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.
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.
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
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
Inguinal hernia with reduction (a–c).