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 herniae rarely obstruct or strangulate, usually become smaller with age 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.
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' Abdomen, Rectum and Anus part I 1969 p208 Figs. 1-4, Publishers Butterworths, with k ath 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 (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 (very rare), you may have to operate. The same principles apply as in any other strangulated hernia.
Fig. 14-20 SOME MORE HERNIAE. 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 with incarceration 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, an incisional herniae following Caesarean section. After Lade Worsunu, with the kind permission of the Editor of Tropical Doctor.