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Umbilical Hernias in Children, Are They Innocent?

Ike Njere¹², Hemant Kumar³, Sadaf Kader*, Dorothy Kufeji¹³, Ahmed Said¹³, Masih Kader¹³

¹University Hospital Lewisham, London, United Kingdom

²Royal Alexandra Children’s Hospital, Brighton, United Kingdom

³Evelina Children’s Hospital, Guys and St Thomas’ Hospital, London, United Kingdom

*Kings College London, United Kingdom

 

Correspondance:

Ike Njere

Department of Paediatric Surgery

Royal Alexandra Childrens Hospital

Eastern Road, East Sussex

Brighton BN2 5BE

United Kingdom

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Introduction

Umbilical hernia is common in infants and children with an incidence of 10-30% reported in the literature. Complications are believed to be rare and most are repaired at school age mainly for psychosocial reasons. Few studies have evaluated the complication rate of umbilical hernias. This study aims to ascertain the complication rate of umbilical hernias in children and review the timing of repair.

Method

A retrospective study of 236 patients that presented to the University hospital Lewisham with umbilical hernia from 2006 to 2010. Case notes were reviewed and parents contacted by telephone where necessary. Umbilical hernia was defined as the presence of a palpable fascial defect beneath the umbilical cicatrix irrespective of size.

Results

There was adequate data in 206/236 patients and 102/206 were males. Of the 206, 124 were of African descent, 73/206 Caucasian, 5/206 Asian and the rest other ethnicity. Total complication rate was 18/206 (8.74%) while incarceration rate was 17/206 (8.25%). Median size of fascial defect was 1cm (range 1- 2cm) for incarcerated and 1.5 cm (range 0.5-10 cm) for the incarcerated.

Conclusion

The complication rate of 8.74% in this study suggests complications are not as rare and may justify earlier repair.

Keywords: umbilical hernia, complications, hernia repair

 

Introduction

Umbilical hernia is a common finding in infants and children with a prevalence of 3-30% reported in the literature [1, 2, 3]. It is more common in people of African descent with Evans noting an incidence of 3% in Caucasian infants and 24.7% in infants of African descent [1]. A higher incidence has also been noted in low birth weight infants and in conditions such as Down syndrome, cretinism and hypothyroidism [1, 2, 4, 5].

The condition is characterized by a defect in the fascia beneath the umbilical cicatrix allowing for protrusion of the cicatrix with increase in intra-abdominal pressure. Umbilical hernias are due to incomplete closure of the umbilical ring allowing intra-abdominal contents to protrude through [4]. The aetiology is unknown but most occur through the umbilical vein part of the umbilical ring [4]. A failure in the normal growth of the dense connective tissue which should occupy the umbilical ring may contribute to the local problem [5].

It would appear that a patent orifice at the umbilicus is present for some time after birth and can be regarded as normal [5]. Vohr et al. had demonstrated the decreasing incidence of the condition in low birth weight babies they followed during the first year of life [4]. They observed a fall in incidence from 75% at 3 months to 0% at 12 months in this group of patients [4]. Walker in 1967 followed up 314 children of African descent with umbilical hernias who were under 3 months of age and noted spontaneous resolution in 85% of them by 6 years of age [6]. He observed that fascial defects with diameters below 1.5 cm closed before the age of 6 years while those bigger than that did not. He therefore recommended the repair of such defects before entry to school to avoid embarrassment. Others have noted a progressive decrease in the prevalence of umbilical hernia with age and observed continued closure of the defect up to the age of 14 years [3, 7].

Complications are believed to be rare in umbilical hernias and most umbilical hernia repairs occur at school age mainly for psycho-social reasons [1, 8, 9]. Complications have been estimated to occur in 1:1500 umbilical hernias [10]. However, more recent publications suggest a complication rate of 5.1- 44% in children with umbilical hernia treated in the hospital [11, 12, 13].

Is the complication rate increasing in this seemingly innocuous condition? This study aims to ascertain the complication rate of umbilical hernias in children and revisit the policy of repair just before school age.

Method

This was a retrospective study of 236 patients who presented to University hospital Lewisham, a tertiary referral center, with a diagnosis of umbilical hernia from 2006 to 2010. Approval was obtained from the research and audit department of the hospital. Case notes were reviewed and parents contacted by telephone where necessary. Umbilical hernia was defined as the presence of a palpable fascial defect beneath the umbilical cicatrix irrespective of size. Data was recorded on an excel spreadsheet. Statistical analysis was carried out using Stata software version 8.2 (Statacorp Lakeway drive, College Station, Texas, USA).

Results

During the study period 236 patients with umbilical hernias of which 206 had adequate data for analysis were seen at our centre. There were 102/206 males. Most 124/206 (60%) were of African descent, 73/206 (35%) were Caucasian, 5/206 were Asian and the rest other ethnicity. Of the 120/206 that had data on gestational age 31 (25%) were born preterm. Most cases 124/206 (60%) were first noted in infancy. The median age of noting was < 2 weeks (range: < 2 weeks – 13 years) while the median age of presentation was 3 years (range 0 – 15 years).

There was a protrusion above the level of the skin in 201/206 (98%). The umbilical hernia was described as large in 46 (22.3%), moderate in 57 (27.7%), small in 80 (38.8%) and not described in 23. The median size of fascial defect was 1.5 cm (range: 0.5 – 10 cm).

Occasional abdominal pain without incarceration was reported by 36/206 (17.5%) of the patients. Overall complication rate was 18/206 (8.7%) with an incarceration rate of 17/206 (8.25%). Incarceration rate was 10/124 (8.1%) in patients of African descent and 4/73 (5.5%) in Caucasians (P=0.52). The incarceration rate was 10/104 (9.6%) in females and 7/102 (6.9%) in males (P=0.47). Five patients were seen prior to presenting with incarceration. The interval between being seen and incarceration was 1 day to 2 months. The median age at incarceration was 2 years (range: 3 months – 9 years). Those that had undergone incarceration had a fascial defect size of 1cm (8/54) or 2 cm (3/40). There was no difference in fascial defect size between those that had an episode of incarceration and those that did not (Table 1).

Table1: Fascial defect size

Median (Range) (cm)

P-value

Incarcerated

1 (1-2)

 0.26

Not incarcerated

1.5 (0.5-10)

Of the 17 with incarceration, 15/17 were reduced while 2/17 had emergency surgery because of failed attempts at reduction. Reduction was spontaneous in 3/15, by the Senior House Officer (SHO) in 1/15, Registrar in 9/15 and consultant in 2/15. Pressure alone was all that was required to achieve reduction in most of the patients (Table 2).

Table 2: Reduction aids

 

Number

Pressure alone 

10

Required morphine

2

In transit

2

Non

1

Twenty four patients did not have an operation. Resolution without interference was noted in 18/206 patients. One remained stable, another was yet to be repaired and in one patient mother declined surgery.

One patient with portal fibrosis and ascites was transferred to the liver center. Most were operated on for psychosocial reasons while 8 had an urgent operation (Table 3). Of the 17 that were incarcerated, 8 had an urgent operation. One patient was lost to follow up following the Accident and Emergency visit and did not have an operation.

Table 3: Reason and mode of operation

Operated on (182)

Reason

for operation

Psychosocial

147

Symptoms

35

 

 

 

Mode of operation

Elective

174

Urgent

8

There was no difference in outcome between those that had an elective procedure and those that had an urgent procedure.The mean age at operation was 5 ± 2.9 years while the average time to operation was 3 months (Table 4). Only 8 (4.4%) patients had the procedure as in-patients and the primary surgeon was the Trainee in 136/182 (75%) of the cases.

Table 4: Age, time and weight at operation

 

Mean ± SD

Age at operation

5 ± 2.9 years

Time on waiting list

2.9 ± 2.6 months

Weight at operation

21.27 ± 10.8 Kg

The sac was empty in 169/182(93%), contained omentum in 6 (3.3%), preperitoneal fat in 2, bowel in 1 and content not specified in 2 patients. Fifty nine (32.4%) patients were reviewed in clinic after operation. The median time of review was 3 (0.5-12) months the median length of follow up was 3 (2-36) months. The postoperative complication rate was 3.3% with a recurrence rate of 2.2%. Median time of recurrence 4.5 (range: 2 - 6) months (Table 5). A trainee was the primary surgeon in the 4 recurrences.

Table 5: Postoperative complications

Wound infection

1 (0.5%)

Redundant umbilical skin

1 (0.5%)

Recurrence

4 (2.2%)

Total

6 (3.3%)

Discussion

The reported prevalence of 3-30% [1, 2, 3] in umbilical hernias makes it a condition parents will always consult the pediatric surgeon for advice and treatment. Umbilical hernias are considered by many to be a low risk condition with an 85% resolution rate by age 6 years and resolution continuing till the age of 14 years [3, 6]. Lassaletta et al reported a complication rate of 5.1% in 1975 while Papagrigoriadis et al in 1998 reported a complication rate of 1:1500 following a literature survey [10, 11]. Most pediatric surgeons defer operative repair till 4 to 6 years or just before the children start school to allow for spontaneous closure [9, 12].

However, more recent literature seems to suggest a higher complication rate. Keshtgar and Griffiths in 2003 reported their experience of 7 cases of incarcerated umbilical hernia seen over 3 years and wondered if the trend was increasing [14]. Ameh, Chirdan and Nmadu in 2003 noted that 30 of 47 children that presented for repair of umbilical hernias over a period of 14 years in Nigeria had complications [15]. Acute incarceration was noted in 15/30, recurrent incarceration in 10 and spontaneous evisceration in 5. Chirdan, Uba and Kidmas in 2004 reported an incarceration rate of 44.2% [13]. In their series of 52 children with umbilical hernias seen over an 8 year period in their institution in Nigeria, they noted acute incarceration in 17 and recurrent incarceration in 6.

These hospital based studies have raised the concern that umbilical hernias may not be as innocent as they seem. This study aims to ascertain the hospital based complication rate of umbilical hernias in children and revisit the policy of repair just before school age.

This study looked at 206 children seen with umbilical hernias in a busy tertiary hospital in London over a 4 year period. The majority (60%) were of African descent as has been reported by previous authors [1, 2, 5, 6]. Twenty five percent of the patients in the study were born preterm. However the study did not attempt to look at the incidence of the condition in preterm babies. Recurrent abdominal pain without incarceration was a presenting feature in 17.5% of the patients. It was not easy to ascertain whether the umbilical hernia was contributory to the discomfort. Wood had noted the presence of abdominal pain in 5/143 patients referred to hospital for consultation [5]. She reported that one patient had repair of the hernia without relief of symptoms.

Our overall complication rate was 8.7% with an incarceration rate of 8.3%. This correlates well with the findings of previous studies. Zendejas et al in a recent study of 489 children who had a primary umbilical hernia repair over a fifty three year period reported a complication rate of 7% [12]. They also noted that the emergent repair/ complication rate remained constant throughout the study period at 6-8% per decade. The other complication noted in our study apart from incarceration was clear fluid discharging from the umbilicus in a 6 month old male infant with portal hypertension and ascites who was transferred to the liver center. There was a slight predominance of incarceration in females in this study. This was different from the findings of Lassaletta et al who noted a slight preponderance of incarceration in males (5.7%) compared to females (3.9%) [11]. They also noted that medium sized fascial defects (0.5-1.5cm) were twice as likely to be incarcerated than smaller or larger defects. Ameh et al had noted that all complications occurred in hernias with a fascial defect with diameter greater than 1.5 cm [15]. Our study did not demonstrate any preponderance of incarceration in patients with a fascial defect of any size. There was no significant difference in fascial defect size between patients with incarceration (median 1cm. Range: 1 - 2 cm) and those without incarceration (median 1.5 cm. range: 0.5- 10 cm). This agrees with the findings of Chirdan et al who noted that incarceration occurred in patients with fascial defect as small as 0.7 cm and as big as 4 cm [13].

Altogether 8/17 with incarceration had an urgent operation and no difference in outcome was noted between those that had an urgent operation (within 48 hours) and those that had an elective day surgery procedure.

Some authors have suggested that umbilical hernias in children should be repaired prophylactically to avoid later complications as adults. Morgan et al in 1970 reported a higher mortality and morbidity in adults with incarcerated umbilical hernia than in children [16]. Of the 108 patients that presented to them with incarcerated umbilical hernias 101 were adults and 7 were children. All the children were operated on with no morbidity or mortality. Thirteen of their adult patients were observed and not operated on of which 4 died while 88 were operated on of which 1 died. They also reported that 90% of their adult patients were obese multiparous women of which many had had recent child births. They therefore concluded that prophylactic umbilical hernia repair should be performed in all girls over 2 years old and in all children over 4 years old to prevent complications as adults.

However other authors have suggested that umbilical hernias in children and adults may not be the same pathology. Woods in 1953 followed up 283 infants in whom an umbilical hernia was noted before the age of 2.5 years [5]. She reported a high incidence of 1: 5.4 in healthy babies seen at the infant welfare clinic. This incidence decreased with age with spontaneous resolution. She suggested that a patent umbilical orifice is present for some time after birth and can be regarded as normal and the anatomical state regarded as no more than a variation of the normal. Gibson and Gaspar in 1959 reviewed 606 cases of umbilical hernias [17]. They were divided into 198 infantile (congenital) umbilical hernias and 408 adult (acquired) umbilical hernias. The infantile hernias were observed soon after birth. Those that persisted beyond the fifteenth birthday they included in the adult group. They concluded that umbilical defects in children are due to a weak umbilical scar or failure of fusion of the fascial ring with the fibrosed umbilical vein while in adults umbilical hernias are due to the widening and stretching of the linear alba due to specific acquired causes.

Jackson and Moglen attempted to evaluate the congenital residue from the adult level. In their study of umbilical hernias in 134 adults, they reported a congenital residue of 10.9% in one of their series [8]. They noted a relatively high proportion of Caucasians compared with those of African descent with acquired umbilical hernias while they had more patients of African descent with the congenital residue. Most of the acquired umbilical hernias were of short duration and had a ring size of less than 1.5 cm in both racial groups. They concluded that umbilical hernias with smaller ring sizes in adults appeared to be of short duration and were often associated with sudden and insidious increase in intra-abdominal pressure.

Lau et al in a recent study looked at the incidence of noninguinal hernias in adults and its relationship with obesity. In their study 74.3% of their patients had nonincarcerated umbilical hernias. They noted that the risk of having a noninguinal abdominal wall hernia increased with advancing age, male gender, white ethnicity and increasing body mass index (BMI).

They also noted that the risk of incarceration increases with BMI, age older than 50 years and female gender. It therefore does seem that adult umbilical hernias are a different pathology with the majority being acquired and the congenital residue constituting only 10% with the morbidity and mortality skewed in favour of the acquired variety. This study was limited by its retrospective nature and the fact that it is hospital based and therefore does not capture all the umbilical hernias in the community and the denominator may therefore be smaller.

Conclusion

Adult umbilical hernias may therefore be a different entity from umbilical hernias in children. However, complication rates in children seem to have remained the same. The complication rate of 8.74% and incarceration rate of 8.06% in this study does suggest that complications are not as rare as previously suggested and may justify an earlier repair. Parents can be counseled there is less than 10% chance of a complication in an umbilical hernia. However a case could be made for earlier repair of large defects in younger age group to further reduce the risk of complications.

 

 

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