Pediatric Umbilical Hernia Repair
Raphael C. Sun
Graeme J. Pitcher
Umbilical hernias are the most common hernias seen in children. They occur as a result of a large or weak umbilical ring that persists after birth. For unknown reasons, these hernias are more common in African American children. The majority of pediatric umbilical hernias will, if given time, close spontaneously and require no surgical intervention. Thus the general rule is to wait until the child is of school-going age before repair. If the hernia defect is large enough to accommodate two fingers or more, it is unlikely to close, and repair can be done earlier when the child is 2 to 3 years old. The risk of incarceration and strangulation is extremely low, so it is reasonable to be conservative.
SCORE™, the Surgical Council on Resident Education, classified umbilical hernia repair in children as an “ESSENTIAL COMMON” procedure.
STEPS IN PROCEDURE
Make incision in the umbilical crease, guided by the location of fascial defect
Usually inferior crease
Superior crease in some situations (high fascial defect)
Dissect through the dermis to the subcutaneous tissue
Develop the plane between the hernia sac and the rectus sheath, clearly defining the edges of the musculofascial defect
Divide sac just anterior to the fascial edge
Dissect the sac off the skin if this can be easily accomplished
Control all bleeding points
Assure that the fascia is free from the sac and/or bowel contents
Close the fascia transversely or longitudinally in an interrupted fashion
Many surgeons prefer a purse-string closure for smaller hernias.
Tack the base of the umbilical skin to the fascial closure to invert the umbilicus
Close the skin
HALLMARK ANATOMIC COMPLICATIONS
Injury to bowel
Failure to identify fascial edge correctly resulting in weak repair using the sac tissue
Fenestrating the skin during dissection of hernia sac from skin
Skin Incision and Initial Dissection (Fig. 48.1)
Technical Points
First, palpate the fascial defect to determine whether an incision above or below the umbilicus will give the best exposure. Accordingly, plan an infra- or supraumbilical curvilinear incision in the typical skin crease (Fig. 48.1).
Continue the incision through the subcutaneous tissue with a combination of electrocautery and blunt dissection. Identify the dissection plane between the subcutaneous tissue and the hernia sac. Take this dissection down to the level of the fascia. Next, identify the hernia sac and dissect circumferentially (Fig. 48.2). In some cases, dissecting with a hemostat between the fascia cranially and the sac allows the sac to be opened and the anatomy better defined. Adequate muscle relaxation or sufficient depth of anesthesia facilitates this step by preventing extrusion of loops of bowel into the wound. Carefully dissect the hernia sac off the skin in order to avoid fenestrating the skin.
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