Abdominal Wall: Hernia in Special Populations

Hernia in Pediatrics

Inguinal Hernia in Pediatrics

  • Most Common Type: Indirect (Persistent Processus Vaginalis)
  • Tx: Reduce First, Then Surgery (Open Sac & High Ligation)
    • Timing:
      • Reducible – Elective Repair in 1-3 Days (Allow Edema Dissipation)
      • Incarcerated – Emergent Repair
  • Sex Considerations:
    • Males – Examine Scrotum & Palpate at End of Procedure
      • With High Ligation Risk Pulling Testicle into Inguinal Canal
    • Females – Open & Inspect Proximal Sac for Sliding Contents
      • May Contain Fallopian Tubes (Most Common), Ovary, Uterus, Bowel or Bladder

Umbilical Hernia in Pediatrics

  • More Common in Blacks
  • Often Close Spontaneously
    • Incarceration Rare in Peds
  • Tx: Delay Repair Until 5 Years Old (Before Enter School)
    • Indications for Immediate Repair: > 2 cm or Symptomatic

Hernia in Pregnancy

Umbilical Hernia in Pregnancy

  • ASx: Monitor
  • Sx: Delayed Repair After Delivery
  • Incarcerated/Strangulated: Emergent Repair

Hernia in Morbidly Obese

Treatment Based on BMI

  • BMI < 30: OK for Elective Repair
  • BMI 30-40: Preoperative Weight Loss Recommended but Consider Surgery
  • BMI > 40: Delay Repair Until Weight Loss Achieved
    • Significantly Increased Risk of Recurrence
    • Staged Repair Improves Outcomes
      • Weight Loss or Gastric Bypass First

Hernia with Ascites

Specific Risks of Surgery

  • High Complication Rates
  • Wound Infection
  • Dehiscence
  • Uncontrolled Ascites Drainage Through the Surgical Site
  • Peritonitis
  • Hemorrhage
  • Hepatic Encephalopathy
  • Hepatorenal Syndrome
  • High Recurrence Rate

Specific Risks of Expectant Management

  • Incarceration
  • Skin Necrosis
  • Skin Perforation & Evisceration
  • Ascites Drainage
  • Peritonitis

Initial Treatment

  • Most are Initially Managed Conservatively
  • Elective Repair After Aggressive Medical Optimization
  • Initial Medical Treatment:
    • Sodium Restriction
    • Diuresis
    • Paracentesis
  • Options if Initial Treatments Fail:
    • Intermittent Paracentesis
    • Transjugular Portosystemic Shunt (TIPS)
    • Temporary Peritoneal Dialysis (PD) Catheter – High Risk of Bacterial Peritonitis & Should Be Avoided
  • If Repaired Urgently Prior to Medical Optimization, Consider Placement of an Intraperitoneal Drain to Control Ascites Postoperatively

Indications & Timing for Repair

  • Elective Repair:
    • Exact Timing is Controversial
    • If Patient is a Liver Transplant Candidate, it is Preferred to Delay Hernia Repair and Do it During the Transplant Operation
    • Consider Elective Repair After Aggressive Medical Optimization with Control of Ascites
  • Urgent Repair:
    • Incarceration/Strangulation
    • Skin Rupture
    • Skin Changes Suggesting Impending Rupture

Use of Mesh

  • Elective Setting: OK to Use Mesh
    • Higher Infection Rate (Mesh Exposure/Fistula/Removal Not Significantly Increased)
    • Lower Recurrence Rate
  • Urgent/Emergent Setting: Avoid Mesh Due to Increased Risk of Infection