hernia
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HERNIA
LIVSON THOMASM.Sc. (N) 1st YearCMC & Hospital, Ludhiana.
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
TYPES OF HERNIA IN CHILDREN
1. Inguinal Hernia
2. Umbilical Hernia
3. Diaphragmatic Hernia
4. Omphalocele & Gastroschisis
INGUINAL HERNIA
An inguinal hernia is a protrusion of abdominal
cavity contents through the inguinal canal.
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.
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.
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.
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.
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.
CLINICAL FEATURES
Bulge or swelling appear in the belly- button area.
Swelling may be noticeable when baby cries.
DIAGNOSTIC EVALUATION
Physical Examination Abdominal X-ray Ultrasound
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
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.
RISK FACTORS
Young mother < 20 Folic acid deficiency Hypoxia Substance abuse High risk pregnancies
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
Failure for the midgut to return and re-enter the abdomen
Omphalocele is formed
CLINICAL FEATURES
4-12 cms, centrally located. Dystocia may occur Rupture may occur Ectopic liver Abdominal and thoracic cavity under developed
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
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
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 hernia2. Morgagni hernia3. Diaphragm eventration
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.
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.
DIAPHRAGM EVENTERATION
It occurs when diaphragm is thinner, allowing the abdominal viscera to protrude upward into chest cavity.
PATHOPHYSIOLOGY
Failure of the diaphragm to completely close during development
Herniation of abdominal content into chest cavity
Congenital Diaphragmatic Hernia
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.
ECMO
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