Incarceration of Umbilical Hernia in Children: Is the Trend Increasing?

Dear Editors,

I read with much interest the paper by Keshtgar and Griffiths ([2]) on the incarceration of umbilical hernia in children. They reported on 7 patients, aged 3.5 - 5 years (median 3 years), with incarceration managed over a period of 3 years in a regional paediatric surgical centre in England. In their report and in one other report ([3]), incarceration was most frequent in umbilical hernias with a defect diameter of 0.5 - 1.5 cm.

In our experience in Zaria, northern Nigeria ([1]), 64 % (30/47) of all children coming for umbilical hernia repair had a complication: 50 % (15/30) had acute incarceration, 33 % (10/30) recurrent incarceration, and 17 % (5/30) evisceration. Sixty-seven percent were below 4 years and 33 % below 2 years of age. Complications occur as early as at the age of 21 days and as late as adulthood. All the complications occurred in hernias with a defect diameter of 1.5 cm or more. Two of the children with acute incarceration had bowel gangrene.

Recent literature from Africa ([1], [4]), where umbilical hernias are most common, suggest that complications in these hernias may be more common than is generally believed, even though there are many more unrepaired and uncomplicated hernias in the environment. However, another report ([5]) from western Nigeria indicated the contrary, and suggested that spontaneous closure may occur up until 14 years of age. It is important to note that in Africa, only patients with complications are likely to come for repair of their umbilical hernias and few will come for cosmetic reasons.

Our experience raises the concern that umbilical hernias carry a definite morbidity and are not as benign as previously believed. Most of the complications tend to occur before the age of 4 years, even though it is true that most umbilical hernias will close or reduce in size by 4 years. Pending prospective population-based studies to resolve the issue, we have modified our policy on umbilical hernias in children thus:

Active observation and follow-up before 4 years; repair hernia at the earliest indication or suspicion of incarceration (unexplained abdominal pain, irreducibility). Repair of hernias with a defect diameter of 1.5 cm or more, if active observation and follow-up will be difficult or is not feasible. Repair of any hernia that has not closed by 4 years.

References

• 1 Ameh E A, Chirdan L B, Nmadu P T, Yusufu L MD. Complicated umbilical hernias in children.  Pediatr Surg Int. 2003;  19 280-282
• 2 Keshtgar A S, Griffiths M. Incarceration of umbilical hernia in children: Is the trend increasing?.  Eur J Pediatr Surg. 2003;  13 40-43
• 3 Lassaletta L, Fonkalsrud E W, Tovar J A, Dudgeon D, Asch M J. The management of umbilical hernias in infancy and childhood.  J Pediatr Surg. 1975;  10 405-409
• 4 Mawera G, Muguti G I. Umbilical hernia in Bulawayo: some observations from a hospital based study.  Cent Afr J Med. 1994;  40 319-323
• 5 Meier D E, OlaOlorun D A, Amodele R A, Nkor S K, Tarpley J L. Incidence of umbilical hernia in African children: redefinition of “normal” and re-evaluation of indication for repair.  World J Surg. 2001;  25 645-648