Coupon Accepted Successfully!


Umbilical Hernia

  1. Definition:
    A condition caused by a small defect in the periumbilical musculature of the anterior abdominal wall resulting in protrusion of the umbilicus.  
  2. Epidemiology:
    1. age of onset: at birth or during the first year of life
    2. risk factors: blacks > whites/ low birth weight/ hypothyroidism/ chromosomal anomalies (i.e., Trisomy 13)/ Mucopolysaccharidoses (i.e., Hurler Syndrome)/ Beckwith-Wiedemann Syndrome  
  3. Pathogenesis:
    1. in normal embryogenesis, the intestines exit the abdominal cavity, return, rotate, then become fixed to the posterior abdominal wall.
    2. an umbilical hernia results from the failure of this process and due to an imperfect closure or weakness of the umbilical ring, a small portion of the intestine remains in the umbilical coelom producing a small sac protruding up through the base of the umbilical cord. 
    3. this sac (hernia) may contain omentum or portions of the small intestine  
  4. Clinical Features:
    1. Protuberant Umbilicus: usually varies from 1-5 cm in diameter/ easily reduced when the infant is relaxed/ is soft, non-tender, and covered by normal skin
    2. Complications: incarceration (irreducible umbilical hernia)/ strangulation of the intestine within the hernia/ perforation of the hernia.  
  5. Management:
    1. ​​​Supportive
      1. observe as most hernias close spontaneously before 5 years of age Q
      2. most hernias that appear before 6 months of age disappear by 1 year of age  
    2. Surgery: indications for surgery:
      1. complications (incarceration, strangulation, perforation)
      2. if the hernia persists to 3-4 years of age
      3. a large hernia (defects larger than 2 cm in diameter are less likely to close spontaneously)
      4. the hernia becomes progressively larger after 1-2 years of age or cosmetic reasons  
    3. Congenital diaphragmatic hernia
      1. Occurs in 1 in 2500-4000 live births
      2. Results from failure of closure of the pleuro-peritoneal canals
      3. The herniation occurs in the 8-10th week of gestation.
      4. 95% occur through the posterior foreman of Bochdalek (occur on the left)
      5. Less than 5% occur through the anterior foreman of Morgagni Q
      6. The midgut herniates into the chest impairing lung development
      7. Abnormalities of the pulmonary vasculature results in pulmonary hypertension
      8. Usually associated with gastrointestinal malrotation  
  6. Anatomy
    1. The diaphragm is composed of muscle and fascia that separates the chest from the abdominal cavity
    2. It is composed of three muscles parts about the rim that lead to a central tendinous portion
    3. The muscle parts are:
      1. The sternal portion that attaches to the breastbone area
      2. The costal (rib) portion that attaches along the ribs
      3. The lumbar portion that attaches along the back
    4. The tissue formed by the fusion of the various parts of the diaphragm is called the pleuroperitoneal membrane
    5. The are three openings in the diaphragm that allow passage of:
      1. The inferior vena cava
      2. The esophagus
      3. The aorta
    6. The diaphragm is covered on both sides by a membranous layer of fascia. The transversalis fascia covers the abdominal side, and the endothoracic fascia covers the thoracic side.
    7. The phrenic nerves control the muscles of the diaphragm  
  7. Clinical features
    1. Often presents with cyanosis and respiratory distress soon after birth
    2. Prognosis is related to the time of onset and degree of respiratory impairment
    3. The abdomen to flat and Air entry is reduced on the affected side
    4. Heart sounds are often displaced
    5. Chest x-ray will confirm the presence of gastrointestinal loops in the chest
    6. Occasionally presents with respiratory distress of intestinal obstruction later in life

Description: XRAPMorgagni

Description: XRLateralMorgagni

Morgagni hernia

Morgagni hernia lateral view  

  1. Management
    Respiratory support with intubation and ventilation is usually required/ A Ryle’s tube should be passed/  Gas exchange and acid-base status should be assessed/ Acidosis may need correction with bicarbonate infusion/  Surgery should be considered early after resuscitation/ Hernial content are usually reduced via and abdominal approach/ Hernial sac is excised and diaphragm repaired with nonabsorbable suture or a Gortex patch/ A Ladd's procedure may be required for malrotation/ Early respiratory failure is associated with a poor prognosis  

Test Your Skills Now!
Take a Quiz now
Reviewer Name