1. HERNIA
LIVSON THOMAS
M.Sc. (N) 1st Year
CMC & Hospital, Ludhiana.

2. DEFINITION
 A hernia is the protrusion of an organ or the fascia of an
organ through the wall of the cavity that normally contains it.
 Hernia is the protrusion of intestine through a weakness in
abdominal muscles

3. TYPES OF HERNIA IN CHILDREN
1. Inguinal Hernia
2. Umbilical Hernia
3. Diaphragmatic Hernia
4. Omphalocele & Gastroschisis

4. INGUINAL HERNIA
 An inguinal hernia is a protrusion of abdominal
cavity contents through the inguinal canal.

5. TYPES OF INGUINAL HERNIA
I. DIRECT: enters through a weak point in the fascia
of the abdominal wall. Present mostly in adults.
II. INDIRECT: It protrudes through the inguinal ring
and is ultimately the result of the failure of
embryonic closure.

6. PATHOPHYSIOLOGY
During fetal development
Out pouching of peritoneum-into scrotum covering the testis
Sac portion is called tunica vaginalis
Proximal portion of vaginalis fail to close- a potential hernial sac
is formed.

7. CONT…
An abdominal structure or abdominal fluid can be pushed into
this potential sac resulting into hernia.
Eventhough the potential sac is present, hernia develops only
until infant is 2 to 3 months old.

8. UMBILICAL HERNIA
 It is the protrusion of the intestine and omentum
through a hernia in the abdominal wall near the
navel; usually self correcting after birth.

9. PATHOPHYSIOLOGY
During development of foetus
A small opening is present in the abdominal muscles, so that the
umbilical cord can pass through, connecting mother to baby.
Usually the abdominal opening closes.
Sometimes these muscles do not meet- creating a small opening.
A loop of intestine can move into the opening between abdominal
muscle and cause and hernia.

10. CLINICAL FEATURES
 Bulge or swelling appear in the belly- button area.
 Swelling may be noticeable when baby cries.

11. DIAGNOSTIC EVALUATION
 Physical Examination
 Abdominal X-ray
 Ultrasound

12. MANAGEMENT
 By 1 year of age the umbilical hernia usually closes.
 Nearly all hernias close by 5 years of age.
 If hernia becomes bigger with age, is not reducible or
still present, its repaired surgically:
 During surgery a small incision is made in the umbilicus
and loop of intestine and the loop of intestine is placed
back into the abdominal cavity.
 The muscles are then sutured together

13. OMPHALOCELE & GASTROCHISIS
 Gastroschisis: It is the congenital anomaly
characterized by a defect in the anterior wall through
which the abdominal contents freely fall.
 Omphalocele: It is a congenital birth defect that
involves the umbilical cord itself, and the organs
remain enclosed in the visceral peritoneum.

14. RISK FACTORS
 Young mother < 20
 Folic acid deficiency
 Hypoxia
 Substance abuse
 High risk pregnancies

15. PATHOPHYSIOLOGY
An omphalocele is caused by error in the embryonic development
Normal development there are 3 distinct portions formed –
foregut, midgut & hindgut
Much of midgut is temporarily herniated outside the abdomen at
the umbilicus
The midgut later re-enters the abdomen and opening of
abdominal wall is closed

16. Failure for the midgut to return and re-enter the abdomen
Omphalocele is formed

17. CLINICAL FEATURES
 4-12 cms, centrally located.
 Dystocia may occur
 Rupture may occur
 Ectopic liver
 Abdominal and thoracic cavity under developed

18. MEDICAL MANAGEMENT
 Neonates with intact omphalocele are usually in no
distress unless associated with pulmonary hypoplasia
 The baby should be carefully examined to detect any
associated problems.
 Maintainence of intravenous fluids are administered
 Prophylatic antibiotics are given

19. SURGICAL MANAGEMENT
 Its treated by mobilizing skin flaps to cover the omphalocele
sac.
 A circumferential incision is made.
 Teflon sheets are sutured along the edge of the fascia and
approximated over the omphalocele sac.
 Reduction is effected by gradually pulling teflon sheet. At the
right time the omphalocele sac is excised and teflon sheet is
removed and a dual patch is sutured circumferentially to the
remaining fascia

21. CONGENITAL DIAPHRAGMATIC HERNIA
CDH is a defect or hole in the diaphragm that allows
the abdominal contents to move into the chest cavity.
TYPES:
1. Bochdalek hernia
2. Morgagni hernia
3. Diaphragm eventration

22. BOCHDALEK HERNIA
 It also known as postero- lateral diaphragmatic
hernia, is most common CHD.
 In this the diaphragm abnormality is characterized
by a hole in the postero- lateral corner of the
diaphragm, which allows passage of the abdominal
viscera into the chest cavity.

23. MORGAGNI HERNIA
 This a rare kind, anterior part of diaphragm or
retrosternal portion a defect is present.
 Herniation occurs through foramen of
Morgagni, located immediately adjacent to xyphoid
process of the sternum.

24. DIAPHRAGM EVENTERATION
 It occurs when diaphragm is thinner, allowing the
abdominal viscera to protrude upward into chest
cavity.

26. PATHOPHYSIOLOGY
 Failure of the diaphragm to completely close during
development
 Herniation of abdominal content into chest cavity
 Congenital Diaphragmatic Hernia

27. MANAGEMENT
 Orogastric tube placement and securing airway
 Baby placed on ventilator
 ECMO- Extra Peritoneal Membrane Oxygenation
 An incision is made in the abdomen. The hernia is stitched
close.

28. ECMO