HERNIA

LIVSON THOMASM.Sc. (N) 1st YearCMC & Hospital, Ludhiana.

DEFINITION

A hernia is the protrusion of an organ or the fascia of an

organ through the wall of the cavity that normally contains it.

Hernia is the protrusion of intestine through a weakness in

abdominal muscles

TYPES OF HERNIA IN CHILDREN

1. Inguinal Hernia

2. Umbilical Hernia

3. Diaphragmatic Hernia

4. Omphalocele & Gastroschisis

INGUINAL HERNIA

An inguinal hernia is a protrusion of abdominal

cavity contents through the inguinal canal.

TYPES OF INGUINAL HERNIA

I. DIRECT: enters through a weak point in the fascia of the abdominal wall. Present mostly in adults.

II. INDIRECT: It protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure.

PATHOPHYSIOLOGY

During fetal development

Out pouching of peritoneum-into scrotum covering the testis

Sac portion is called tunica vaginalis

Proximal portion of vaginalis fail to close- a potential hernial sac is formed.

CONT…

An abdominal structure or abdominal fluid can be pushed into this potential sac resulting into hernia.

Eventhough the potential sac is present, hernia develops only until infant is 2 to 3 months old.

UMBILICAL HERNIA

It is the protrusion of the intestine and omentum

through a hernia in the abdominal wall near the

navel; usually self correcting after birth.

PATHOPHYSIOLOGY

During development of foetus

A small opening is present in the abdominal muscles, so that the umbilical cord can pass through, connecting mother to baby.

Usually the abdominal opening closes.

Sometimes these muscles do not meet- creating a small opening.

A loop of intestine can move into the opening between abdominal muscle and cause and hernia.

CLINICAL FEATURES

Bulge or swelling appear in the belly- button area.

Swelling may be noticeable when baby cries.

DIAGNOSTIC EVALUATION

Physical Examination Abdominal X-ray Ultrasound

MANAGEMENT

By 1 year of age the umbilical hernia usually closes. Nearly all hernias close by 5 years of age.

If hernia becomes bigger with age, is not reducible or still present, its repaired surgically:

During surgery a small incision is made in the umbilicus and loop of intestine and the loop of intestine is placed back into the abdominal cavity.

The muscles are then sutured together

OMPHALOCELE & GASTROCHISIS

Gastroschisis: It is the congenital anomaly characterized by a defect in the anterior wall through which the abdominal contents freely fall.

Omphalocele: It is a congenital birth defect that involves the umbilical cord itself, and the organs remain enclosed in the visceral peritoneum.

RISK FACTORS

Young mother < 20 Folic acid deficiency Hypoxia Substance abuse High risk pregnancies

PATHOPHYSIOLOGY

An omphalocele is caused by error in the embryonic development

Normal development there are 3 distinct portions formed – foregut, midgut & hindgut

Much of midgut is temporarily herniated outside the abdomen at the umbilicus

The midgut later re-enters the abdomen and opening of abdominal wall is closed

Failure for the midgut to return and re-enter the abdomen

Omphalocele is formed

CLINICAL FEATURES

4-12 cms, centrally located. Dystocia may occur Rupture may occur Ectopic liver Abdominal and thoracic cavity under developed

MEDICAL MANAGEMENT

Neonates with intact omphalocele are usually in no distress unless associated with pulmonary hypoplasia

The baby should be carefully examined to detect any associated problems.

Maintainence of intravenous fluids are administered

Prophylatic antibiotics are given

SURGICAL MANAGEMENT

Its treated by mobilizing skin flaps to cover the omphalocele sac.

A circumferential incision is made.

Teflon sheets are sutured along the edge of the fascia and approximated over the omphalocele sac.

Reduction is effected by gradually pulling teflon sheet. At the right time the omphalocele sac is excised and teflon sheet is removed and a dual patch is sutured circumferentially to the remaining fascia

CONGENITAL DIAPHRAGMATIC HERNIA

CDH is a defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity.

TYPES:1. Bochdalek hernia2. Morgagni hernia3. Diaphragm eventration

BOCHDALEK HERNIA

It also known as postero- lateral diaphragmatic hernia, is most common CHD.

In this the diaphragm abnormality is characterized by a hole in the postero- lateral corner of the diaphragm, which allows passage of the abdominal viscera into the chest cavity.

MORGAGNI HERNIA

This a rare kind, anterior part of diaphragm or retrosternal portion a defect is present.

Herniation occurs through foramen of Morgagni, located immediately adjacent to xyphoid process of the sternum.

DIAPHRAGM EVENTERATION

It occurs when diaphragm is thinner, allowing the abdominal viscera to protrude upward into chest cavity.

PATHOPHYSIOLOGY

Failure of the diaphragm to completely close during development

Herniation of abdominal content into chest cavity

Congenital Diaphragmatic Hernia

MANAGEMENT

Orogastric tube placement and securing airway

Baby placed on ventilator

ECMO- Extra Peritoneal Membrane Oxygenation

An incision is made in the abdomen. The hernia is stitched close.

ECMO