Continuing Education Activity

An umbilical hernia presents as a bulge at the site of the umbilicus; it is a common finding during routine well-baby visits for the first few months of life. New parents who are not very familiar with this anomaly might verbalize great concerns during these visits because they tend to become very worried when they see the bulge in their infant's belly button. In addition, parents might be concerned with the idea that their child will suffer serious complications from an umbilical hernia, and they wonder if there are any measures that they should take to avoid complications. This activity reviews the pathophysiology, evaluation, and management of umbilical hernias and highlights the role of the interprofessional team in the care of infants with this condition.

Objectives:

• Identify the etiology of pediatric umbilical hernias.
• Describe the presentation of an infant with an umbilical hernia.
• Describe the treatment and management options available for umbilical hernias.
• Explain the importance of improving coordination amongst the interprofessional team to enhance care for patients affected by umbilical hernias.

Introduction

Umbilical hernia presents as a bulge at the site of the umbilicus. It is a common finding during routine well-baby visits for the first few months of life. New parents who are not very familiar with this anomaly tend to be very worried when they see the bulge in their infant’s belly button. On the one hand, parents might be concerned with the idea that their child will suffer serious complications from an umbilical hernia, and they wonder if there are be any measures that they should take to avoid complications. It is important to understand the normal embryology and etiology of the umbilical hernia in order to answer these questions and when it is time to refer the patient for surgical evaluation.[1][2][3]

Etiology

Umbilical hernia in children results from incomplete closure of the fascia of the umbilical ring, through which intraabdominal contents may protrude[4]. After separation of the umbilical cord, usually, the ring undergoes spontaneous closure through the growth of the rectus muscles and fusion of the fascial layers. A failure or delay in this process leads to the formation of an umbilical hernia[5]. The exact etiology is unknown, but usually, occurs through the umbilical vein component of the ring[5].

Epidemiology

Umbilical hernias are common in children, It is estimated 10-30 % of all white children at birth, decreasing to 2-10% at one year, with boys and girls affected equally[6][7]. An umbilical hernia is particularly common in African-American infants with the incidence reported to be as high as 26.6%, for reasons not precisely understood [10]. It is also more commonly seen in premature and low-birth-weight babies with an incidence as high as 84% in newborn infants weighing 1000 to 1500 grams while the incidence is 20.5% in those weighing 2000 to 2500 grams[8].

Pathophysiology

During fetal development, the primitive umbilical ring appears as early as 4th week of gestation on the ventral surface of the body. It contains umbilical vessels (one vein and two arteries), allantois, vitelline duct, vitelline vessels and loop of midgut. As the herniated midgut return back, the definitive umbilical cord will develop which contains the umbilical vessels surrounded by Wharton's jelly. The Umbilical vessels obliterate after birth and will be replaced by a ligamentous structure[9]. Congenital disorders of the umbilicus include umbilical hernia, patent urachus, omphalomesenteric fistula and umbilical polyp. It is important to recognize these defects as early as possible is essential to prevent complications[9]. Failure of the umbilical ring to be obliterated after separation of the umbilical cord will predispose to the development of umbilical hernia. The umbilicus also represents a relatively weak point in the abdominal wall that is prone to herniation as a result of increased intra-abdominal pressure[9].

History and Physical

During a well-child care visit, the history given by parents might include a swelling of the belly button, which increases when the baby is crying, coughing, or straining. The size of the umbilical hernia defect should be measured, determine the reducibility, or the presence of signs of incarceration or strangulation. Patients with incarcerated or strangulated umbilical hernia usually present with abdominal pain, nausea, and vomiting. The physical examination will be significant for abdominal tenderness, distension and skin erythema[10].

Evaluation

In the majority of cases, there are no medical sequelae to umbilical hernias. No tests are recommended, a thorough physical exam is sufficient to make the diagnosis and to discuss the common course of the condition with concerned parents. Although pediatric umbilical hernias are a common entity in healthy infants, they are also associated with some specific conditions, which the pediatrician or the pediatric surgeon should keep in mind when evaluating a patient. Pediatric umbilical hernias are seen more often in common autosomal trisomies (e.g., Trisomy 21 and 18), metabolic disorders (e.g., hypothyroidism, mucopolysaccharidoses) and some dysmorphic syndromes (e.g., Beckwith-Wiedemann syndrome, Marfan syndrome). For this reason, it is important to distinguish healthy patients with an innocent finding of an isolated umbilical hernia, from patients with an umbilical hernia and other syndromic features, for example, macroglossia or hypotonia, the latter group warranting further evaluation.

Treatment / Management

Repair of the umbilical hernia in infants is usually postponed due to a low rate of complications and the majority of the umbilical defects will be closed spontaneously within 2 years[11]. The size of the hernial ring provide a useful indicator for spontaneous closure[12]. Expectant management of asymptomatic umbilical hernias until age 4-5years is both safe and the standard care of many pediatric hospitals[3]. Surgery is indicated for complications of the hernia which includes incarceration, strangulation, or rupture[4]. It is also recommend to repair any umbilical hernias with the defect of 1.5 cm or more in children over the age of 2 years because of minimal chance of spontaneous closure[13][14]. Umbilical hernia repair is a day case surgery performed under general anesthetic, with a non-absorbable suture obliterating the umbilical ring through an infra-umbilical incision[5]. Umbilicoplasty may be performed specially for those with a large umbilical hernia to improve the cosmetic results [5].

Differential Diagnosis

• Epigastric hernia

• Hernia of the umbilical cord

• Omphalocele

• Pediatric Hydrocele and Hernia Surgery

• Varicocele in Adolescents

Complications

Most studies looking into the complications of umbilical hernias have a significant selection bias because they only take into account patients that have undergone a surgical correction, leaving out a large proportion of patients with umbilical hernias who have never had any complication. The consensus remains that the risk of complications of an unrepaired umbilical hernia is very low[15][10]. The overall risk of incarceration is estimated to be 0.07-0.3%[10].

Umbilical hernia repairs have a low postoperative complications rate. Complications include superficial wound infection, hematoma, and seroma. There is also a 2% risk of recurrence on long term follow up[16][16]. 

Pearls and Other Issues

1. Timimg of the repair:

a. strangulated umbilical hernia should be repaired emergently with adequate resuscitation

b. incarcerated umbilical hernia should be reduced followed by repair at early convenient time

c. reducible umbilical hernia usually repaired at 4-5 years of age

2. Type of the repair:

a. usually performed as an open technique 

b. through infraumbilical skin incision

c. fascial repair with sutures (Herrniorrhaphy) 

3. How the umbilical cord is clamped or cut after birth has no effect on whether an umbilical hernia will develop or not develop.

4. strapping the umbilicus is not effective for the treatment umbilical hernias and it is associated with skin complications and may result in restriction of the normal activity of the abdominal muscles [17] but few observational study showed it may promot early spontaneous umbilical hernia closure[18] [19][20].

Enhancing Healthcare Team Outcomes

The management of an umbilical hernia is with an interprofessional team that includes a pediatrician, pediatric nurse, primary care provider, pediatric surgeon, and the emergency department physician. The key is to understand that the majority of pediatric umbilical hernias will spontaneously close by ages 5-7. Unless the infant has signs of bowel obstruction or incarceration, the child can be followed. If in doubt, a referral to a pediatric surgeon is recommended.[21]