Hernias and Abdominal Wall

Defects in Children
Tarek A. Hassan
FRCS, MD
Prof. of Pediatric Surgery

Definition of Hernia
Protrusion of a sac of peritoneum
together with preperitoneal fat or an
organ through a congenital or acquired
defect in the muscles of the abdominal
wall through which they do not
normally pass

Prof. Tarek Hassan

Classification of Hernias in Children

Inguinal Hernia
Umbilical Hernia
Diaphragmatic Hernia
Incisional Hernia
Rare Hernias :

Epigastric,
Lumber, Femoral and Spigellian

Other abdominal wall defects:

Omphalocele, Gastroschisis, Bladder extrophy
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Prof. Tarek Hassan

PROCESSUS VAGINALIS
Closes at 6
months of age .
Doesnt mean
inguinal hernia
Potential space

Prof. Tarek Hassan

INGUINAL HERNIA In Males

Failure of
obliteration
Inguinal
bulge
May be the
1st.time
irreducable
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Prof. Tarek Hassan

INGUINAL HERNIA In Males

Inguinoscrotal
Reduction is
difficult .
Sliding viscera

Prof. Tarek Hassan

Inguinal Hernia In Males

Type: Indirect
Content : intestine, omentum
Bilateral < 50%
Complications: irreducibility, testicular
atrophy, strangulation, obstruction,
infection
Operation : Unilateral herniotomy ,once
detected
Contra lateral exploration ??

Prof. Tarek Hassan

Inguinal Hernia In Males

Prof. Tarek Hassan

Inguinal Hernia In Males (cont.)

Prof. Tarek Hassan

Inguinal Hernia In Females

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Type : Indirect
Content : Ovary
Bilateral > 50%
Complication : Ovarian affection
Operation : Herniotomy once detected
Contra lateral exploration ??

Prof. Tarek Hassan

Inguinal Hernia In Females

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Prof. Tarek Hassan

CONGENITAL HYDROCELE
High incidence in
newborns .
Conservative till 9-12
months .
Indication of surgery :
*Increase in size
*With hernia
*Of hernial sac
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Prof. Tarek Hassan

ENCYSTED HYDROCELE OF THE CORD

Encysted fluid
Difficult dif.
diagnosis from
irred. Hernia .
Follow up for
the younger
age group.
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Prof. Tarek Hassan

DEVELOPMENT OF A NORMAL UMBILICUS

6 weeks embryo
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Normal umbilicus
Prof. Tarek Hassan

UMBILICAL HERNIA
Umbilical defect covered
by skin and contains
intestine.
Incidence: 1 every 6
newborn.
9 times more in black
Spontaneous closure is
the rule.
Complications are rare.
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Prof. Tarek Hassan

UMBILICAL HERNIA
Herniotomy & Anatomical
repair is indicated if it
persists beyond 2 to 3 yrs
*Defect< 1 cm------- 6 yrs
*Defect 1-2 cm------ 4 yrs
*Defect
>2 cm------- 2yrs
Role of truss is uncertain.
D.D. : Para-umbilical hernia.
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Prof. Tarek Hassan

Congenital Diaphragmatic Hernias

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Prof. Tarek Hassan

Congenital Diaphragmatic Hernias

Cong. diaphragmatic hernia
(Bochdalek)
Cong. hiatal hernia
Parasternal hernia (Morgagni)
Eventration of the diaphragm.
Traumatic diaphragmatic hernia

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Prof. Tarek Hassan

CONGENITAL DIAPHRAGMATIC
HERNIA (Bochdalek)
Due to persistent pleuroperitoneal
canal
90% are on the left side
Associated pulmonary hypoplasia is
the most important factor determining
survival
Antenatal diagnosis by U.S.
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Prof. Tarek Hassan

CONGENITAL DIAPHRAGMATIC
HERNIA (Bochdalek)
Presentation: dyspnea, cyanosis,
dextrocardia, diminished chest
movements, scaphoid abdomen,
intestinal sounds in the chest.

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Prof. Tarek Hassan

CONGENITAL DIAPHRAGMATIC
HERNIA (Bochdalek)
Diagnosis: X-ray chest & abdomen

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Prof. Tarek Hassan

CONGENITAL DIAPHRAGMATIC
HERNIA (Bochdalek)
Treatment: Paralyzed, ventilated, and
stabilized for 24-48 hrs
Reduction of the contents and closure
of the defect through a trans. abdominal
incision.
Mortality: 50% depending on the degree
of lung hypoplasia
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Prof. Tarek Hassan

CONGENITAL DIAPHRAGMATIC HERNIA (Bochdalek)

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Prof. Tarek Hassan

CONGENITAL HIATAL HERNIA

Usually sliding rarely para-oesophageal
Associated with gastro-oesophageal reflux

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Prof. Tarek Hassan

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Prof. Tarek Hassan

CONGENITAL HIATAL HERNIA

&Gastro-oesophageal reflux
Presentation: Vomiting, failure to thrive,
chest infection, dyspnea
Diagnosis: Barium meal, Endoscopy ,
PH metry, Manometry
Complications: Oesoph. Ulcers ,
strictures, hematemesis, shortening,
Barret oesophagus
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Prof. Tarek Hassan

CONGENITAL HIATAL HERNIA Sliding

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Prof. Tarek Hassan

CONGENITAL HIATAL HERNIA

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Para-oesophageal

Prof. Tarek Hassan

CONGENITAL HIATAL HERNIA

& Gastro-oesophageal reflux
Medical ttt for reflux : Positioning, Anti
acids, H2 blokers , Proton pump
inhibitor
Indications for Surgical ttt :
*Failure of medical ttt
*Associated hernia
*Development of complications
Surgery: Nissen Fundoplication
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Prof. Tarek Hassan

Parasternal hernia (Morgagni)

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Prof. Tarek Hassan

Eventration of the diaphragm

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Prof. Tarek Hassan

OMPHALOCELE
Umbilical defect
covered by
amniotic
membrane and
contains
intestine.
Major: diameter
more than 5cm
and contains
liver.
Minor: diameter
less than 5cm.
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Prof. Tarek Hassan

OMPHALOCELE
Congenital anomalies are
common especially
chromosomal and
cardiac.
Antenatal diagnosis: U.S.
Preoperative
management.
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Prof. Tarek Hassan

OMPHALOCELE
Primary closure

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Prof. Tarek Hassan

OMPHALOCELE
Gradual reduction & delayed primary closure

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Prof. Tarek Hassan

OMPHALOCELE
Non-operative treatment

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Prof. Tarek Hassan

GASTROSCHISIS
Abdominal wall
defect 2 to 4cm in
diameter and is
lateral (to the right)
of the umbilical cord.
It has no sac.
Intestine is thick and
oedematous.
Malrotation is usually
present
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Prof. Tarek Hassan

GASTROSCHISIS
Associated
congenital
anomalies are rare.

Needs emergency
surgery:
Primary closure.
Gradual
reduction&
delayed closure.
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Prof. Tarek Hassan

EXTROPHY OF THE URINARY BLADDER

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Prof. Tarek Hassan

CLOACAL EXTROPHY

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Prof. Tarek Hassan

PRUNE BELLY SYNDROM

Abdominal
muscle deficiency
Dilated urinary
system
Bilateral
undescended
testes
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Prof. Tarek Hassan

THANK YOU

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Prof. Tarek Hassan