Approach
Small, asymptomatic hernia
Traditional management of small hernias (<1.5 cm) involves observation until 4 or 5 years of age.[2] This allows for spontaneous closure in up to 80% of children.[5] If the hernia persists beyond 4 to 5 years of age, it can be managed with elective outpatient surgical repair. However, the risk of complications in older children, as well as the likelihood of eventual spontaneous closure, cannot be clearly defined from the available data.[9] If a hernia incarcerates during the period of observation, it should be reduced by manual pressure and repaired surgically, generally within 24 hours. If an incarcerated hernia cannot be reduced, an emergency operation is indicated. It can be challenging to convince the child's carers that observation alone will be successful in most cases and that an operation is not indicated.
Large or symptomatic hernia
Fascial defects >1.5 to 2 cm are unlikely to close spontaneously. Many surgeons advocate elective repair at 2 to 3 years of age for such hernias.[10] Earlier repair is also indicated if intermittent symptoms of incarceration or recurring pain develop.[11] There is some evidence that complications may be increased in children undergoing repair at an earlier age; a study suggests deferring elective repair until the child is 4 years of age or older, and this was the management strategy used most commonly in a survey of American Pediatric Surgical Association members.[12][13] Compression therapy (such as abdominal binders) have no role in management and may be harmful or complicate the repair.
Incarcerated hernia
If an individual with an unrepaired umbilical hernia presents with discomfort or a tender umbilical mass, incarceration with or without strangulation should be suspected and treated immediately, regardless of age or size. Incarceration occurs if intra-abdominal contents (e.g., abdominal viscera or omentum) become trapped in the protruding hernial sac. This is termed 'strangulation' if the blood supply to the bowel is compromised, causing ischaemia.[2]
Management consists of an immediate attempt at reduction (in the absence of signs of peritonitis) by milking air or fluid out of the incarcerated loop of intestine and applying firm, steady pressure to the mass. If reduced, the patient should be admitted and observed for peritonitis, with surgical repair the following day. If the hernia cannot be reduced, emergency repair is indicated. Assessment of bowel integrity should be part of the procedure, particularly if bloody peritoneal fluid is encountered during surgery.
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