pediatric hernias: when to refer disclosures · 10/10/2013 4 inguinal hernias •clinical...
TRANSCRIPT
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Pediatric Hernias: When to Refer
Katrina Cardenas, MMS, PA-C
October 12, 2013
http://lifestyle-advertising-photographer-la.blogspot.com/
Disclosures
• Nothing to disclose
Outline
• Inguinal Hernias
• Epigastric Hernias
• Umbilical Hernias
• Diastasis Recti in Infancy
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Blake, 2 month male
• CC: Bulge in groin
• HPI:
▫ Intermittent bulge seen in
left groin X 1 month
▫ Seen when crying or straining
▫ Disappears when at rest
▫ Eating and stooling without
difficulty
▫ Deny noticing skin changes at
anytime
• ROS: Unremarkable
• PMHX: Prematurity: 30 wks
gestation, 8 wk NICU stayhttp://madamenoire.com/284096/black-babies-are-the-least-
expensive-to-adopt-in-the-u-s/
Blake, 2 month male
http://www.meddean.luc.edu/lumen/MedEd/urology/inghrnia.htm
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Pediatric Inguinal Hernias
• Epidemiology:
▫ Incidence: range 1-5% of children
� ~60% occur on the right side
▫ Occur equally among all races1
▫ More common in males than females ratio 3-10:12
▫ Premature infants at increased risk: 16%-25%
▫ Bilateral hernias present: 10%3
▫ Family history: 11.5 %1
Langman’s Medical Embryology, 7th Ed 1995 1, 2
Male Embryology
Atlas of Pediatric Surgery, Nakayama
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Inguinal hernias
• Clinical presentation:
▫ Intermittent bulging seen
in the groin, labia, or
scrotum
▫ Seen with an increase in
intra-abdominal pressure
▫ Typically asymptomatic
� Older children may
complain of pain in groin
Inguinal Hernia
• Physical exam:▫ Inguinal masses or asymmetry
in groin
▫ Males:
� hold testicle in scrotum and
assess for additional masses
� Palpate spermatic cord for
thickening
▫ Infants: allow to strain and/or
cry
▫ Older children: examine
supine and standing while
performing Valsalva maneuver
http://www.pediatricurologybook.com/inguinal_hernia.html
Silk Glove Sign
• Single finger over the
spermatic cord at the level
of the pubic tubercle
rubbing side-to-side
• + Silk Glove sign:
▫ thickening with palpation
▫ described as rubbing two
pieces of silk together
▫ not always accurate and
subjective based on
clinical practice1
http://dynamic.psu.ac.th/kidsurgery.psu.ac.th/Pediatric%20surgery/KID/LESSON15.HTM
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Inguinal Hernias
• Diagnostic imaging- rarely needed:
▫ Herniography: rarely used
▫ US: gained popularity as an adjunct to the
physical exam1
• Management:
▫ Surgical referral when diagnosis of inguinal
hernia
� is made
� or suspected
Inguinal Hernias
• Complications: � Incarceration or strangulation of intestine or
omentum
� In females: potential for incarceration or strangulation of ovary, fallopian tube, and in rare cases the uterus
� Incidence of incarceration: 14-31%� 85% occur before the first year of life3
▫ Incarceration and strangulation are
SURGICAL EMERGENCIES
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M
Strangulated Inguinal Hernias
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Inguinal Hernia
• Surgical Complications2
▫ Scrotal Swelling
▫ Hematoma
▫ Injury to the Vas
Deferens
▫ Testicular atrophy
▫ Recurrence
� 3% elective repair
� 20% incarcerated
hernia repair
Contralateral Exploration
• Males with unilateral IH, surgeons performing
routine contralateral exploration under 2 yrs:
▫ 2005: 44%
▫ 1993: 65%
• Females with unilateral IH, surgeons
performing routine contralateral exploration
under 4 yrs:
▫ 2005: 47%
▫ 1993: 84%
American Academy of Pediatrics, Section on Surgery, Hernia Survery, 20054
Normal
4
Laparoscopic Appearance of Right
Internal Inguinal Ring
Open
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Molly, 4 yr female
• CC: Bump on Abdomen
• HPI:
▫ Bump present for the last
5 months
▫ Increasing in size
▫ Occasionally tender
▫ No skin color changes
▫ Eating and stooling
without difficulty
• ROS: Unremarkable
• PMHX: Otherwise healthy 4
yr female http://emilystarlingphotography.com/wp-
content/uploads/2012/12/little_girl_model_Shreveport_photography06(p
p_w860_h571).jpg
Molly, 4 yr female
http://www.bestpediatricsurgeon.com/umbilical-para-umbilical-hernias/
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Epigastric Hernias
• Epidemiology:
▫ Causes are multi-
factorial
▫ More common in males
3:1
▫ 20% can have multiple
hernias5
• Clinical Presentation:
• Epigastric mass
• +/- pain6
http://www.pediatricsconsultant360.com/content/lumps-and-bumps-children-abdominal-and-inguinal-hernias
Epigastric Hernia
• Physical Exam: ▫ Palpable bulge along the abdominal midline
between the xiphoid process and umbilicus
▫ Variable in size, typically <1 cm6
▫ Can be immediately adjacent to the umbilicus and difficulty to distinguish—careful examination is needed1
▫ Risk of strangulation is low• Management
▫ Need surgical repair▫ Referral to pediatric surgery once diagnosis made
Epigastric Hernia Repair
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Adam, 4 yr male
• CC: Bulge in the belly button
• HPI:
▫ Present since birth
▫ Continues to grow with him
▫ Never complains of pain
▫ Eat and stool without difficulty
▫ No reports of ever becoming stuck
• ROS: Unremarkable
• PMHX:
▫ Premature, born at 32 weeks, had
10 wk unremarkable NICU stay
▫ Asthma
� Albuterol PRNhttp://hopeyscorner.com/2013/01/19/test2/
Adam, 4 yr male
http://abdomend.com/blog/hernia/abdominal-hernia/
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Umbilical Hernia
• Epidemiology
▫ Equal frequency in males and females
▫ Increased incidence in African American infants
▫ Increased incidence in premature infants
� 75% of infants <1500 grams will spontaneously resolve1
▫ Less likely to close spontaneously if:
� Larger then 1.5 cm fascial defect
� Significant amount of protruding skin
� Have underlying conditions: Ehlers-Danlos, Beckwith-
Wiedemann syndrome, Down’s syndrome, trisomy 13,
trisomy 18, mucoploysaccharidoses, hypothyroidism1,7
Umbilical Hernia
• Fascial opening (umbilical ring) exists to allow
passage of vessels from mother to the fetus7
• Umbilical ring is open throughout most of
gestation, but becomes progressively smaller as
gestation progresses
• After birth, the umbilical ring continues to
close as the fascia of the umbilical defect
strengthens1
Umbilical Hernia
• Clinical Presentation:
▫ Typically asymptomatic
▫ Seen with increased
intra- abdominal
pressure
▫ Easily reducible
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Umbilical Hernia
Umbilical Hernia
• Management:
▫ UH <1 cm
� Observation, most will
spontaneously close
� Referral for surgical repair
at 4-5 yrs if no
spontaneous resolution
▫ UH 1.0-1.5 cm
� Observation for decrease
in fascial defect size
� Referral for surgical repair
at 4-5 yrs if no
spontaneous resolution
▫ UH>1.5 cm
� Observation till at least 2
yrs of age
� Less likely to spontaneous
resolve on their own7
� Surgical referral if no
spontaneous closure
▫ **If symptomatic or increase
in size: refer sooner
Umbilical Hernia
• Complications:
▫ Incarceration or strangulation of intestine or omentum
▫ Estimated to be 1:1500 hernias2
▫ Incarceration and strangulation are:
SURGICAL EMERGENCIES
http://www.yoursurgery.com/ProcedureDetails.cfm
?Proc=73
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http://www.bestpediatricsurgeon.com/umbilical-para-
umbilical-hernias/
Incarcerated Umbilical Hernia
http://www.surgeryencyclopedia.com/St-
Wr/Umbilical-Hernia-Repair.html#b
Umbilical Hernia Repair
http://www.bestpediatricsurgeon.com/umbilical-para-umbilical-hernias/
Umbilical Hernia Repair
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http://www.bestpediatricsurgeon.com/umbilical-para-umbilical-hernias/
Umbilical Hernia Repair
Umbilical Hernia Repair
• Post-operative
complications:2
▫ Recurrence
▫ Seroma or
Hematoma
▫ Trapped or
perforated bowel
▫ Bowel obstruction
http://www.kidspot.com.au/familyhealth/Going-to-hospital-
Common-surgeries-Umbilical-hernia-
repair+3227+262+article.htm
Proboscoid Umbilical Hernia
• Large fascial defect and
pendulous protrusion
▫ chance of spontaneous
closure low1,2,7
• If umbilical ring does not
narrow, then recommend
surgical repair during
first 2 years of life1,7
• Require surgical referral
during 1st year of life
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http://www.rileypediatricsurgery.com/blog/2013/03/11/disorders/what-is-an-umbilical-hernia/
Proboscoid Umbilical Hernia
Katie, 1 month infant
• CC: Large abdominal
bulge
• HPI:
▫ Large bulge involving
most of upper abdomen
▫ Worsens when crying
▫ Gone when at rest
▫ Eating and stooling
without difficulty
▫ +gaining weight
• ROS: Unremarkable
• PMHX: Unremarkablehttp://us.cdn4.123rf.com/168nwm/arekmalang/arekmalang
0801/arekmalang080100129/2466862-a-shot-of-a-cute-asian-
baby-boy.jpg
Katie, 1 month infant
http://newborns.stanford.edu/PhotoGallery/DiastasisRecti1.html
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Diastasis Recti in Infancy
• Epidemiology:
▫ More common in premature infants
▫ More common in African American newborns6
• Clinical Presentation:
▫ May appear as a “bubble” or “ridge” running
down the abdomen from the xiphoid process to
the umbilicus
▫ More prominent with increased intra-abdominal
pressure
Diastasis Recti in Infancy
http://www.primehealthchannel.com/diast
asis-recti.html
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Diastasis Recti in Infancy
� Physical Exam:
� Edges of rectus
abdominis muscles
typically palpable
� Easily seen when
infant is straining or
crying
� May not be seen when
lying supine and
relaxed
http://newborns.stanford.edu/PhotoGalle
ry/DiastasisRecti2.html
Diastasis Recti in Infancy
� Management:
� No diagnostic
imaging needed
� No surgical referral
needed unless
uncertain about
diagnosis
� Observation
http://noahsdad.com/core/
Take Home Points on Pediatric Hernias
• Inguinal Hernias: Need early surgical referral if suspected or if diagnosed
• Epigastric Hernias: Need surgical referral if suspected or if diagnosed
• Diastasis Recti in Infancy: No surgical referral needed, observation, will resolve with time
• Umbilical Hernias:▫ UH <1 cm
� Observation, most will spontaneously close
� Referral and surgical repair ~4-5 yrs if no spontaneous resolution
▫ UH 1.0-1.5 cm� Observation/Referral and
surgical repair ~4-5 yrs if no spontaneous resolution
▫ UH>1.5 cm� Observation till at least 2 yrs
of age, less likely to resolve spontaneously, surgical referral
** If symptomatic or increase in size: refer sooner
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References• 1. Coran AG, Adzick NS, Krummel TM, Laberge JM, Shamberger RC, Caldamone
AA, eds. Pediatric Surgery. 7th ed. Philadelphia, PA. Elsevier; 2012.
• 2. Katz, DA. Evaluation and management of Inguinal and Umbilical Hernias.
Pediatric Annals. 2001;30:729-735.
• 3. Ramsook C, Endom EE. Overview of inguinal hernia in children. In:
UpToDate, Singer JI, Drutz JE (Ed), UpToDate, Waltham, MA, 20013.
• 4. Antonoff MB, Kreykes NS, Saltzman DA, Acton RD. American Academy of
Pediatrics Section on Surgery hernia surgery revisited. J Pediatr Surg.
2005;30:1009-1014.
• 5. Coats RD, Helikson MA, Burd RS. Presentation and Management of Epigastric
Hernias In Children. J Pediatr Surg. 2000;35:1754-1756.
• 6. Brooks, DC. Overview of abdominal hernias. In: UpToDate, Turnage, R (Ed),
UpToDate, Waltham, MA, 2013.
• 7. Palazzi DL, Brandt, ML. Care of the umbilicus and management of umbilical
disorders. In: UpToDate, Duryea TK, Garcia-Prats JA (Ed), UpToDate, Waltham,
MA, 2013.
Thank you
• Ravindra Vegunta MD,FRCSEd,FACS,FAAP
• Joseph Janik MD,FACS,FAAP