Pediatric Hernias: When to Refer Disclosures - c.ymcdn.com · PDF filePediatric Hernias: When to Refer Katrina Cardenas, MMS, PA-C ... Hernia Survery, 2005 4 Normal 4 Laparoscopic

10/10/2013

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Pediatric Hernias: When to Refer

Katrina Cardenas, MMS, PA-C

October 12, 2013

http://lifestyle-advertising-photographer-la.blogspot.com/

Disclosures

• Nothing to disclose

Outline

• Inguinal Hernias

• Epigastric Hernias

• Umbilical Hernias

• Diastasis Recti in Infancy

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Blake, 2 month male

• CC: Bulge in groin

• HPI:

▫ Intermittent bulge seen in

left groin X 1 month

▫ Seen when crying or straining

▫ Disappears when at rest

▫ Eating and stooling without

difficulty

▫ Deny noticing skin changes at

anytime

• ROS: Unremarkable

• PMHX: Prematurity: 30 wks

gestation, 8 wk NICU stayhttp://madamenoire.com/284096/black-babies-are-the-least-

expensive-to-adopt-in-the-u-s/

Blake, 2 month male

http://www.meddean.luc.edu/lumen/MedEd/urology/inghrnia.htm

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Pediatric Inguinal Hernias

• Epidemiology:

▫ Incidence: range 1-5% of children

� ~60% occur on the right side

▫ Occur equally among all races1

▫ More common in males than females ratio 3-10:12

▫ Premature infants at increased risk: 16%-25%

▫ Bilateral hernias present: 10%3

▫ Family history: 11.5 %1

Langman’s Medical Embryology, 7th Ed 1995 1, 2

Male Embryology

Atlas of Pediatric Surgery, Nakayama

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Inguinal hernias

• Clinical presentation:

▫ Intermittent bulging seen

in the groin, labia, or

scrotum

▫ Seen with an increase in

intra-abdominal pressure

▫ Typically asymptomatic

� Older children may

complain of pain in groin

Inguinal Hernia

• Physical exam:▫ Inguinal masses or asymmetry

in groin

▫ Males:

� hold testicle in scrotum and

assess for additional masses

� Palpate spermatic cord for

thickening

▫ Infants: allow to strain and/or

cry

▫ Older children: examine

supine and standing while

performing Valsalva maneuver

http://www.pediatricurologybook.com/inguinal_hernia.html

Silk Glove Sign

• Single finger over the

spermatic cord at the level

of the pubic tubercle

rubbing side-to-side

• + Silk Glove sign:

▫ thickening with palpation

▫ described as rubbing two

pieces of silk together

▫ not always accurate and

subjective based on

clinical practice1

http://dynamic.psu.ac.th/kidsurgery.psu.ac.th/Pediatric%20surgery/KID/LESSON15.HTM

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Inguinal Hernias

• Diagnostic imaging- rarely needed:

▫ Herniography: rarely used

▫ US: gained popularity as an adjunct to the

physical exam1

• Management:

▫ Surgical referral when diagnosis of inguinal

hernia

� is made

� or suspected

Inguinal Hernias

• Complications: � Incarceration or strangulation of intestine or

omentum

� In females: potential for incarceration or strangulation of ovary, fallopian tube, and in rare cases the uterus

� Incidence of incarceration: 14-31%� 85% occur before the first year of life3

▫ Incarceration and strangulation are

SURGICAL EMERGENCIES

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M

Strangulated Inguinal Hernias

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Inguinal Hernia

• Surgical Complications2

▫ Scrotal Swelling

▫ Hematoma

▫ Injury to the Vas

Deferens

▫ Testicular atrophy

▫ Recurrence

� 3% elective repair

� 20% incarcerated

hernia repair

Contralateral Exploration

• Males with unilateral IH, surgeons performing

routine contralateral exploration under 2 yrs:

▫ 2005: 44%

▫ 1993: 65%

• Females with unilateral IH, surgeons

performing routine contralateral exploration

under 4 yrs:

▫ 2005: 47%

▫ 1993: 84%

American Academy of Pediatrics, Section on Surgery, Hernia Survery, 20054

Normal

4

Laparoscopic Appearance of Right

Internal Inguinal Ring

Open

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Molly, 4 yr female

• CC: Bump on Abdomen

• HPI:

▫ Bump present for the last

5 months

▫ Increasing in size

▫ Occasionally tender

▫ No skin color changes

▫ Eating and stooling

without difficulty


• PMHX: Otherwise healthy 4

yr female http://emilystarlingphotography.com/wp-

content/uploads/2012/12/little_girl_model_Shreveport_photography06(p

p_w860_h571).jpg

Molly, 4 yr female

http://www.bestpediatricsurgeon.com/umbilical-para-umbilical-hernias/

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Epigastric Hernias

• Epidemiology:

▫ Causes are multi-

factorial

▫ More common in males

3:1

▫ 20% can have multiple

hernias5

• Clinical Presentation:

• Epigastric mass

• +/- pain6

http://www.pediatricsconsultant360.com/content/lumps-and-bumps-children-abdominal-and-inguinal-hernias

Epigastric Hernia

• Physical Exam: ▫ Palpable bulge along the abdominal midline

between the xiphoid process and umbilicus

▫ Variable in size, typically <1 cm6

▫ Can be immediately adjacent to the umbilicus and difficulty to distinguish—careful examination is needed1

▫ Risk of strangulation is low• Management

▫ Need surgical repair▫ Referral to pediatric surgery once diagnosis made

Epigastric Hernia Repair

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Adam, 4 yr male

• CC: Bulge in the belly button

• HPI:

▫ Present since birth

▫ Continues to grow with him

▫ Never complains of pain

▫ Eat and stool without difficulty

▫ No reports of ever becoming stuck


• PMHX:

▫ Premature, born at 32 weeks, had

10 wk unremarkable NICU stay

▫ Asthma

� Albuterol PRNhttp://hopeyscorner.com/2013/01/19/test2/

Adam, 4 yr male

http://abdomend.com/blog/hernia/abdominal-hernia/

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Umbilical Hernia

• Epidemiology

▫ Equal frequency in males and females

▫ Increased incidence in African American infants

▫ Increased incidence in premature infants

� 75% of infants <1500 grams will spontaneously resolve1

▫ Less likely to close spontaneously if:

� Larger then 1.5 cm fascial defect

� Significant amount of protruding skin

� Have underlying conditions: Ehlers-Danlos, Beckwith-

Wiedemann syndrome, Down’s syndrome, trisomy 13,

trisomy 18, mucoploysaccharidoses, hypothyroidism1,7

Umbilical Hernia

• Fascial opening (umbilical ring) exists to allow

passage of vessels from mother to the fetus7

• Umbilical ring is open throughout most of

gestation, but becomes progressively smaller as

gestation progresses

• After birth, the umbilical ring continues to

close as the fascia of the umbilical defect

strengthens1

Umbilical Hernia


▫ Typically asymptomatic

▫ Seen with increased

intra- abdominal

pressure

▫ Easily reducible

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Umbilical Hernia

Umbilical Hernia

• Management:

▫ UH <1 cm

� Observation, most will

spontaneously close

� Referral for surgical repair

at 4-5 yrs if no

spontaneous resolution

▫ UH 1.0-1.5 cm

� Observation for decrease

in fascial defect size

� Referral for surgical repair

at 4-5 yrs if no

spontaneous resolution

▫ UH>1.5 cm

� Observation till at least 2

yrs of age

� Less likely to spontaneous

resolve on their own7

� Surgical referral if no

spontaneous closure

▫ **If symptomatic or increase

in size: refer sooner

Umbilical Hernia

• Complications:

▫ Incarceration or strangulation of intestine or omentum

▫ Estimated to be 1:1500 hernias2

▫ Incarceration and strangulation are:

SURGICAL EMERGENCIES

http://www.yoursurgery.com/ProcedureDetails.cfm

?Proc=73

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http://www.bestpediatricsurgeon.com/umbilical-para-

umbilical-hernias/

Incarcerated Umbilical Hernia

http://www.surgeryencyclopedia.com/St-

Wr/Umbilical-Hernia-Repair.html#b

Umbilical Hernia Repair



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• Post-operative

complications:2

▫ Recurrence

▫ Seroma or

Hematoma

▫ Trapped or

perforated bowel

▫ Bowel obstruction

http://www.kidspot.com.au/familyhealth/Going-to-hospital-

Common-surgeries-Umbilical-hernia-

repair+3227+262+article.htm

Proboscoid Umbilical Hernia

• Large fascial defect and

pendulous protrusion

▫ chance of spontaneous

closure low1,2,7

• If umbilical ring does not

narrow, then recommend

surgical repair during

first 2 years of life1,7

• Require surgical referral

during 1st year of life

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http://www.rileypediatricsurgery.com/blog/2013/03/11/disorders/what-is-an-umbilical-hernia/

Proboscoid Umbilical Hernia

Katie, 1 month infant

• CC: Large abdominal

bulge

• HPI:

▫ Large bulge involving

most of upper abdomen

▫ Worsens when crying

▫ Gone when at rest

▫ Eating and stooling

without difficulty

▫ +gaining weight


• PMHX: Unremarkablehttp://us.cdn4.123rf.com/168nwm/arekmalang/arekmalang

0801/arekmalang080100129/2466862-a-shot-of-a-cute-asian-

baby-boy.jpg

Katie, 1 month infant

http://newborns.stanford.edu/PhotoGallery/DiastasisRecti1.html

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Diastasis Recti in Infancy

• Epidemiology:

▫ More common in premature infants

▫ More common in African American newborns6


▫ May appear as a “bubble” or “ridge” running

down the abdomen from the xiphoid process to

the umbilicus

▫ More prominent with increased intra-abdominal

pressure


http://www.primehealthchannel.com/diast

asis-recti.html

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� Physical Exam:

� Edges of rectus

abdominis muscles

typically palpable

� Easily seen when

infant is straining or

crying

� May not be seen when

lying supine and

relaxed

http://newborns.stanford.edu/PhotoGalle

ry/DiastasisRecti2.html


� Management:

� No diagnostic

imaging needed

� No surgical referral

needed unless

uncertain about

diagnosis

� Observation

http://noahsdad.com/core/

Take Home Points on Pediatric Hernias

• Inguinal Hernias: Need early surgical referral if suspected or if diagnosed

• Epigastric Hernias: Need surgical referral if suspected or if diagnosed

• Diastasis Recti in Infancy: No surgical referral needed, observation, will resolve with time

• Umbilical Hernias:▫ UH <1 cm

� Observation, most will spontaneously close

� Referral and surgical repair ~4-5 yrs if no spontaneous resolution

▫ UH 1.0-1.5 cm� Observation/Referral and

surgical repair ~4-5 yrs if no spontaneous resolution

▫ UH>1.5 cm� Observation till at least 2 yrs

of age, less likely to resolve spontaneously, surgical referral

** If symptomatic or increase in size: refer sooner

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References• 1. Coran AG, Adzick NS, Krummel TM, Laberge JM, Shamberger RC, Caldamone

AA, eds. Pediatric Surgery. 7th ed. Philadelphia, PA. Elsevier; 2012.

• 2. Katz, DA. Evaluation and management of Inguinal and Umbilical Hernias.

Pediatric Annals. 2001;30:729-735.

• 3. Ramsook C, Endom EE. Overview of inguinal hernia in children. In:

UpToDate, Singer JI, Drutz JE (Ed), UpToDate, Waltham, MA, 20013.

• 4. Antonoff MB, Kreykes NS, Saltzman DA, Acton RD. American Academy of

Pediatrics Section on Surgery hernia surgery revisited. J Pediatr Surg.

2005;30:1009-1014.

• 5. Coats RD, Helikson MA, Burd RS. Presentation and Management of Epigastric

Hernias In Children. J Pediatr Surg. 2000;35:1754-1756.

• 6. Brooks, DC. Overview of abdominal hernias. In: UpToDate, Turnage, R (Ed),

UpToDate, Waltham, MA, 2013.

• 7. Palazzi DL, Brandt, ML. Care of the umbilicus and management of umbilical

disorders. In: UpToDate, Duryea TK, Garcia-Prats JA (Ed), UpToDate, Waltham,

MA, 2013.

Thank you

• Ravindra Vegunta MD,FRCSEd,FACS,FAAP

• Joseph Janik MD,FACS,FAAP

Documents

Pediatric Hernias: When to Refer Disclosures - c.ymcdn.com · PDF filePediatric Hernias: When to Refer Katrina Cardenas, MMS, PA-C ... Hernia Survery, 2005 4 Normal 4 Laparoscopic