In many areas of the developing world a child commonly has a defect in his linea alba at his umbilicus through which a hernia forms. These hernias rarely obstruct or strangulate, usually heal themselves without treatment, and seldom need repair. In areas where they are common, and accepted as being merely a variant of the normal, there will be little demand for surgery. Accept this and don't operate without good reason.
If you do have to operate, repair is usually straightforward. The patient's umbilical scar is weak and the neck of the sac wide; it has one compartment, and is covered by skin, to which it may be closely adherent. It may contain small gut, omentum, or large gut, and rarely strangulates. Strapping it is useless.
KAKAZI, a 14 year old Munyankole girl, who had just received a letter admitting her to a secondary school, presented at a remote rural hospital (Stojo) with an obstructed, infected, ulcerated, gangrenous umbilical hernia the size of a small fist. She was vomiting and her abdomen was was distended. There were no sterile drums, and no diesel with which to run the generator and operate the electrical sterilizer. There was no petrol for the ambulance, so she could not be referred. Equipment was sterilized on a charcoal stove. She was given the hospital's last bottle of intravenous fluid and anaesthetized with ether from an EMO. There was no hernial sac to isolate, because infection had destroyed it. Gangrenous small gut was resected and anastomosed, her abdomen was closed, and she recovered completely. LESSON Never give up! Dr Bosco Rwakimari's patient. Fig. 14-19 THE INFANTILE TYPE OF UMBILICAL HERNIA. A, make a curved incision below the child's umbilicus. B, reflect a skin flap which includes it. C, open the sac at its neck, and close it with a purse string suture. D, close the opening in his linea alba with a few interrupted sutures. E, the operation complete. After Rob C and Smith R, ''Operative Surgery: Part I: Abdomen, Rectum and Anus (2nd edn 1969) p.208 Figs. 1 to 4. Butterworths, with kind permission.
UMBILICAL HERNIAS IN CHILDREN For exomphalos, see Section 28.8.
MANAGEMENT. If a child is born with a small hernia, reassure his mother that it will become a little larger up to 4 or 5 years, then it will become relatively smaller as he grows, before it finally disappears. If she blames a hernia for recurrent bouts of periumbilical pain, make sure that this is not due to hookworms or sickle-cell crises.
OPERATIVE TREATMENT for an uncomplicated hernia is only indicated if a child has reached the age of 6, and his hernia is more than 5 cm across at its neck (rare).
INCISION. Preserve his umbilicus if you can; if his hernia is large you may have to excise it.
Make a curved transverse incision, below the hernia (A, in Fig. 14-19). Dissect down to his anterior rectus sheath and around his umbilicus, so as to reflect an upper flap to include his umbilicus. If dissecting the fundus of the sac free from his umbilicus is difficult, leave it. Find and define the sac back to his linea alba (B).
Reduce the contents of the sac, if it is not already empty, and open it between haemostats, as usual when entering the peritoneal cavity (9-2). Enlarge the opening with small lateral incisions. Transfix the sac with a purse string suture, or, transfix, tie, and excise it (C).
Drop the stump back into his abdomen. Overlap the edges of his rectus with interrupted sutures (D). Close his skin, and apply a firm dressing (E).
If an umbilical hernia does become irreducible, or strangulates (rare), you may have to operate. The same principles apply as in any other strangulated hernia. See the story of Kakazi above.
Fig. 14-20 SOME MORE HERNIAS. A, an umbilical and an inguinal hernia in boy of 3 years. His inguinal hernia will need repairing, but his umbilical one will not. B, and C, a paraumbilical hernia containing most of the patient's gut and omentum. Note the healed ulcer on the fundus. The mass is knobbly because of visible peristalsis. D, and E, incisional hernias following Caesarean section. After Lade Worsunu, with the kind permission of the Editor of Tropical Doctor.