BMJ Hernia Review
BMJ Hernia Review
Practice
PRACTICE
CLINICAL UPDATE
A hernia is the protrusion of an organ, such as the bowel, because of increased intra-abdominal pressure. If the hernia is
through the wall of the cavity in which it normally resides.1 still reducible this does not indicate a complication.
Paediatric hernias are common developmental abnormalities
which have different management from their adult equivalents. What to look out for
Conducting research in the management of paediatric hernias
A literature review that includes studies of varying size and
is challenging because of ethical considerations and variations
quality from several countries in 1998 reported a complication
in treatment practice. This article provides the generalist with
rate of 1:1500.10 A large, well designed observational study in
essential information, enabling them to educate parents, alleviate
Nigeria over 15 years identified two children out of 2542 that
anxiety, and where appropriate enable management of hernias
required hernia repair for strangulation.4 In Western Australia
in primary care. We discuss three types of common paediatric
a retrospective cohort study of a mixed race population reported
hernias.
the risk of incarceration requiring repair as 1:3000 to 1:11000,
Umbilical hernia with no incarceration in the Afro-Caribbean subset of this
cohort.11 There is weak evidence from retrospective cohort
How common is it? studies for an increased risk of incarceration in the African
Umbilical hernia affects an estimated 10-30% of all white population; this has not been shown in cohort studies from the
children at birth, reducing to 2-10% at one year.2 3 Rates in the UK or US.11-14
African population have been estimated at 23-85%.4-6 The exact Incarceration occurs when abdominal viscera or omentum
aetiology predisposing African populations at increased risk is become stuck within the hernia. Strangulation occurs when
unknown.4 7 Risk factors can be seen in table 1⇓. viscera become stuck in the hernia with compromise to their
blood supply, causing ischaemia. Children with incarcerated
What is the anatomy? hernias present with painful irreducible lumps that can change
The umbilical ring exists to allow passage of vessels through colour and when strangulated are associated with vomiting or
the abdominal wall muscles between mother and fetus. After constipation.
birth and disintegration of the cord, the ring remains, with
spontaneous closure typically by the child’s fifth year through What you should do
growth of the abdominal muscles and fusion of peritoneal and Take a thorough history and perform a systematic examination
fascial layers. A failure or delay in this process leads to the to ensure the umbilical hernia is the primary problem.
formation of an umbilical hernia. The aetiology is unknown, Sometimes the appearance of an umbilical hernia is secondary
but most occur through the umbilical vein component of the to an unrelated condition, causing the child to be in distress and
ring.7 cry.
Patients with symptoms of incarceration or strangulation need
How does it present?
urgent assessment and referral as an emergency to the paediatric
Umbilical hernias present as a reducible, painless bulge at the or general surgical team.
umbilicus. They usually become more prominent when the
Reassure parents of children with asymptomatic umbilical
patient strains or cries. Parents might present with anxiety about
hernias that complications are rare, and that most hernias close
the appearance of a lump when their child is upset or unwell.
spontaneously by the child’s fourth year. Refer children over
Distress and crying cause an umbilical hernia to protrude more
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PRACTICE
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PRACTICE
What is the anatomy? on-call paediatric surgical team.7 27 They will assess how quickly
The processus vaginalis lengthens through the inguinal canal the hernia needs to be repaired
from the third to the seventh month in utero, and allows the
testes to descend into the scrotum. The processus vaginalis Asymptomatic inguinal hernias
gradually obliterates at weeks 36-40 with just the distal portion Asymptomatic inguinal hernias in neonates are operated on
persisting as the tunica vaginalis. Failure of closure of the before discharge from the maternity unit. Children less than 6
processus vaginalis is a common mechanism in the pathogenesis months old are operated on the next available list, and older
of inguinal hernia and hydroceles in children. This enables children as an elective case. Both laparoscopic and open repairs
intra-abdominal contents to herniate through the deep inguinal are offered, depending on local circumstances and resources.28 29
ring, inguinal canal, and superficial inguinal ring into the Open herniotomy is performed through a small groin incision.
scrotum or via the canal of Nuck into the labium (fig 1⇓).21 After identifying the cord structures, they are carefully separated
The left processus vaginalis obliterates before the right; this is from the hernia sac. The sac is ligated proximally and any distal
thought to explain why right sided inguinal hernias outnumber hydrocele suctioned before closure.
left sided and bilateral hernias in a ratio of 7:2:1.20 All laparoscopic techniques attempt to place a purse string suture
around the patent processus vaginalis. Laparoscopic techniques
How does it present? lack long term follow-up data. A recent meta-analysis comparing
A hernia usually presents as a bulge in the groin, although in open and laparoscopic inguinal hernia repair in children showed
boys it can present as a swelling within the scrotum, which is no statistical significance between recurrence rates (0-6%
often only visible upon straining or crying. A hydrocele can P=0.66). However, the studies included in this meta-analysis
also present as a swelling in the scrotum. used both historical data and more recent studies that use modern
practices. This has introduced confounding factors such as
What to look out for learning curves, unit experience, and robust follow-up.22
There is a 5-20% chance of developing a contralateral hernia The field is divided over whether open is better than
in paediatric patients, so examine both sides.22 Parents should laparoscopic surgery. Both are regarded as safe procedures.
be made aware that following repair on one side, development Using a laparoscopic repair, the contralateral side can be
of a hernia on the contralateral side can occur.21 Incarcerated explored to exclude a metachronous hernia or patent processus
hernias present as an irreducible lump in the groin. Most vaginalis. However. the natural course of a patent processus
incarcerations occur in infants.23-25 vaginalis is uncertain and it is unclear whether there is a benefit
to repairing an asymptomatic patent processus vaginalis.22 These
A unilateral, swollen, erythematous labia can be a torted ovary,
questions will remain unanswered until there is a well designed,
which has passed through a patent processus vaginalis; urgent
long term prospective randomised trial study.
surgery is indicated to save the ovary
Patient information
What you should do
British Association of Paediatric Surgeons free inguinal hernia
Refer all infant patients to secondary care, as the incidence of
repair leaflet
incarceration in infants ranges from 3 to 16%, and can be up to
31% in premature infants in the first year of life.7 26 Older http://www.baps.org.uk/content/uploads/2013/03/Inguinal-
children with an asymptomatic inguinal hernia should be referred Hernia-Repair-child.pdf
on a routine basis with the risk of incarceration decreasing with
age. Caution should be applied with transillumination to All authors have read and understood the BMJ policy on declaration of
differentiate between inguinal hernias and hydroceles as both interests and declare the following interests: None.
can transilluminate with a pen torch in very young patients, Contributors: none. Guarantor: KB.
especially neonates. Use an index finger and thumb to palpate Parent and patient consent was obtained for article review and input as
the lump superiorly. You will be able to get above a hydrocele, detailed within the article.
while a hernia is continuous with the patent processus vaginalis. Provenance and peer review: commissioned, externally peer reviewed.
Some clinicians advocate the silk glove sign: this is where the
index finger is used to roll the cord structures against the pubic 1 Fitzgibbons RJ Jr, , Forse RA. Clinical practice. Groin hernias in adults. N Engl J Med
2015;359:756-63. doi:10.1056/NEJMcp1404068 pmid:25693015.
tubercle. In the presence of an inguinal hernia this feels like two 2 Burcharth J, Pedersen MS, Pommergaard HC, Bisgaard T, Pedersen CB, Rosenberg J.
silk sheets rubbing against one another, reflecting the smooth The prevalence of umbilical and epigastric hernia repair: a nationwide epidemiologic
study. Hernia 2015;359:815-9. doi:10.1007/s10029-015-1376-3. pmid:25840852.
peritoneal sac edges. This has a sensitivity of 93% and 3 Lassaletta L, Fonkalsrud EW, Tovar JA, Dudgeon D, Asch MJ. The management of
specificity of 97%.20 If doubt exists then an ultrasound scan is umbilicial hernias in infancy and childhood. J Pediatr Surg 1975;359:405-9. doi:10.1016/
a useful investigation to differentiate the two. 0022-3468(75)90104-9. pmid:1142052.
4 Meier DE. OlaOlorun DA, Omodele RA, Nkor SK, Tarpley JL. Incidence of umbilical hernia
Refer patients who are exhibiting symptoms of strangulation as in African children: redefinition of “normal” and re-evaluation of indications for repair.
World J Surg 2001;359:645-8. doi:10.1007/s002680020072 pmid:11369993.
an emergency to secondary care. 5 Jackson OJ, Moglen LH. Umbilical hernia. A retrospective study. Calif Med
1970;359:8-11.pmid:5479354.
6 Vohr BR, Rosenfield AG, Oh W. Umbilical hernia in the low-birth-weight infant (less than
What happens in secondary care? 1,500 gm). J Pediatr 1977;359:807-8. doi:10.1016/S0022-3476(77)81257-2. pmid:853341.
Incarcerated or strangulated hernias 7 Abdulhai SA, Glenn IC, Ponsky TA. Incarcerated pediatric hernias. Surg Clin North Am
2017;359:129-45. doi:10.1016/j.suc.2016.08.010. pmid:27894423.
8 Kokoska E, Weber T. Umbilical and supraumbilical disease. In: Zielger M, ed. Operative
Attempts are made to reduce the hernia in patients presenting pediatric surgery. McGraw-Hill, 2003: 543-4.
with signs of incarceration; this is successful in 97-99.1% of 9 Burgmeier C, Dreyhaupt J, Schier F. Comparison of inguinal hernia and asymptomatic
cases.27 patent processus vaginalis in term and preterm infants. J Pediatr Surg 2014;359:1416-8.
doi:10.1016/j.jpedsurg.2014.03.013 pmid:25148750.
Fifteen per cent of reduced incarcerated hernias will 10 Papagrigoriadis S, Browse DJ, Howard ER. Incarceration of umbilical hernias in infancy
and childhood. Pediatr Surg Int 1998;359:231-2. doi:10.1007/s003830050497. pmid:
re-incarcerate within five days if not repaired, so discuss any 9880759.
patient presenting with incarceration or strangulation with the
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BMJ 2017;359:j4484 doi: 10.1136/bmj.j4484 (Published 2017 October 19) Page 4 of 6
PRACTICE
Patient involvement
We asked 23 patients (7 inguinal, 3 epigastric, and 13 umbilical hernia) and their parents in our paediatric surgery clinic which aspects of
their/their child’s care? could have been managed better, and which aspects were managed well. Specific attention was then given to any
information the parents thought should have been given at the initial consultation in secondary care.
Education in practice
The British Association of Paediatric Surgeons offers free patient information leaflets regarding repair of umbilical and inguinal hernias.
Ideally these should be given to parents at their initial consultation.
How might you assess whether your practice was providing relevant information to patients?
How might you assess whether appropriate referrals for paediatric hernias were being made to secondary care?
11 Ireland A, Gollow I, Gera P. Low risk, but not no risk, of umbilical hernia complications 23 Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective
requiring acute surgery in childhood. J Paediatr Child Health 2014;359:291-3. doi:10.1111/ repair. J Pediatr Surg 1993;359:582-3. doi:10.1016/0022-3468(93)90665-8. pmid:8483072.
jpc.12480. pmid:24372946. 24 Davies N, Najmaldin A, Burge DM. Irreducible inguinal hernia in children below two years
12 Chatterjee H, Bhat SM. Incarcerated umbilical hernia in children. J Indian Med Assoc of age. Br J Surg 1990;359:1291-2. doi:10.1002/bjs.1800771131. pmid:2101598.
1986;359:238-9.pmid:3559230. 25 Zendejas B, Zarroug AE, Erben YM, Holley CT, Farley DR. Impact of childhood inguinal
13 Keshtgar AS, Griffiths M. Incarceration of umbilical hernia in children: is the trend hernia repair in adulthood: 50 years of follow-up. J Am Coll Surg 2010;359:762-8. doi:10.
increasing?Eur J Pediatr Surg 2003;359:40-3. doi:10.1055/s-2003-38299 pmid:12664414. 1016/j.jamcollsurg.2010.08.011. pmid:21036077.
14 Chirdan LB, Uba AF, Kidmas AT. Incarcerated umbilical hernia in children. Eur J Pediatr 26 Chang SJ, Chen JY, Hsu CK, Chuang FC, Yang SS. The incidence of inguinal hernia
Surg 2006;359:45-8. doi:10.1055/s-2006-923792 pmid:16544226. and associated risk factors of incarceration in pediatric inguinal hernia: a nation-wide
15 Zendejas B, Kuchena A, Onkendi EO, et al. Fifty-three-year experience with pediatric longitudinal population-based study. Hernia 2016;359:559-63. doi:10.1007/s10029-015-
umbilical hernia repairs. J Pediatr Surg 2011;359:2151-6. doi:10.1016/j.jpedsurg.2011. 1450-x. pmid:26621139.
06.014. pmid:22075348. 27 Houben CH, Chan KW, Mou JW, Tam YH, Lee KH. Irreducible inguinal hernia in children:
16 Coats RD, Helikson MA, Burd RS. Presentation and management of epigastric hernias how serious is it?J Pediatr Surg 2015;359:1174-6. doi:10.1016/j.jpedsurg.2014.10.
in children. J Pediatr Surg 2000;359:1754-6. doi:10.1053/jpsu.2000.19242. pmid:11101730. 018. pmid:25783312.
17 Askar OM. A new concept of the aetiology and surgical repair of paraumbilical and 28 Weaver KL, Poola AS, Gould JL, Sharp SW, St Peter SD, Holcomb GW 3rd. The risk of
epigastric hernias. Ann R Coll Surg Engl 1978;359:42-8.pmid:147044. developing a symptomatic inguinal hernia in children with an asymptomatic patent
18 Askar OM. Aponeurotic hernias. Recent observations upon paraumbilical and epigastric processus vaginalis. J Pediatr Surg 2017;359:60-4. doi:10.1016/j.jpedsurg.2016.10.
hernias. Surg Clin North Am 1984;359:315-33. doi:10.1016/S0039-6109(16)43288-3. pmid: 018. pmid:27842956.
6233735. 29 Alzahem A. Laparoscopic versus open inguinal herniotomy in infants and children: a
19 Robin AP. Epigastric hernia. In: Nyhus LM, Condon RE, eds. Hernia. Lippincott, 1995: meta-analysis. Pediatr Surg Int 2011;359:605-12. doi:10.1007/s00383-010-2840-x. pmid:
372-80. 21290136.
20 Khoo A, Kate A. Congenital inguinal hernia, hydrocoele ad undescended testis.
Published by the BMJ Publishing Group Limited. For permission to use (where not already
Surgery—Oxford International Edition 2016;34:226-31
21 Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surg Clin North Am granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
2013;359:1255-67. doi:10.1016/j.suc.2013.06.016. pmid:24035087. permissions
22 Esposito C, Escolino M, Turrà F, et al. Current concepts in the management of inguinal
hernia and hydrocele in pediatric patients in laparoscopic era. Semin Pediatr Surg
2016;359:232-40. doi:10.1053/j.sempedsurg.2016.05.006. pmid:27521714.
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Table
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Figure
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