Thissiteisintendedforhealthcareprofessionals

AbdominalHerniasTreatment&Management
Updated:Dec22,2016
Author:AssarARather,MBBS,MD,FACSChiefEditor:JohnGeibel,MD,DSc,MSc,AGAFmore...

TREATMENT

ApproachConsiderations
Trussesplacepressureontheskinandbowel,inducerelatedinjury,andmasksignsofincarceration
andstrangulation.Thetemporaryuseofbindersorcorsetscanbeusefulinpatientswithlargenecked
hernias,duringthepreoperativeperiod,orinsituationswherethereisahighriskofoperationona
longtermbasis.
Herniareductionorrepairmaybecarriedout,dependingonthetypeofherniaandonwhether
incarcerationispresent(seebelow).Reductioncanoftenbecarriedoutintheemergencydepartment
(ED),butasurgeonshouldbeconsultedforthefollowingreasons[30,4,7]:
Inabilitytoreducethehernia
Concernforastrangulatedbowelandapatientwithatoxicappearanceallincarceratedor
strangulatedherniasdemandadmissionandimmediatesurgicalevaluation
Comorbidrisksforsedationpatientswithsuchrisksshouldhaveasurgeonpresentfortheinitial
reductionattempt
Surgicaloptionsdependonthetypeandlocationofthehernia.

Inguinalhernia
Ingeneral,thepresenceofaninguinalhernia,intheabsenceofmitigatingfactors,constitutesan
indicationforrepairtopreventthecomplicationsofprolongedexposure(eg,incarceration,
obstruction,andstrangulation).[31]Althoughpressurereductionofanincarceratedherniaisgenerally
safe,failuretoreduceisnotinfrequentandmandatespromptexploration.
Signsofinflammationorobstructionshouldruleoutattemptsatreduction.Difficultreductionshould
promptlybefollowedbyrepair.Unintentionalreductionoftheintestinewithvascularcompromise
leadstoperforationandperitonitiswithhighmorbidityandmortality.Enmassereductionafter
vigorousattemptsatreducingaherniawithasmallfibrousneckresultsinongoingcompromiseofthe
entrappedbowel.

Umbilicalhernia
Inadults,umbilicalherniarepairisindicatedforincarceration,asmallneckinrelationtothesizeof
thehernia,ascites,chromaticskinchange,orrupture.Inchildren,theapproachtomanagingan
umbilicalherniaisrelatedtothenaturalhistoryofumbilicalherniasandtheirimportanceinadulthood.
Mostumbilicalherniasclosespontaneouslyinchildrenduringthepreschoolageperiod.Therefore,
repairofanumbilicalherniaisnotindicatedinchildrenyoungerthan5yearsunlessthechildhasa

largeproboscoidherniawiththin,hyperpigmentedskinorisundergoinganoperationforother
reasonsoriftheherniacausesfamilialorsocialproblems.
Itisthesizeofthefascialdefect,ratherthanthesizeoftheexternalprotrusion,thatpredictsthe
potentialforspontaneousclosure.Walkerdemonstratedthatfascialringsmeasuringlessthan1cmin
diameterusuallyclosespontaneously,whereasringslargerthan2cmseldomdo.[22]Accordingly,
manypediatricsurgeonswillrepairumbilicalherniaswithlarge(>2.5cm)fascialdefectsearlierthan
herniaswithsmallerfascialdefects.
Incarcerationofumbilicalherniasisrareinthepediatricpopulation.Overa15yearperiod,onlyseven
childrenwithanincarceratedumbilicalherniawerereportedattheJohnsHopkinsHospital.In
comparison,101casesofumbilicalherniaincarcerationoccurredinadultsatthatinstitutionduringthe
same15yearperiod.Omentumisthemostfrequentlyincarceratedorgan.

Otherherniatypes
Painfulpreperitonealfatinanepiploceleorparaumbilicalherniamaybeincarcerated.Becausethese
defectswillnotclosespontaneouslyandapropensityexistsforpainfulstrangulation,elective
outpatientrepairisrecommended.
Becauseofthepotentialforincarceration,spigelianherniasshouldberepaired,asshould
interparietal,supravesical,lumbar,obturator,sciatic,andperinealhernias.Notably,strangulationcan
occurinaRichterherniawithoutevidenceofincarcerationorobstruction.

Electiveversusacuterepair
Aretrospective,singleinstitutionstudyreportedthatpatientswithfemoral,scrotal,andrecurrent
hernias,aswellaspatientsofadvancedage,aremorelikelytoundergoacuteherniarepairversus
electiveherniarepair.[32]Acuteherniarepairreportedlyhasahighermorbidityandlowersurvival
ratesthanelectiveherniarepairdoes.
Contagiousdisease,diaperrash,nearbyopenwounds,anupperrespiratorytractillness,orother
intercurrentillnessshoulddelayanelectiveprocedureotherdelaysprobablyincreasetherisksof
operativecomplications.Incaseswheretheriskofoperationexceedsthatofpotentialproblemsfrom
thehernia,nonoperativeobservationiswise.

HerniaReduction
Inattemptingherniareduction,thefirststepistoprovideadequatesedationandanalgesiasoasto
preventstrainingorpain.[1,6,33]Thepatientshouldberelaxedenoughthatheorshewillnot
increaseintraabdominalpressureortightentheinvolvedmusculature.
Thepatientshouldbesupine,withapillowundertheknees.Foraninguinalhernia,thepatientshould
beplacedinaTrendelenburgpositionofapproximately1520.Theipsilaterallegisplacedinan
externallyrotatedandflexedpositionresemblingaunilateralfroglegposition.Apaddedcoldpack
maybeappliedtotheareatoreduceswellingandbloodflowwhileappropriateanalgesiais
established.Icecoolingofanincarceratedherniaiscounterproductive.
Simplepressureoverthedistalsacusuallyisineffective,inthattheincarceratedvisceraarelikelyto
mushroomovertheexternalring(seethefirstimagebelow).Instead,twofingersareplacedatthe
edgeofthehernialring,andfirm,steadypressureisappliedtothesideoftheherniacontentscloseto
theherniaopeningandmaintainedforseveralminuteswhiletheherniaisbeingguidedbackthrough
thedefect(seethesecondimagebelow).

Herniacontentballoonsoverexternalringwhenreductionisattempted.

ViewMediaGallery

Herniacanbereducedbymedialpressureappliedfirst.

ViewMediaGallery
Inchildren,pressureshouldbeappliedfromtheposterioranddirectedlaterallyandsuperiorlythrough
theexternalring.Itshouldbekeptinmindthattheinternalringininfantsismoremedialthanthe
internalringinolderchildrenandadults.Thehourglassconfigurationofaherniahydrocelecomplex
willnotreducewithpressureappliedtothehydroceleportion.
Ifsuccessisnotachievedafteroneortwoattemptsatreduction,asurgeonshouldbeconsulted
repeatedforcefulattemptsarecontraindicated.Painafterasuccessfulreductionmayindicatea
strangulatedhernia,necessitatingfurtherevaluationbyasurgeon.
Thespontaneousreductiontechniquerequiresadequatesedationandanalgesia,Trendelenburg
positioning,andpaddedcoldpacksappliedtotheherniafor2030minutes.Thiscanbeattempted
beforemanualreductionattempts.

TopicalTherapy
Cauterizationwithsilvernitrateaidsintheresolutionofanumbilicalgranuloma.Ifthereisastalk,
ligationofthebaseresolvestheproblem.Delayingtherepairofumbilicalorasymptomaticepigastric

herniasuntilchildrenareolderthan5yearsallowsspontaneousclosureinmostchildren.Strapping,
withorwithoutacoin,isnotindicatedinthetreatmentofumbilicalhernia,becauseofproblemswith
skinerosionandlackofeffectiveness.
Grobintroducedtheuseofmerbrominasanescharoticforscarifyingtheintactsacofagiant
omphalocele.However,thedevelopmentofmercurypoisoningterminateditsuse.Chemicaldressings
usingsilversulfadiazine(whichhasleukopeniaasacomplication),povidoneiodinesolution
(hypothyroidismasacomplication),0.5%silvernitratesolution(argyrismasacomplication),and
gentianviolethaveservedasagentstoprotectagainstinfectionwhilethesacepithelializes.
Incurrentpractice,onlylifethreateningassociatedconditions,poorprobabilityofsurvivalininfants,or
failureofbettermeansofcoveragewarrantuseofthesemethods.Alargeresidualventralhernia
results,whichmaybeproblematicbecauseoflossofdomain.
Progressivecompressiondressingofanomphalocelesacwithaninnerlayerofsalinemoistened
dressingsandanouterdressingofaselfadhesivecompressionbandagecanreducevisceraover5
10days,afterwhichtimedelayedprimaryfascialandskinclosureisaccomplished.
Forchildrenwithanomphaloceleandlifethreateningassociatedconditions,apoorprobabilityof
survival,oraverylargeomphalocele,thecombinationoftopicalescharoticagentsanddaily
abdominalwrappingwithanelasticbandagehasproducedsuccessfulclosureinmanypatients.
Asthechildgrows,thedefectremainsthesamesizeandbecomessmallerrelativetotheincreasing
abdominalwall.Delayedclosurefollowingepithelializationcanallowprimaryfascialclosurewithno
prosthesis,whicheliminatestheneedformultipleoperations.Externalcoveragewithpigskin,skinlike
polymermembrane,orhumanamnioticmembranecanbeusedadjunctivelyinthetreatmentofgiant
omphaloceleorafterfailedprimarytherapy.

SurgicalRepairofInguinalHernia
Thefundamentalsofindirectinguinalherniarepairarebasicallythesame,regardlessoftheageat
presentation.Reductionorexcisionofthesacandclosureofthedefectwithminimaltensionarethe
essentialstepsinanyherniarepair.Iftissueissufficientlyattenuatedastoprecludefollowingthese
precepts,manytechniquesinvolvingthereleaseoftensionbyflaps,prostheticmaterials,orasimple
relaxingincisioninadjacenttissuewillfulfilltherequirements.Overlay,underlay,andsandwichingof
theedgeswithplasticmeshesconstitutemosttechniquestoday.
Returntoworkisdictatedbytheapproachandtheamountofphysicalactivityinvolvedwiththejob.
Accuratepostoperativeinstructionandeasyaccesstocare(ifproblemsarise)areaseffectiveasafull
postoperativevisitfollowingroutineinguinalherniarepairs.

Basicrepairtechniques
BassiniandShouldicerepairs
TheessenceoftheBassinirepairisappositionofthetransversusabdominis,transversalisfascia,and
lateralrectussheathtotheinguinalligament.Thisisusuallyperformedbyimbrication(seetheimage
below).TheShouldicetechniqueusestwolayersofcontinuoussutureinasimilarfashion.

Bassinityperepairapproximatingtransversusabdominisaponeurosisandtransversalisfasciatoiliopubictract
andinguinalligament.

ViewMediaGallery
Cooperrepair
TheCooperrepairapproximatestheconjointarea,transversusabdominis,andtransversalisfasciato
thepectineal(Cooper)ligament.Overlyingthevein,thesestructuresaresewntotheiliopubictract.
Thistechniquealsoprovidesagoodapproachfortherepairoffemoralhernias.
Tensionfreemeshrepairs
Thestandardadultherniarepairnowusesprosthesestoreinforcethefloor,usuallypolypropylene
mesh.Thematerialcanoverlay,underlay,orsandwichtheareaorcanbeusedasaplug.This
providesatensionfreerepairandexcellentresults,butitcarriesaslightlyincreasedriskofwound
infection.TheLichtensteinhernioplastyiscurrentlyoneofthemostcommonlyperformedmeshbased
tensionfreerepairs(seeOpenInguinalHerniaRepair).
Thepreperitonealapproachhasadvocateswhoclaimthatthisapproachmakesiteasiertoidentify
thesac,reducethecontents,anddissectthecordstructures.Mechanicaladvantagesincludetheuse
ofnaturalintraabdominalpressuretokeepthemeshinplaceoverallpotentialherniasites.Thebest
usesareintherepairofherniasincidentallyencounteredduringotherabdominalprocedures,
recurrenthernias,andfemoralhernias.
APfannenstiel,lowermidline,orotherincisionisusedtoreachthepreperitonealplane.Theinternal
inguinalringandtheherniasacareidentifiedlateraltotheinferiorepigastricvessels.Afterthesacis
dissectedfromthetesticularvesselsandvasdeferens,itisdividedandtheperitoneumclosed.The
repairfollowsthepectinealapproachandoftenhasmeshapplied.
Simplerepairforpediatrichernias
Asimpleinguinalherniarepairispossibleinchildrenbecauseofthesmallersize,bettermuscletone
inthecanal,andrapidrecuperation.Excisionofthehernialsac(processusvaginalis)isusually

sufficient,withlittleneedforprostheticrepairofanattenuatedinternalringorposteriorwallofthe
inguinalcanal.Eitherpreincisionalinjectionoftheincisionsiteoracaudalblockispreferabletono
preincisionaltherapy.[34]
Asmallincisionismadejustsuperiorandlateraltothepubictubercleinthesuprapubicskincrease,
centeringtheoperativefieldneartheinternalring.Theexternalobliqueaponeurosisisincisedinthe
directionofitsfibers,ortheinternalandexternalringsaretransposedbylaterallyretractingthelatter.
Tuggingonthetestishelpsvisualizecordstructures.Theglisteningwhiteherniasacoftenbulgesup
amidthecord.Thesac,locatedanteromedialtothecord,iselevatedfromthefloorandcarefully
dissectedfreefromthevasdeferensandtesticularvessels.
Shortherniasacsarefreedtotheinternalring,butlongsacsareoftenbestdivided.Proximal
dissectiontotheinternalringshouldextenduntilpreperitonealfatisvisiblecircumferentially.Twisting
thesacbeforeligationprovidesstrengthandnarrowstheinternalring.Thesacisligatedatitsbase.
Becauseofoccasionalpostoperativespittingofanonabsorbable(eg,silk)suture,syntheticsutures
areusedforsacligation.
Iffascialrepairseemsnecessary,thetransversalisfasciaissuturedtotheshelvingmarginofthe
ilioinguinalligament.Theincisionisclosedinlayers,andasingleadhesivestripisplaced.Thetestis
mustbepulledintothescrotumtopreventiatrogeniccryptorchidism(seetheimagebelow).

Iatrogeniccryptorchidtestisinchild.Takingcaretopositiontestisinscrotumisintegralpartofcompletionofhernia
repairinboys.

ViewMediaGallery
Approximately2%ofgirlswithinguinalherniashaveanintersexdifferentiationsyndrome.Eachgirl
shouldhavethefallopiantubesandovariesexamineddirectlyorviaperitoneoscopy.Theherniasac
ofafemalepatientmustbescrupulouslyexaminedforsignsoftesticulartissueifitcontainsanovary.
Themostcommoncauseofthisistesticularfeminization(androgeninsensitivity)syndrome,which
resultsfromendandrogenresistanceandleadstoasmalltestisandarudimentaryvagina(persistent
genitourinarysinus)withoutfallopiantubesorauterus.Ifagirlwithaherniahastesticular
feminization,agonadectomyononesideandisolationoftheothergonadinasuperficialpositionuntil
pubertypermitssecondarysexualcharacteristicstodevelop.Hermaphroditeshaveanasymmetric
ovotestis,whichshouldnotberemoved.

Anincarceratedobjectwithinaninguinalherniainagirl,especiallyinaninfant,isusuallyanovary.An
incarceratedovaryisnotusuallyreducible,butstrangulationisinfrequent,makingsurgicalreduction
oftheirreducibleovarylessurgentthanreductionofanincarceratedintestinewouldbe.Achildwith
anincarceratedherniacontainingtheintestinethatsuccessfullyisreducedshouldbeadmittedfor1
daytoallowresolutionofedemabeforerepair.
Achildwithtachycardia,fever,orsignsofobstructionmustbeoperatedonimmediately.Fluidand
electrolytecorrectionandantibioticadministrationprecedetheoperation.Testicularatrophyoccurs
withincarceratedpediatrichernias,andtheparentsshouldbewarnedofthepossibility.
Exposingandopeningthesacbeforedividingtheexternalringpermitsthecontainedintestinetobe
controlledwithaclamp,preventingunintentionalreleaseofthebowelintotheabdomen.Oncethe
viabilityoftheincarceratedintestineisensured,dividingtheexternalring(andsometimestheinternal
obliquemuscles)laterallywillreduceit.
Laparoscopythroughtheherniasaccanbeusedtoassessvisceralviabilityifincarceratedintestinal
contentsreducebeforevisualization.Thegangrenousbowelisresected,anendtoendanastomosis
isperformed,andtheintestineisreturnedtotheabdomen.Repairofthecontralateralside,ifrequired,
isdeferred.Anapparentlyinfarctedtestisisleftinplaceafteracapsulotomyisperformed.

Laparoscopicrepairtechniques
Laparoscopictechniquesareincreasinglybeingusedtorepairbothprimaryherniasandrecurrent
hernias(seeLaparoscopicInguinalHerniaRepair).Thetotallyextraperitoneal(TEP)approachis
usuallyfavoredoverthetransabdominalpreperitoneal(TAPP)approachbecauseofthecomplications
thatarisefromexposedintraperitonealmeshinthelatter.Postoperativepain,timetofullrecovery,and
returntoworkareimprovedwiththelaparoscopicapproach,butitismoreexpensive.Shortterm
recurrencedataarecomparablesofar.
Formostabdominalwallhernias,laparoscopicrepairprobablyrepresentsthefuture.[35]Asthecost
ofinstrumentationdecreases,procedurespecificinstrumentdesignimproves,andthelaparoscopic
learningcurveisobliterated,thesayingifallelseisequal,lesspainandbettercosmesiswinoutwill
holdtrue.Forexample,prospectivestudiesoutofEuropefoundlaparoscopicrepairofpediatric
herniastobecomparabletotheresultsofopensurgery.[36]Theuseofnewmaterialsortechniques
mayaltertheapproach.[37]
Inaretrospectivecohortstudyof79patientswhounderwentlaparoscopicrepairofprimaryventral
herniasand79whounderwentopenherniarepair,patientswithalaparoscopicventralherniarepair
weresignificantlylesslikelytodevelopasurgicalsiteinfection(7.6%vs34.1%).However,patients
whounderwentlaparoscopicrepairweremorelikelytodevelopapostoperativeileus(10.1%vs
1.3%),tohaveapersistentbulgeattheoperativesite(21.5%vs1.3%),andtohavealongerhospital
stay.[38,39,40]

Treatmentapproach
Adults
Afteradiagnosisisestablished,thesigns,symptoms,andrisksofincarceration,aswellasthetiming,
conduct,andriskoftherepairprocedure,shouldbeexplainedtothepatientorcaregiver.Mostrepairs
proceedwithinseveralweeks,withtheprecisetimingdependentonmultiplefactors(eg,employment
andinsurance).

Withmassivehernias,prostheticmaterialisusuallyneededtoaidclosure,andappropriatematerials
shouldbeavailableintheoperatingroombeforeincision.Progressivepneumoperitoneum,using
increasingvolumesofairovertime,mayallowaccommodationtoincreasedintraabdominalpressure
butprobablydoeslittletoincreasethesizeoftheabdominalcavity.
Adultswithverylargechronicherniasshouldbeadmittedpostoperativelybecauseofthecombination
ofileusfromextensivemanipulationandlossofdomainwiththeattendantproblemsofincreased
pressureonthediaphragm,venacava,kidneys,andherniaclosure.Adultswhopresentwithbilateral
herniaswithouttheneedforformalreconstructioncanundergosimultaneousrepairmorecomplex
proceduresrequiretherepairstobeseparatedbyatleast1month.
Localanesthesiaissufficientformostrepairsinadultshowever,prolongedprocedures,repairof
herniaswithalargeintraperitonealcomponent,includinglaparoscopy,andrepairofrecurrenthernias
arebestmanagedwithspinal,epidural,orgeneralanesthesia.
Routinepreoperativeantibioticprophylaxisisnotcurrentlyrecommendedforlowriskadults
undergoingastandardtensionfreemeshbasedrepairmultiplestudieshaveshownthispracticeto
beofnobenefitindecreasingpostoperativewoundinfection.
Patientsundergoinganeurectomyhaveasignificantlylowerprevalenceofneuralgiawithout
increasedparesthesia.
Children
Inhealthyfullterminfantboyswithasymptomaticreducibleinguinalhernias,regardlessofageor
weight,pediatricsurgeonstypicallycarryoutrepairsoonafterdiagnosis.[20]Infulltermgirlswitha
reducibleovary,mostsurgeonsoperateatacloseelectivedate,butmoreurgentschedulingof
surgeryispreferrediftheovaryisnotreduciblebutasymptomatic.
Prematureinfantswithinguinalherniasusuallyundergorepairbeforebeingdischargedfromthe
neonatalintensivecareunit(NICU),butthispracticeischanging,andinfantsarenowbeing
dischargedhomeatmuchlowerweights.Somesurgeonsprefertopostponethesurgeryinthesevery
smallbabiesfor12monthstoallowfurthergrowth.
Allchildrenwithabilateralpresentationshouldundergobilateralinguinalherniarepairunderasingle
anesthesia.However,thereremainssomecontroversyregardingthecorrectapproachtoexploration
ofthecontralateralsideinpediatricinguinalhernias.[41]Thepotentialdamagetothespermaticcord
structuresinboysandthelowincidenceofcontralateralherniadevelopmentininfants(<1y)and
olderchildrenargueagainstroutinecontralateralgroinexploration.[42,43]
Thepreviouspracticeofroutinelyexploringtheoppositesideinallboysyoungerthan2yearsandall
girlsyoungerthan45yearsisnolongerpopular.Mostsurgeonsdonotroutinelyperformopen
explorationofthecontralateralgroin,exceptincasesofhighanestheticrisk,significantriskfor
developingcontralateralherniasecondarytoincreasedintraabdominalpressure,orlimitedaccessof
thechildtoappropriatemedicalcareshouldanincarcerationoccurontheoppositeside.
Currentpracticeinmanypediatriccentersusesperitoneoscopythroughtheipsilateralinguinalsacto
identifycontralateralpatentprocessesandhernias.[44]Longtermfollowupisneededbecauseonly
20%ofthepatentprocessesidentifiedbecomeclinicallyapparentherniasintheshortterm.
Asurgeonwhoisunfamiliarwiththetissuecharacteristicsandmetabolicandpsychologicalneedsof
childrenorwhodoesnothaveaskilledpediatricanesthesiologistavailableshouldnotattempta
herniaoperationinayoungchild.Olderchildrenusuallyhavegeneralinhalationanesthesia,whereas
someanesthesiaprovidersusespinalorcontinuouscaudalanesthesiawithpreterminfants.

Preemptiveregionalanesthesia,byilioinguinalandiliohypogastricnerveblockorbycaudalblock,
decreasespostoperativediscomfort.
Routineuseofperioperativeantibioticsforuncomplicatedinguinalherniarepairsinchildrenisnot
generallyindicated.Somecardiologistsadviseprophylacticantibioticusetolowertheriskof
endocarditisinchildrenwithassociatedcardiacdefectspatientswithventriculoperitonealshuntsmay
alsobenefit.
Postoperativeapneaiscommoninprematureinfants.[45]Thoseyoungerthan50weeksgestational
ageshouldbeadmittedfor24hourspostoperativelyandplacedonacardiorespiratorymonitor.[46,47,
48]

Slidinghernia
Inabout40%ofgirlswithaninguinalhernia,thefallopiantube(or,occasionally,theovaryoruterus)is
aslidingcomponentoftheherniathatcannotbeeasilyreducedintotheabdominalcavity.Thesac
wallmayseemtoothickinthemedialorlateralquadrants,orthecontainedviscus(particularlythe
fallopiantubeandovary)maynotbereducibleintotheperitoneum.Thewallsmustthenbeinspected
foraslidingcomponent.
Torepairaslidinghernia,thesacisligateddistaltothefallopiantubeanddivided.Theproximalsacis
ligatedandtheninvaginatedintotheperitonealcavity.Apursestringsutureinsidetheopenedhernia
sacmaybeusedtoaidinvisualizationduringsacclosure.Theinternalringisclosedwithsutures
fromthetransversalisfasciatotheiliopubictract.

SurgicalRepairofOtherHerniaTypes
Massesinfemoralcanal
Atypicaltuberculousadenitisisbesttreatedbymeansoflocalexcision.Repeatedtraumamaycause
painfulreactiveinguinalorfemorallymphnodes.Excisionoftheinvolvednoderelievessymptoms.
Thepotentialformalignancyinafemoralcanalmassthatpersistsdespiteantibiotictherapywarrants
biopsy.Anyenlargedlymphnodethatisexcisedshouldbedivided,withonehalfsentfreshfor
lymphomaprotocolandtheotherhalfsenttomicrobiology.Asuspectedfemoralhernia,usuallyaftera
missedinguinalherniarepair,alsowarrantsexploration.
Thebestapproachforbothadenopathyandfemoralherniaisapreperitonealapproach.Reductionof
anincarceratedintestineiseasy,andthereisclearaccesstothelymphnode.Apectinealligament
repairorlaparoscopicmeshplacementclosestheopeningintothefemoralcanal.Groinincisions
usuallyhealbetterthanthighincisions,particularlywithlymphchanneldisruption.

Umbilicalhernia
Inchildren,umbilicalherniarepairisbestperformedwithgeneralanesthesia,whereasinadults,
regionalorlocalanesthesiacanbeused.Asemicircularincisionintheinfraumbilicalskincrease
exposestheumbilicalsac.Aplanethatiscreatedtoencirclethesacatthelevelofthefascialring
expeditesrepair.Thedefectisclosedprimarilyinatransversedirectionwithasinglelayerof
interruptedsutures.Ifthedefectisverylarge,meshisoccasionallyrequired.
Althoughexcessivelywrinkledskincanappearcosmeticallytroublesome,elasticityandgrowthusually
correctstheproblembecausetheskinincisionlieswithintheumbilicalfold.Incaseswithsevere
redundantskin,removalofacircleofskinandperitoneumtoaccessthehernia,followedbyapurse

stingclosure,providesanexcellentcosmeticresult.Apressuredressingisappliedforseveraldays
afterrepair.

Epigastrichernia
Immediatelybeforetheoperation,thedefectshouldbemarkedwiththepatientstanding.After
anestheticinduction,asmallverticalincisiondirectlyoverlyingthedefectiscarriedtothelineaalba.
Incarceratedpreperitonealfatmaybeeitherexcisedorreturnedtotheproperitoneum.Theedgesof
thefascialdefectareapproximatedtransverselywithinterruptedsutures.Recurrenceisrare,thougha
secondepigastricherniamaydevelopelsewhereasaseparatedefect.

Spigelianhernia
Despitebeingrareanddifficulttodiagnose,spigelianherniasareeasilyapproached.Atransverse
incisionovertheherniatothesacallowsdissectiontotheneck,andcleanapproximationofthe
internalobliquemuscleandtransversusabdominiscompletestherepair.Laparoscopicrepairallows
accuratedelineationoftheanatomyandhelpsestablishthediagnosisinsuspectinstances.

Interparietalhernia
Becausemostinterparietalherniasareassociatedwithanundescendedtestis,thespermaticcord
shouldbeidentified.Inayoungchild,anorchiopexyisperformedifthetestisisnotgangrenousinan
olderchildoradult,thetesticleshouldberemoved.Fortheusualpresentationofbowelincarceration,
aproperitonealindirectinguinalherniarepairisthebestapproach.

Supravesicalhernia
Supravesicalherniasarerepairedwiththestandardtechniquesusedforinguinalandfemoralhernias,
usuallyviaofaparamedianormidlineincision.Theinternalsupravesicalherniarepairshouldinclude
divisionandclosureoftheneckofthesac.

Lumbarhernia
Alumbarherniaisbestapproachedwiththepatientinthelateraldecubituspositionandwiththeuse
ofalumbarrollorkidneyrest.Askinlineobliqueincisionextendsfromthe12thribtotheiliaccrest.A
layeredclosureormeshonlayforlargedefectsissuccessful.

Obturatorhernia
Obturatorherniasareapproachedabdominallyandcanberepairedlaparoscopically.Ifthehernia
contentisdifficulttoreduce,incisionoftheobturatormembraneattheinferiormarginwilllessen
damagetotheobturatorvesselornerve.Meshclosureisnecessaryforatensionfreerepair.The
othersidemustbeviewedtoprecludeproblemswithacontralateralhernia.

Sciatichernia
Atransperitonealapproachisusedintheeventofincarceration.Avoidingneurovascularinjuryduring
reductionandrepairrequirescarefulattentionposteriorlyandinferolaterallyforthesuprapiriform
hernia,superomediallyfortheinfrapiriformhernia,andmediallyforthesubspinoushernia.Thedefect
isclosedwithprostheticmaterial.

Atransglutealrepaircanbeusedifthediagnosisisestablishedandtheintestineisclearlyviable.The
patientisplacedprone,andtheincisionisextendedfromtheherniatowardthegreatertrochanter.
Thefibersofthegluteusmaximusarespreadtoexposethepiriformis,theglutealneurovascular
bundle,andthesciaticnerve.Aprostheticpatchclosesthedefectbetweenthepiriformisandtheiliac
orischialbone.

Perinealhernia
Atransabdominalapproachwithprostheticclosureisthepreferredapproachintherepairofperineal
hernias.

SurgicalRepairofGastroschisis,Omphalocele,andOther
Defects
Gastroschisisandomphalocele
Themorbidityandmortalityassociatedwithomphaloceleorgastroschisisininfantsoverthepast35
yearshasgreatlydecreasedbecauseofbetterpreoperativeandpostoperativecare.Specifically,
theseimprovedoutcomesaresecondarytoadvancesinneonatalventilatorcareandthedevelopment
anduseoftotalparentalnutritionduringtheperiodoftransitiontonormalbowelfunction.
Patientswithsyndromicomphaloceleshavehadonlymodestincreasesinmortalitysecondarytothe
unchangedseverityoftheirassociateddefects.Theimprovementinthispopulationresultsfrom
prenatalrecognition,earlierprenataltransporttopediatricsurgicalreferralcenters,andenhanced
perioperativecare.
Perioperativeconsiderations
Thegreatestlossofcontractilityandmucosalfunctionofthebowelandthefibrouscoatingofthe
bowelingastroschisisoccurslateingestation.Deliveryofinfantswithprenatallydiagnosed
abdominalwalldefectscanbeviavaginalorcesareandeliveryneithermethodhasaclearadvantage
overtheother.
Preterminductionafterensuringlungmaturitymaybeadvantageousincasesofgastroschisiswhere
serialimagingofthebowelrevealsincreasingdilationsuggestiveofarestrictivedefect.Toavoid
damagetothesacfromlaboranddelivery,electivepretermcesareansectionisnolonger
recommendedforinfantswithlargeomphaloceles.
Placingtheinfantuptotheaxillaeinasterileplasticbagmaintainssterility,preventsevaporative
waterloss,anddecreasesheatloss.Infantswithgastroschisiscanbeplacedontheirrightsideuntil
siloplacementiscompletetopreventvascularcompromisefromtwistingorkinkingofthefascial
edge.Althoughrecommendationsintheliteraturevary,thetrendistowarduniversalsiloplacement
andgradualreduction.Broadspectrumantibioticsshouldbegiven,mostcommonlyampicillinand
gentamicin.
Theinflamedperitonealandintestinalcapillarymembranesstabilizein1218hoursaftersurgery,and
thefluidrequirementsthenmarkedlydecrease.Whenthecapillarymembranestabilizes,exogenous
albuminmaybeadministeredtoelevateserumlevelsto2.53g/dL.Thetestesmaybeextracorporeal
andshouldbeplacedneartheprocessusvaginalis,becausetesticularproximityisacriticalfactorin
theformationofthegubernaculum.
Managementapproaches

Themajorchallengesingastroschisisarereductionoftheinflamedvisceraintotheabdomenand
maintenanceofeffectivenutrition.Thetwomajorproblemsinthemanagementofomphalocelesare
(1)closureofthedefectwithoutunduetensionand(2)treatmentofassociatedanomalies,particularly
cardiacdefectsandpulmonaryhypoplasia.Associatedanomaliesmustbestabilizedswiftlybefore
operation.
Primaryclosureoffasciaandskinisthebestapproachforomphaloceleandgastroschisis.However,
increasedintraabdominalpressurefromimmediatereductioncancompromiseventilationandleadto
abdominalcompartmentsyndromewithinferiorvenacavalcompression,intestinalandrenal
hypoperfusion,andlowerextremityedema.
Enlargementoftheabdominalcavitybystretchingtheabdominalwall,decompressionofthestomach
andirrigationoftheintestineandcolontoremovemeconium,andpostoperativeuseofventilatorsand
musclerelaxantsfrequentlycanfacilitatesuccessfulprimaryclosure.Thesacisremovedatthe
fascialedge.Umbilicalarteryorveincatheterscanbetransposedtoanextraumbilicallocationfor
postoperativemonitoringandfluiddelivery.Vigorousattemptstodecompresscancauseintestinal
tearsandshouldbeavoided.
Nonoperativemanagementofgastroschisis,alsoknownasplasticclosure,isanalternativeto
conventionalprimaryoperativeclosureorstagedsiloclosure.Althoughitisconsideredsafe,
nonoperativemanagementisnonethelessassociatedwithanincreasedincidenceofumbilical
hernias.[49]
Intraabdominalpressuremeasurementshelppreventintraabdominalcompartmentsyndrome.
ExcessivelyhighpressuresmandateimmediateconversiontoaSilonchimneysuturedtotheskinor
thefascialrim(seetheimagebelow).Thegradualreductionofliverandintestinerepresentsan
improvementoverpreviousmethods,andmostpediatricsurgeonsusethistechnique.Fascialand
skinclosureoccursaftercompletereductionofcontentsintotheabdomen,whichusuallyoccursover
37days.

InfantwithSilonchimneyplacedintreatmentofgastroschisis.

ViewMediaGallery
Analternativetechniqueforomphalocelesisabdominalbinding.Withsequentialpressure,theviscera
canbereducedintotheabdomenoverasimilarperiod,followedbydelayedprimaryclosure.During
finalabdominalclosure,aprostheticpatchofexpandedpolytetrafluoroethylene(ePTFE)or

biosyntheticmeshcanbridgethegapbetweentherectusmuscles.Tissueexpanderscanfacilitate
thisstage.[50]Orchiopexycanbeperformedforcryptorchidtestesatthetimeoffinalclosure.
Intestinalatresiaiscommon.Anastomosisattheclosureoperationissometimespossible,depending
onthedegreeofbowelthickening.Repairaftera4to6weekperiodofboweldecompressionand
parenteralnutritionispreferable,butthisiscontraindicatedinthefaceofalargeproximaldistal
discrepancyornecroticintestine.Thecombinationofstomasandprostheticmaterialcanbeavoided
inalmostallpatients.

BeckwithWiedemannsyndrome
ThediagnosisofBeckwithWiedemannsyndromeshouldbesuspectedinalargeneonatewith
macroglossia.Astheseinfantsareatriskforseverehypoglycemia,closemonitoringandearly
administrationofglucosecanpreventtheserioussequelaofhypoglycemia.

PentalogyofCantrell
PentalogyofCantrellisamalformationoftheupperabdominalfoldcharacterizedbyananterior
diaphragmaticandpericardialdefect,ashortbifidsternum,andcardiacdefectsassociatedwithan
epigastricomphalocelesacorhypotrophicepigastricskin.Temporarycoverageoftheomphalocele
duringevaluationofthecardiacdefectswillallowsubsequentcompleterepairofcardiac,
diaphragmatic,andpericardialdefects.
Vesicointestinalfissureorcloacalexstrophyisamalformationofthelowerfolddefinedbyaninferiorly
sitedomphalocele,exstrophyofthececumbetweenthehemibladders,diastasisofthesymphysis
pubis,ashortdistalcolon,norectum,ashortenedsmallbowel,andoccasionalmeningosacral
anomalies.Theseinfantscansurviveaftermultiplecorrectiveintestinalandurinarytractprocedures.

Umbilicalremnants
Mucosalbiopsyprovidesdiagnosticconfirmationoftheclinicalsuspicion.Apatent
omphalomesentericductrequirespromptexcisiontopreventintussusception.About50%ofchildren
withexternalmucosalremnantswillhaveanadditionalcomponentwithintheabdomen.Urachal
remnantsshouldbeexcisedlocallyattheumbilicusandfollowedcaudallyforashortdistancetoward
thedomeofthebladder,wheretheyshouldbesutured,ligated,anddivided.

LongTermMonitoring
Forpatientswitheasilyreducibleherniasorwithherniasfounduponphysicalexamination,followup
visitswiththegeneralsurgeonshouldbescheduledwithinthe12weeksfollowingtheprocedure.
Patientswithumbilicalherniasmaybedischargedwithclosefollowupcareifthedefectislessthan2
cmindiameterandtheherniaisnotincarceratedorstrangulated.
Accuratepostoperativeinstructionandeasyaccesstocare(ifproblemsarise)areaseffectiveasafull
postoperativevisitafterroutineinguinalherniarepairs.Patientsshouldbeeducatedtoavoidthose
activitiesthatincreaseintraabdominalpressureandinstructedtoreturniftheynoteanirreducible
hernia,increasedpain,fever,orvomiting.
Medication
WhattoReadNextonMedscape

RelatedConditionsandDiseases

UmbilicalHerniaRepair
LaparoscopicIncisionalHerniaRepair
HerniaReduction
HiatalHernia
PediatricHernias
DiaphragmaticHernias
News&Perspective

PreventingParastomalHerniaUsingaModifiedSugarbakerTechniqueWithCompositeMesh
DuringLaparoscopicAbdominoperinealResection

LaparoscopicGastropexyforGastricVolvulusinHighOperativeRiskPatients
KidsinPoorCountriesHaveHigherDeathRatesFromAbdominalSurgery
Tools

DrugInteractionChecker
PillIdentifier
Calculators
Formulary
Slideshow

11AbdominalEmergenciesinInfants

MostPopularArticles

AccordingtoGeneralSurgeons
1.It'sFinal:FDABansPowderedGlovesinSurgery,Medicine
2.Nearly20%ofGeneralSurgeryResidentsQuitTheirProgram
3.NovelThyroidectomyRemovesOrganThroughtheLip
4.PalliativeCareAssessmentRareBeforeFeedingTubePlacement
5.CostEffectivenessofNewSurgicalTreatmentsforHemorrhoidalDisease
ViewMore