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Clinical and surgical aspects of strangulated umbilical hernias in children: a prospective study of 35 cases

Ngom G, Gassama F, Kane A, Seck M, Ndour O, Ndoye M
Department of Pediatric Surgery, Aristide Le Dantec Hospital
Dakar, Senegal

 

 

Correspondence 

Gabriel NGOM
BP 6863 Dakar Etoile
Tel: 00 221 77 552 00 80
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

Abstract

Purpose: To report on clinical and surgical aspects of strangulated umbilical hernias in children in a developing country.

Patients and methods: A prospective study was conducted in the only Pediatric Surgery Department in Senegal from May 2006 to April 2009. Thirty five children, of whom 20 boys and 15 girls, with a mean age 34 months presented a strangulated umbilical hernia. We studied the clinical and surgical aspects among these children. The variables of interest were: time to admission, complains, clinical findings, contents of the hernial sac, diameter of umbilical defect, surgery performed and postoperative outcomes. Mean follow up time was 18months.

Results: Patients were admitted within 36 hours after the onset of symptoms. Complains were painful umbilical swelling (97.1%), vomiting (62.8%), occlusive syndrome (11.4%) and fever (2.9%). Physical examination revealed strangulated umbilical hernia in all cases, malnutrition in 40% of cases, dehydration in 20% of cases and peritonitis in 2.9% of cases. Viscera found in the hernial sac were small bowel (65.7%), omentum (22.9%) and the association of the two viscera ( 11.4%). The viscera were viable in 82.9% of cases and necrotic in 17.1% of cases. The diameter of the umbilical defect was medium size in 62.9% of cases and larger in 37.1% of cases. We noted a case of wound infection which was well managed with local treatment. There was no recurrence or death.

Conclusion: Children with strangulated umbilical hernia are received late in Senegal. This long admission’s delay explains the poor status of children and the frequency of necrosis.

keywords: strangulated umbilical hernia, long admission’s delay, necrotic viscera

 

Introduction

Umbilical hernia is common in children especially in the black [1]. The frequency of complications related to this pathology is different in black and white children. In white children, complications are exceptional explaining conservative therapy advocated by authors in western world [2, 3]. In black children, complications are frequent justifying surgery recommended by African authors [4-7]. Several retrospective studies on clinical and surgical aspects of strangulated umbilical hernia were conducted in the literature. Our study is the only prospective work reported in the literature. Its purpose was to report the clinical and surgical aspects of strangulated umbilical hernia in a developing country.

Patients and methods

 We conducted a prospective study which included 35 children who presented a strangulated umbilical hernia. The study was conducted at the only Pediatric Surgery Department in Senegal from May 2006 to April 2009. The series is formed by 20 boys and 15 girls. Mean age was 34 months (range: 2 months, 9 years). The clinical aspects taken into consideration were time to admission, complains, and clinical findings. For surgical aspects we considered the content of the hernial sac, the diameter of umbilical defect, the surgery performed and the postoperative out- comes. The diameter of umbilical defect was considered using Lassaletta classification (small hernia<0.5 cm; medium hernia; 0.5cm-1.5cm; larger hernia> 1.5cm). The children were followed after an average period of 18 months. 

Results

Clinical findings

The children were admitted within 36 hours after the onset of symptoms. The distribution of children according to the admission’s delay is shown in Table I. Painful umbilical swelling was the common complain (97.1%). It was followed by vomiting (62.8%), occlusive syndrome (11.4%) and fever (2.9%). Clinical examination revealed in all cases a painful and irreducible umbilical swelling suggesting strangulated umbilical hernia ( fig 1). Forty percent of children were undernourished and 20% were dehydrated. One child presented peritonitis.

5 JPSS 8 1 2010-5 

Figure 1: Strangulated umbilical hernia in a child aged 3 years 

Surgical aspects

The viscus found in the hernia was usually the small bowel (Table II). The content of the hernia was viable in 82.9% of cases and necrotic in 17.1% of cases with a case of intestinal perforation. We performed three omental resections and three bowel resections with end–to-end anastomosis. The diameter of the umbilical defect was assessed during surgery. Medium umbilical hernias accounted for 62.9% of cases and large hernias represented 37.1% of cases. Post operatively, the child who presented bowel perforation developed wound infection which evolved favorably. There was neither recurrence nor death.

Time to admission

Number of children

Percentage

1-12 h

8

22,9%

13-24h

12

34.2%

25-48h

7

20%

Beyond 48h

8

22.9%

Table I: Time to admission after the onset of symptoms

 

Viscera

Number of children

Percentage

Small bowel

23

65,7%

Omentum

8

22.9%

Small bowel + omentum

4

11.4%

Table II: Viscera found in the hernia 

Discussion

In Africa children with strangulated umbilical hernia arrive late to the reference center. In Benin, over 55% of children were received beyond the 12th hour with a range of 1 hour and 7 days [4]. Harouna in Niger found an average time to admission of 22 hours [5]. In Burkina, the children were admitted within 51.2 hours delay [8]. In Senegal, the average time to admission was 36 hours. Compared with data from Western authors, these delays are high. Some difficulties could explain these results. In Africa, roads are often in poor condition so that patients take time before reaching the reference center. On the other hand, the parents’ ignorance and lack of diagnosis in secondary hospitals may delay the referral of children. Finally, poverty explains the reluctance of parents to consult the reference center, because costs are high. Painful umbilical swelling was the main complain. It was responsible of excessive crying in children. Vomiting ranks in the second position. It was isolated in 62.8% of cases and part of an occlusive syndrome in 11.4% of cases. Vomiting was absent in 25,8% of cases. In the literature, vomiting may be absent, isolated or part of an occlusive syndrome [5,8,9].

In Africa, occlusive syndrome has previously shown to be frequent: 41,5% in Senegal [9], 80% in Burkina Faso [8], 50% in Niger [5] and 11.4% in our series. Fever was one of the symptoms of peritonitis in a child who presented bowel perforation. It is sometimes reported in Africa and was due to peritonitis by intestinal perforation [5,9]. Repeated vomiting and occlusive syndrome explain the poor condition of children who frequently present malnutrition and dehydration [5,8,9]. Physical examination confirmed the diagnosis of strangulated umbilical hernia in the presence of painful and irreducible umbilical swelling. In Africa we sometimes observe peritonitis and intestinal umbilical fistula which are late manifestations of the strangulation as reported by Harouna in Niger [5], Ahmed in Nigeria [11] and Bandré in Burkina Faso [8]. These late manifestations of strangulated umbilical hernia are not reported by Western authors. They are mainly related to the delayed admission. All authors agree on the fact that the small bowel is most often found in the hernia, followed by omentum [4, 5, 8, 9, 12, 13]. Others viscera are much rarer. Cases of necrosis of the content of the hernia are reported by African authors: 8.2% for Koura in Benin [4], 16.7% for Bandré in Burkina Faso [8], 12% for Fall in Senegal [9], 6% for Chirdan in Nigeria [14] and 17.1% in our study.

Umbilical hernias with medium size were more commonly strangulated. They are followed by hernia with larger size. Small umbilical hernias did not evolve into strangulation. These results are in line with the literature data [9, 10, 14]. Most of authors prefer to perform immediate surgery in case of strangulated umbilical hernia [4, 5, 9, 10]. But others prefer to reduce hernia under general anesthesia and delay the treatment [14]. In Africa, that option requires a hospital-based surveillance to watch for signs of peritonitis, as it is known that children often arrive late to the reference center. The surgical procedure performed depends on the state of the viscera found in the hernia. If the content is viable, it is reintegrated into the abdominal cavity and the umbilical defect is closed. If the content of the hernia is necrotic, resection is performed. If the bowel is necrotic, most authors perform bowel resection followed by immediate anastomosis [4, 9]. Others prefer to perform a stoma if the patient is in poor general condition [5, 8]. In any case the umbilical defect is closed after resection. Because of the long admission’s delay morbidity and mortality are raised in Africa.

Fall in Senegal [9] reported two cases of wound infection and one case of re- currence. Chirdan in Nigeria [14] reported one case of wound infection in a child who experienced a perforated Meckel diverticulum. In Benin, Koura [4] reported two deaths, while Harouna in Niger [5] reported one death in a child who was admitted one week after the onset of symptoms. Bandré [8] reported a wound infection in 20% of cases and one death related to peritonitis. In our series a case of wound infection was observed. These results are different from those of Western authors who do not report death with virtually no morbidity. 

Conclusion

In Africa, children with strangulated umbilical hernia are received late at the reference center, unlike in Western countries. This explains the poor status in which they are admitted and the frequency of bowel necrosis. This long admission’s delay also explains the importance of morbidity and mortality. These results justify the operative approach currently being promoted by African authors.

 

 

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