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Abdominal wall defects in children present as a range of anomalies, from minor hernias of the umbilical or inguinal region to major protrusions of the abdominal wall, such as omphaloceles and gastroschisis. The range of care for these defects spans elective outpatient surgery to emergent care with extended stays in the neonatal intensive care unit. Advances in medical care have greatly improved the survival of infants born with congenital abdominal wall defects such as gastroschisis and omphalocele. Advances include parenteral nutrition, perinatal care, and surgical techniques when primary closure is not possible. However, after the perinatal period challenges for these children with abdominal wall defects may continue for some time.

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Hernias and Embryologic Remnants

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Abdominal wall hernias are very common in the pediatric population, and the surgical treatments are among the most common procedures performed by pediatric surgeons. Hernias are defined by location as well as reducibility. Reducibility will dictate treatment management of a hernia. A reducible hernia allows the patient or examiner to place the abdominal contents back into the abdominal cavity with palpation. An incarcerated hernia is one in which reduction of the abdominal contents is not possible. A strangulated hernia is an incarcerated hernia that is being rendered ischemic by loss of blood supply, a true surgical emergency.

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Epigastric hernias are small midline protrusions located between the umbilicus and the xiphoid process. These hernias have no sac and consist of preperitoneal fat protruding through a small fascial defect. Although small, epigastric defects do not close spontaneously and operative closure is recommended to avoid symptomatic fat entrapment. Umbilical hernias develop when the umbilical ring is unsupported, and the rectus muscles fail to approximate in the midline and close the fascial ring through which the umbilical cord protrudes.1

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The most common hernia treated by pediatric surgeons is an inguinal hernia. Inguinal hernias are formed by failure of the processus vaginalis to completely close, leaving a potential peritoneal diverticulum into which abdominal viscera may herniate or into which fluid can accumulate and form a cystic fluid-filled cavity (hydrocele). In males, persistent patency of all or part of the processus vaginalis may result in various anomalies, including an inguinal hernia (Figure 14–1), a scrotal hernia (Figure 14–2), a communicating hydrocele, a hydrocele of the spermatic cord (Figure 14–3), and a scrotal hydrocele. In females, inguinal hernias and hydroceles can present as a protrusion or mass in the labia majora but arise far less commonly due to the absence of gonadal descent (Figure 14–4).

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