Approach to Congenital abdominal wall defects .pptx
- 1. Approach to a Newborn with Congenital Abdominal Wall Defects Presenter: Abdi L. (GSR- I) Moderator: Dr Abreham (Ass’t. Prof. of Pediatric Surgery) Oct., 2022 G.C
- 2. Objectives • To describe embryological basis of congenital abdominal wall defects • To discuss clinical presentation and diagnosis of these anomalies • To list differences between omphalocele and gastroschisis • To explain their complications and principles of management 2
- 3. Outlines • Introduction • Embryology of abdominal wall defects • Gastroschisis • Omphalocele • Umbilical hernia • Summary • References 3
- 4. Introduction • Gastroschisis and omphalocele are the 2 most common congenital abdominal wall defects • Often diagnosed prenatally by US • Associated with other anomalies in different rate 4
- 5. Embryology of abdominal wall • At 4th week GA, embryo develops 4 folds that will enclose the body cavities • 2 Lateral folds, • Cephalic fold and • Caudal fold • The 2 lateral folds form the pleuroperitoneal canals once they meet anteriorly in the midline. 5
- 6. Embryo…Cont’d • The Cephalic fold brings down with it the developing heart; also carries the septum transversum • The Caudal fold brings with it the developing bladder/ allantois • The gut tube has communication at the umbilicus to the yolk sac. • At 6th wk - physiological midgut herniation • At 10th wk - the already herniated gut returns to the peritoneal cavity 6
- 7. Cont’d… 7
- 8. Cont’d… 8
- 10. Spectrum of congenital abdominal wall defects • Gastroschisis • Omphalocele • Umbilical hernia • Pentalogy of Cantrell • Exstrophy of bladder 10
- 11. Gastroschisis Incidence: • 1 in 4000 live births; M>F • Preterm delivery is more frequent in infants with gastroschisis (28%) • The most common of abdominal wall defects Embryology: • Caused by failure of the umbilical coelom to develop. • The elongating intestine then ruptures out of the body wall directly into the amniotic cavity • The defect is almost always to the right of umbilicus (2-3cm diameter) 11
- 12. Etiology: Different theories • Failure of the mesoderm to form in the anterior abdominal wall • Failure of the lateral folds to fuse in the midline leaves a defect to the right side of umbilicus • Thrombosis of the right omphalomesenteric vein(umbilical vein) causes necrosis of surrounding abdominal wall • Maternal use of smoking and vasoconstrictive drugs( ephedrine, cocaine) 12 Gastroschisis
- 13. Risk factors for Gastroschisis • Tobacco, Aspirin and ibuprofen • High levels of nitrosamines (environmental exposure) • Decongestants (pseudophedrine) • Use of addictive drugs (cocaine, methamphetamine, marijuana) • Low levels of glutathione & a-carotene • Young maternal age • Low socioeconomic status • Primigravida 13 Gastroschisis
- 14. Clinical Presentation • It has no covering membrane • Is not associated with chromosomal abnormalities • So the survival rate is excellent. • But volvulus resulting in a compromised blood supply may lead to fetal death. • The most common associated anomaly is intestinal atresia(7-28%) • IUGR has been noted in many of these fetuses. 14 Gastroschisis
- 15. Diagnosis • Antenatal 2nd TM U/S, it also helps to detect associated anomalies • Gastroschisis: Detection of Bowel loops freely floating in the amniotic fluid Defect in abdominal wall to right of umbilical cord insertion • Elevated alpha fetoprotein (AFP) in both maternal serum and amniotic fluid • Elevated amniotic fluid acetylcholinesterase (AChE) • More increase in gastroschisis 15 Gastroschisis
- 16. Prenatal mgt and delivery • Ideal test is to accurately differentiate gastroschisis fetuses at risk for complications • Mode & time of delivery should be based on obstetric indications • Literature suggests both SVD and CS are safe • Preterm delivery has been advocated to limit exposure of the bowel to amniotic fluid 16 Gastroschisis
- 17. Postnatal Mgt Neonatal care • There is significant evaporative water losses from exposed bowel • The herniated bowel should be wrapped in warm saline-soaked gauze • The baby should be positioned on right side to prevent kinking of mesentery • IV fluid resuscitation, NG decompression • Central venous access should be established early • Examine the bowel for atresia, necrosis or perforation 18 Gastroschisis
- 18. Postnatal… Risk stratification: • Simple or • Complex gastroschisis • This risk was based on the presence or absence of any intestinal complication (atresia, ischemia, perforation, or NEC) 19 Gastroschisis
- 19. Surgical Mgt : Gastroschisis • Goal: return the bowel with minimal risk • Options: • Silo placement, serial reductions, and delayed abdominal wall closure • Primary reduction with operative closure • Bands crossing the bowel loops should be lysed before reduction 20 Gastroschisis
- 20. Primary closure : gastroschisis • After bowel reduction a piece of silastic sheeting can be placed under abdominal wall if there is concern of increased IAP • Intra-abdominal Pressure (IAP) can be measured by: • Intravesical pressure using bladder catheter • Intragastric pressure using NGT • Pressures higher than 10-15 mmHg indicates elevated IAP • Associated with decreased renal & intestinal perfusion • Splanchnic perfusion pressure= MAP – IAP • If < 44 mmHg implies decrease intestinal blood flow 21 Gastroschisis
- 21. Staged silo reduction • Placing the bowel into a silo, its base placed or sutured into fascial openings • The bowel is reduced 1-2x per day as the silo is shortened by sequential ligation • Continuously assess bowel viability while in the silo • Definitive closure done when all contents are reduced entirely • This process usually takes up to 14 days; majority within 5- 6 days 22 Gastroschisis
- 22. • Definitive closure: sutureless Vs skin Vs fascial closure 23 Gastroschisis
- 23. Complications • Intestinal atresia • NEC • Short bowel syndrome • Prolonged parenteral nutrition related: • Cholestatic liver disease • Central-line related sepsis 24 Gastroschisis
- 24. Management of intestinal atresia • Depends on the state of intestine, and the time of diagnosing the atresia • If detected at time of birth, stoma can be created • If diagnosed a few weeks later, operation deferred for 3-4 weeks 25 Gastroschisis
- 25. Postop course • Ensure there are no effects from increased IAP • If suspected, prompt laparotomy and silo placement • NG decompression • Parenteral nutrition • Early oral stimulation to prevent loss of sucking reflex 26 Gastroschisis
- 26. Omphalocele Incidence • In utero 1 in 1100; but at birth 1 in 4000-6000 • The second most common abdominal wall defect Embryology • Failure of the bowel to return to the body cavity from its physiological herniation • Develops due to a failure of body folds to complete their journey • Most are lateral fold defects 27 Omphalocele
- 27. Omphalocele… Clinical presentation • Is a large defect ( > 4cm), • The sac is covered by amnion & peritoneum • Contents: small & large intestine, ± liver, stomach, spleen and gonads • It has a relatively high incidence of associated defects Chromosomal abnormalities found in > half of patients • Trisomies 13,18, 21, 45X, Beckwith-Weideman syndrome, Pentalogy of Cantrell 28 Omphalocele
- 28. Cont’d…. • Most patients are large for gestational age/LGA/ • Usually other organ systems are affected as well • 45% of patients with omphalocele have a cardiac abnormality. • Pulmonary hypoplasia is also commonly associated with omphalocele • The severity and number of these associated issues determine the outcomes in omphalocele 29 Omphalocele
- 29. Risk factors for Omphalocele • Extremes of maternal age • Maternal obesity • Failure to use multivitamins during pregnancy 30 Omphalocele
- 30. 31
- 31. 32
- 32. Prenatal Diagnosis • Ultrasound in 2nd trimester • Also useful for detection of associated anomalies • Elevation of maternal serum AFP • O/HC or O/AC ratios may be correlated with postnatal morbidity & mortality: Giant omphalocele 33 Omphalocele
- 33. Perinatal care • Mode of delivery- CS if obstetric indication • However, giant omphaloceles are being delivered by C-section due to fear of liver injury 34 Omphalocele
- 34. Omphalocele: Initial care • Early NG tube placement to decompress the intestines • Rectal stimulation to evacuate meconium • Maintenance of body temperature • Ventilator support as needed • IV maintenance fluid –preferable IV access above the diaphragm/ upper limbs 35 Omphalocele
- 35. Initial care… • Prophylactic antibiotics • Defect is covered by non-adherent sterile gauze • If large omphalocele, babies should be positioned on their side • Directed cardiac evaluation- echocardiography • Abdominal US- to look for renal abnormalities • Check for hypoglycemia=> Beckwith-Weidemann syndrome 36 Omphalocele
- 36. Risk assessment Based on presence or absence of associated anomalies • Isolated or not Location of the bulge in relation to the abdomen • Hypogastric, central, and epigastric Based on size • Hernias of the cord, small, medium, large, and giant defects 37 Omphalocele
- 37. Management • Non-operative therapy, • Primary closure when possible, and • Staged reduction with a temporary Silastic ‘pouch’ • These treatment options depend on the size of the defect, GA and presence of associated anomalies 38 Omphalocele
- 38. Non-operative mgt Scarification treatment • If life-threatening associated anomalies, especially cardiac • Painting the sac with eschar forming agents Silver nitrate solutions or silver sulfadiazine cream • The eschar and epithelialization may take 4-10 weeks. • Eventually a covered ventral hernia resulted 39 Omphalocele
- 39. Operative mgt Immediate primary closure • For small to medium sized omphaloceles • Excision of the sac, with primary closure of fascia and skin • If fascia closure increases IAP, skin closure alone is advisable 40 Omphalocele
- 40. Mgt… Staged neonatal closure • The sac is excised and replaced with mesh and then closed over time Delayed staged closure • Attaching Silastic pouch to the fascia allows gradual reduction of contents into abdomen (10-14days), • Skin flap closure needed eventually • Sometimes prosthetic patch needed to close fascial defect 41 Omphalocele
- 42. 43 Omphalocele
- 43. 44 Omphalocele
- 44. Large omphalocele: staged repair 45
- 45. Post op care • Systemic antibiotics • Parenteral nutrition until bowel function returns • Respiratory support with ETT • Keep NGT till bowel functions/ distention decreased Complications • Due to highly increased intra- abdominal pressure after closure: • Respiratory distress – mechanical ventilation • Acute hepatic congestion – reoperation • Renal failure – dialysis • Bowel infarction • Dehiscence 47 Omphalocele
- 46. • Outcome depends on presence and degree of: • prematurity • Associated anomalies • Loss of bowel length due to atresia or gut infarction Long term outcomes • Common in patients with larger omphaloceles • GERD • Pulmonary insufficiency • Recurrent lung infection • Feeding difficulty • Neurodevelopmental delay 48 Omphalocele
- 47. Umbilical hernia • Failure of umbilical ring to close leads to central defect in the linea alba • The protrusion is covered by normal umbilical skin and subcutaneous tissue • 20% of full-term neonates may have incomplete closure of umbilical ring at birth. • Girls > boys 49
- 48. Cont’d… • The extent of skin protrusion is not always indicative of the size of the fascia defect • Palpate the actual facial defect by reducing the hernia manually • Premature and LBW infants have a higher incidence 50
- 49. Umbilical hernia… • Generally are asymptomatic • Causes considerable parental anxiety • Complications like incarceration are rare (0.2%) during childhood • Abdominal pain, bilious emesis, tender mass thru umbilicus • 80% of umbilical hernias close spontaneously by 4 or 5 years of age. • Defects of >1.5cm diameter rarely close spontaneously • Surgery is indicated if:- • No spontaneous closure by 5 years, • Larger defect regardless of age • Symptomatic 51
- 50. Mgt: Umbilical hernia • Observation • Pressure dressing is not advisable • Operative repair • Recurrence is rare, but common in children with elevated intraabdominal pressures, like those with a VP shunt. 52
- 51. • Steps for operative repair for umbilical hernia 53
- 52. Summary 54
- 53. References • Holcomb and Ashcraft’s Pediatric surgery, 7th ed • Coran pediatric surgery, 7th ed • Operative pediatric surgery by Arnold G Coran, 7th ed • Langman’s medical embryology, 12th ed 55
- 54. 56
Editor's Notes
- #5: **Although often considered together, they are distinct and separate entities in every way from their etiology to management principles.
- #6: Contraction of the umbilical ring completes the process of abdominal wall formation.
- #7: *Umbilical coelom is a cavity in the body stalk on the anterior surface of the embryo. *At 6th wk –the elongating midgut enters the umbilical coelom. This is because the abdominal cavity is small to accommodate the developing midgut. *At 10th wk, the already herniated gut returns from the space within the umbilical stalk to the peritoneal cavity and undergoes rotation and fixation. The 1st, 2nd,3rd part of duodenum, ascending & descending colon assume their fixed, retroperitoneal positions.
- #8: At the end of 3rd week, intraembryonic mesoderm on each side of the midline differentiates into a paraxial portion, an intermediate portion, and a lateral plate (Fig. 10.1A). *When intercellular clefts appear in the lateral mesoderm, the plates are divided into two layers: the somatic mesoderm layer and the splanchnic mesoderm layer. The latter is continuous with mesoderm of the wall of the yolk sac (Fig. 10.1B). The space bordered by these layers forms the intraembryonic cavity (body cavity).
- #9: ***The lateral abdominal folds of embryo meet in the anterior midline and surround the yolk sac, eventually constricting the yolk sac into yolkstalk that becomes the site of the umbilical cord. At first, the right and left sides of the intraembryonic cavity are in open connection with the extraembryonic cavity, but when the body of the embryo folds cephalocaudally and laterally, this connection is lost.
- #10: *At 6th wk –the elongating midgut enters the umbilical coelom. This is because the abdominal cavity is small to accommodate the developing midgut. *At 10th wk, the already herniated gut returns from the space within the umbilical stalk to the peritoneal cavity and undergoes rotation and fixation. The 1st, 2nd,3rd part of duodenum, ascending & descending colon assume their fixed, retroperitoneal positions.
- #11: **Cephalic fold defects result in ectopia cordis or pentalogy of Cantrell **Pentalogy of Cantrell is a collection of five congenital midline birth anomalies involving the heart, pericardium, diaphragm, sternum, and ventral abdominal wall. *Caudal fold defects cause bladder and cloacal exstrophy *Defect is infraumbilical and accompanied by exstrophy of bladder, epispadias, diastasis of pubic rami and imperforate anus **Rupture of the cloacal membrane after fusion with the urorectal septum results in bladder exstrophy, whereas rupture before fusion gives rise to the more severe presentation of cloacal exstrophy.
- #12: *Becoming commonest, due to increased incidence and survival of premature babies. *Gastroschisis is common on the right side because the right side of the umbilicus is relatively unsupported as a result of resorption of the right umbilical vein at 4 week of GA. **Occasionally, a skin bridge may be present between the cord and the defect, but the abdominal wall and its muscles are normal.
- #13: *Currently, the ventral body folds theory is more widely accepted. **This implies that a gastroschisis develops early in gestation and before an omphalocele might develop.
- #14: No genetic or familial risk factors Obesity is protective
- #15: *Gastroschisis is one of a constellation of disorders in the limb-body wall defect syndrome( amniotic band syndrome). In this rare syndrome, thoracic wall anomalies or gastroschisis are found associated with limb abnormalities, meningocele, abnormal genitalia, intestinal atresias, and umbilical cord abnormalities.
- #16: Omphalocele can be distinguished from gastroschisis by the presence of a sac and from umbilical cord hernia by the presence of the liver in the defect. *In cases of neural tube defects and several other abnormalities, including omphalocele, gastroschisis, bladder exstrophy, amniotic band syndrome, sacrococcygeal teratoma, and intestinal atresia, AFP levels increase in amniotic fluid and maternal serum. ***Elevated alpha fetoprotein (AFP) in both maternal serum and amniotic fluid and elevated amniotic fluid acetylcholinesterase (AChE) have been correlated with abdominal wall defects when there is no myelomeningocele **AFP concentrations decrease as, for example, in Down syndrome, trisomy 18, sex chromosome abnormalities, and triploidy.
- #17: *Complications such as intestinal loss or closing defects *Since the exact definition of normal and abnormal of the complications has discrepancy among centers, so not applicable for early delivery. *** Early delivery for fetus with gastroschisis has been advocated previously, in order to limit exposure of the bowel to amniotic fluid, so to reduce inflammatory peel on the bowel which may otherwise result in dysmotility of the bowel. *Damage to the pacemaker cells and nerve plexi may contribute to the profound dysmotility and malabsorption seen in these infants. *Currently available evidence doesn’t support elective preterm delivery for gastroschisis.
- #19: *Although gastroschisis most often is an isolated anomaly, thorough examination of the neonate is important. *Excess fluid resuscitation is detrimental and results in edema, increase in time to closure and increased risk of abdominal compartment syndrome.
- #20: *Complex Need multiple operations, prolonged hospitalization and have increased rates of sepsis, intestinal failure, cholestasis *This classification allowed better counseling & planning, also for an improved ability to compare treatments
- #21: *The primary goal is to return the viscera to abdominal cavity while minimizing the risk of damage to the viscera due to direct trauma or to increased intra-abdominal pressure. *The choice of which option to apply is dependent on the presentation of the bowel, surgeon and institution preferences.
- #22: *If the surgeon is concerned about worsening of pulmonary function with fascial and skin closure, after bowel is reduced a piece of silastic sheet can be placed under abdominal wall to prevent evisceration. The sheet is removed in 4 to 5 days, the abdomen is closed then. *Pressures >20mm Hg can lead to organ dysfunction (renal failure and bowel ischemia) *Splanchnic perfusion pressure= MAP- IAP ;( also used to guide reduction, if less than 44 mmHg implies decrease intestinal blood flow)
- #23: **This technique has increasingly come in favor, b/c it avoids high IAP, so that ischemic injury to the viscera is avoided and permit earlier extubation. *a prefabricated silo with circular spring at the end, enables to insert it at the bedside/delivery room without the need for sutures or GA. **
- #24: *severely matted bowel or complex cases likely require longer delayed approach. **for simple gastroschisis, no difference in outcome with either silo or immediate closure.
- #25: *The presence of bowel atresia is the most important prognostic determinant for a poor outcome. **Upto 10% of neonates with gastroschisis have an associated intestinal atresia.(jejunal or ileal)
- #26: *Atresia is usually diagnosed later in life when there is no return of bowel function and contrast study is obtained. *An intestinal atresia should be differentiated from “vanishing bowel” in infants with gastroschisis. **Closing gastroschisis is when the defect size decreases prior to delivery; so blood supply diminishes and result in atresia. *in severe cases extra abdominal bowel completely disappears and results in congenital short bowel syndrome.
- #28: *The current understanding of the etiology for an omphalocele suggests that this defect is not from a failure in body wall closure or migration. Rather, because the umbilical cord is attached to the sac, it is thought that an omphalocele develops due to a failure of the viscera to return to the abdominal cavity. **The location of the defect is in the mid-abdominal or central region but may occur in the epigastric or hypogastric regions as well.
- #29: *Unless ruptured, omphaloceles are covered with a sac consisting of inner peritoneum and outer amnion. *The umbilical cord is attached to the sac itself. *Beckwith-Wiedemann (Hallmark features are: omphalocele, macrosomia and hypoglycemia) POC: This condition has been divided into two categories, complete or partial. Complete, as the name indicates, refers to the presence of all five defects, while others may present with only partial defects. *POC may also carry genetic associations with trisomy 13, 18, 21, and Turner syndrome
- #30: *This abnormality occurs early in embryogenesis, so other organ systems are affected as well **Also down syndrome is associated. *the risk of chromosomal abnormality is more common in infants with central omphalocele and those containing only bowel, when compared with epigastric omphaloceles or those containing liver & bowel.
- #31: The majority (≈75%) of infants with omphalocele have associated congenital anomalies/syndromes, including BeckwithWiedemann syndrome (omphalocele, macrosomia, hypoglycemia), and other chromosomal (29%, including trisomies 13 and 18) and nonchromosomal (45%) multiple and isolated congenital anomalies (musculoskeletal, 24%; urogenital, 20%; cardiovascular, 15%; and central nervous system, 9%). The survival rate is approximately 80% overall, but in infants with isolated omphalocele, the survival rate is >90%.
- #34: *Isolated omphalocele( those without other defects) has a survival rate of over 90%. **Omphalocele pts have cardiac (14-47% incidence of anomalies) and CNS (3-33% anomalies). **Ratios between the greatest omphalocele diameter compared with abdominal circumference (O/AC, or omphalocele ratio), the femur length (O/FL), and the head circumference (O/HC), and have attempted to correlate these ratios with postnatal morbidity and mortality.
- #35: *Mode of delivery should be decided on the basis of obstetric indications, not on the presence of an abdominal wall defect. *CS may be suggested in case of giant omphalocele, containing more than 75% of liver, so have risk of rupture at delivery.
- #36: *Infants with omphalocele do not have as significant fluid and temperature losses as those with gastroschisis, but the losses are higher than those with an intact abdominal wall. *Placement of the intravenous line above the diaphragm is preferable because of the possibility of inferior cava compression and partial obstruction as the eviscerated bowel and/or liver are reduced. *
- #37: **Infants with large omphaloceles, especially when the liver is in the sac, should be positioned on their side to prevent twisting of the inferior vena cava from the sac ‘tipping’ to one side.
- #38: *isolated defects have a better prognosis *cloacal exstrophy is associated with a hypogastric defect, *epigastric ones are associated with pentalogy of Cantrell **increasing size has a direct correlation with worse outcome
- #39: *Because the condition of the bowel in gastroschisis and distention of the bowel and size of the liver in omphalocele are often related to the time between delivery and repair, it is important to make arrangements for repair as soon as possible after delivery.
- #40: *Because of the possibility of serious, life-threatening, or even lethal associated anomalies, infants with omphalocele are occasionally treated non-operatively. *Painting the sac with antiseptic and eschar forming solutions is still useful when operative closure is not possible. *Early use of alcohol, iodine, and mercury-containing compounds produced toxicity due to systemic absorption of these compounds; so replaced by silver
- #41: *defects less than 1.5cm in diameter= hernia of the cord *If fascia closure increases intra-abdominal pressure sufficiently to cause respiratory embarrassment, skin closure alone, with later repair of the ventral hernia, is advisable.
- #42: *the omphalocele sac is excised and the Silastic sheeting is sewn to the rectus fascia. Alternatively, the silo can be sutured to the full thickness of the abdominal wall. *Serial reductions for the silo that is sewn to the fascia are performed on a once- to twice-daily schedule until definitive closure can be obtained. If the fascial edges cannot be approximated in a reasonable time, prosthetic or mesh closure can be utilized.
- #43: *most surgeons favor excision of the sac to allow complete intraabdominal exploration. The sac is sharply removed at the skin/fascia edge
- #44: *careful identification and ligation of the umbilical vessels. *The abdominal cavity can be enlarged by manual stretching. *The intestine is replaced first and then the liver. Care must be given to the position of hepatic veins b/c kinking will result in acute obstruction.
- #45: *The skin is carefully ‘undermined’, separating it from the deep fascia layers. *The fascia is closed with running or interrupted absorbable sutures (polyglactin or polydioxanone) and the umbilicus reconstructed. *sutures are placed through all layers of the abdominal wall except the skin; including the rectus abdominis mm
- #46: *Large omphaloceles, frequently containing most of the liver, are usually not fully reducible at the first operation, and staged repair is necessary. After undermining the skin, the skin is closed over the abdominal viscera, producing a ventral hernia that can be repaired 6–12 months later **Giant omphalocele mgt: painting the sac with antiseptic, use of skin flaps, use tissue expander.
- #47: **mgt of ruptured omphalocele is the same as for the infant with gastroschisis. *The viscera are gradually reduced into the abdominal cavity, using gentle squeezing pressure on top of the ‘pouch’, which is then occluded by umbilical tape tie or suture to maintain reduction. This is usually performed without anesthesia every other day, over a 7–10-day period, until the gut is fully reduced.
- #48: -Abx should continue until the prosthesis are removed. -after NGT removal, wait for 12 hrs and start feeding gradually *the time to resume enteral feeding may be shorter with primary closure.
- #49: *GERD, the reflux improves as the child ages *Respiratory insufficiency ass. With giant omphaloceles may be due to narrow thorax and small lung area leading to pulmonary hypoplasia. *feeding difficulty may require a gastrostomy.
- #50: ***75–80 percent of premature infants weighing between 1.0 and 1.5 kg may show evidence of an umbilical hernia at birth. *The hernia sac protrudes through a defect in umbilical ring due to failure of complete obliteration at the site where the fetal umbilical vessels are joined to placenta during gestation. *** The extent of skin protrusion is not indicative of the size of the fascia defect.
- #51: It is important to palpate the actual facial defect by reducing the hernia manually to assess whether operative or nonoperative treatment is appropriate.
- #52: *Smaller defects(<1cm) will close spontaneously, so most cases should not undergo early repair. **Incarceration is more common in smaller defects than the larger ones. *if incarceration happens immediate exploration and repair of the hernia should be done. **Mostly treatment is governed by size of the defect, age of patient and parental concern.
- #53: **Pressure dressings to keep hernia reduced do not speed the resolution and may result in skin irritation and breakdown; so NOT ADVISABLE. *Fascia repaired with permanent or long lasting absorbable, interrupted sutures palced in transverse plane. The skin closed using subcuticular sutures.
- #54: A-an infraumbilical skin crease incision is made B- umbilical hernia sac has been encircled with a hemostat C- umbilical hernia sac is excised, transverse closure of fascial defect is done with interrupted long-lasting absorbable sutures D- umbilicus has been tacked to the fascial closure, and skin is approximated with a subcuticular closure. A- an infraumbilical skin crease incision is made B- hernia sac is opened, leaving a portion of the sac attached to umbilical skin for ease of subsequent umbilicoplasty. C- umbilical sac has been completely divided and excised to strong fascia D- fascial defect is closed in transverse fashion with interrupted, simple non absorbable sutures. E- the remaining umbilical sac, which is attached to the umbilical skin, is secured to the fascia with interrupted, absorbable suture F- the skin incison is closed with a subcuticular suture