitch it to the abdominal walls.
The latter is of a stronger hold and is commonly
used for larger tears in the abdominal wall. Most
surgeons will repair the hernia 6 weeks after the
baby is born.
aperture they may cause scarring and
enlargement of the aperture. In addition,
most trusses with older designs are not
able effectively to contain the hernia at all
times, because their pads do not remain
permanently in contact with the hernia.
The more modern variety of truss
(medicine) is made with non-intrusive flat
pads and comes with a guarantee to hold
the hernia securely during all activities.
Although there is as yet no proof that such
devices can prevent an inguinal hernia
from progressing, they have been
described by users as providing greater
confidence and comfort when carrying out
physically demanding tasks. Their
popularity is likely to increase, as many
individuals with small, painless hernias are
now delaying hernia surgery due to
recently published reports on the incidence
of Post Herniorrhaphy Pain Syndrome.

1. Prompt recognition of an inguinal NURSING 1. The appearance of an umbilical hernia may

hernia is imperative. The hernica may MANAGEME be disconcerting to parents; therefore they
first be noticed when infant is crying or NT need reassurance that the defect is not
straining stool (Valsalva manuever). harmful. Tapping or strapping the abdoment
Nursing care of the infant or child with of latten the protrustion does not aid in
an inguinal hernia involves preoperative resolution and can produce skin irritation.
preparation of the infant and
appropriate explanation to the parents 2. Nursing care of the child with an umbilical
of the child’s expected postoperative hernia repair is essentially the same as that
status. Most hernia repairs can be for other minor GI surgery. The procedure
managed in an outpatient basis. The may be performed on an outpatient basis,
preterm infant usually will have hernia and a pressure dressing is maintained for
repair several days before discharge approximately 48 hours postoperatively. The
from the neonatal intensive care unit. child may resume a normal diet and activity
The former preterm infant diagnosed postoperatively, howeverm strenuous activity
after discharfe is admitted the day of or play is restricted for 2 to 3 weeks.
surgery and after repair is observer 12
to 24 hours for occurences of apnea and
bradycardia.
2. Postoperatively the wound is kept
dry and clean, and the infant;s pain is
managed appropriately. In infants and
small childrenm who are not yet toilet
trained, the wound may be covered with
an occlusive fressing or left without a
dressing. Changing diapers as soon as
they become damp helps reduce the
chances of irritation or infection of the
incision
3. Parents are instructed to give child
sponge baths for 2 to 5 days to change
diapers frequently. There are no
restrictions placed on the infant’s or
toddler’s activity, but older children are
cautioned against lifting, pushing,
 wrestling, or fighting, cycling, and
atlethics for at least 3 weeks.
4. If surgery is postponed, parents
need to be taught the signs of
incarcerated hernia, simple measures to
reduce it (a warm bath, avoidance of
upright positioning, and comfort
measures to reduce crying) and where
to call for assistance if relief is not
obtained in reasonably short time.

5.