LECTURE No. 8. Hernia of the umbilical cord

Hernia of the umbilical cord is a severe congenital disease, the mortality rate in which to date is from 20,1% to 60%.

clinical picture

The hernia of the umbilical cord has a typical external manifestation. At the first examination after birth, a child is found in the center of the abdomen with a tumor-like protrusion that is not covered by skin, emanating from the base of the umbilical cord. The protrusion has all the elements of a hernia: a hernial sac, consisting of stretched amniotic membranes, a hernial ring formed by the edge of a skin defect and aponeurosis, as well as the contents of the hernia - the abdominal organs.

Classification of the defect: small hernias (up to 5 cm in diameter, for premature babies - 3 cm); 2 medium hernias (up to 8 cm in diameter, for premature babies - 5 cm); large hernias (over 8 cm in diameter, for premature babies - 5 cm).

All hernias, regardless of their size, are divided into two groups:

1) uncomplicated;

2) complicated:

a) congenital eventration of the abdominal organs;

b) ectopia of the heart;

c) combined malformations (occur in 45-50% of children);

d) purulent fusion of the membranes of the hernial protrusion.

An uncomplicated hernia of the umbilical cord is covered with moist, smooth, grayish, stretched amniotic membranes. In the first hours after birth, the membranes are so transparent that you can see the contents of the hernia: liver, intestinal loops, stomach and other organs.

In places, the membrane is thickened due to the uneven distribution of Wharton's jelly, which usually accumulates at the top of the hernial sac. A dense circular groove is felt at the entry point of the umbilical vessels (a vein and two arteries). The amniotic membranes pass directly into the skin of the anterior abdominal wall along the edge of the "hernial ring". The transition line has a bright red color (the zone of break of the skin capillaries), a width of up to 2-3 mm.

In some cases, the skin spreads on the base of the hernia in the form of a ring up to 1,5-2 cm high.

With an inattentive examination of the child in the maternity hospital, such an "umbilical cord" can be tied up along with the intestinal loops located there.

The contents of small hernias is the intestines. The general condition of such newborns does not suffer. Medium-sized hernias are filled with a significant number of intestinal loops and may contain part of the liver.

Children usually come to the clinic in serious condition, with severe cyanosis, chilled. Newborns with large hernias of the umbilical cord, as a rule, do not tolerate transportation from the maternity hospital, and their condition is regarded as severe or extremely severe.

In the hernial sac, a significant part of the liver is always determined, in addition to the intestine. The volume of the hernial protrusion significantly exceeds the size of the abdominal cavity.

Complications of hernias of the umbilical cord have a peculiar clinical picture, are congenital or acquired.

The most severe complication is rupture of the hernial sac. A child is born with intestinal loops that have fallen out of the abdominal cavity.

Among the children admitted to the clinic with this type of complication, there are two main groups:

1) with intrauterine congenital eventration characterized by altered prolapsed intestinal loops - they are covered with fibrinous plaque, the walls are edematous, the vessels of the mesentery are dilated. Abdominal wall defect, usually small (3-5 cm), its edges are rigid, the skin partially passes into the remains of the amniotic membranes of the umbilical cord;

2) with "obstetric" congenital eventration, which arose in connection with a partial rupture of the membranes during the birth of a child with a large hernia of the umbilical cord. The membranes are usually damaged at the base of the hernial protrusion. The prolapsed intestinal loops are quite viable, there are no visible signs of peritonitis (the serous membrane is shiny, clean, fibrinous raids are not determined). Children with congenital eventration are usually delivered to the clinic in the first hours after birth. Their general condition is extremely difficult. Ectopia of the heart occurs in children with large hernias of the umbilical cord. Diagnosis of the defect is simple, since on examination, a pulsating protrusion is clearly defined in the upper part of the hernia under the amniotic membranes - a displaced heart.

The combined malformations for the most part do not change the general condition of the newborn and do not require emergency surgical intervention (facial clefts, deformities of the limbs, etc.).

However, some concomitant congenital diseases make it difficult or impossible to surgically treat a hernia of the umbilical cord.

Incomplete reverse development (non-closure) of the vitelline duct is detected during the first careful examination of the hernial protrusion: at the base of the umbilical remnant an intestinal fistula with bright red edges of the inverted mucous membrane is determined. Its diameter usually does not exceed 0,5-1 cm. Meconium is periodically released from the hole, which contaminates and infects the surrounding tissues.

Exstrophy of the bladder is often combined with hernia of the umbilical cord. In the presence of these defects, the abdominal wall is absent almost along its entire length - in the upper part it is represented by a hernial protrusion, the membranes of which directly pass into the mucosa of the split bladder and urethra.

Congenital intestinal obstruction is the most “insidious”, from a diagnostic point of view, combined developmental defect.

More often there is a high obstruction due to duodenal atresia or a violation of the normal rotation of the middle intestine. Persistent vomiting with bile, which occurs by the end of the first day after birth, makes it possible to suspect the presence of this disease. With low obstruction, the first sign is meconium retention. X-ray examination clarifies the diagnosis.

Severe congenital heart defects sharply worsen the general condition of the newborn and are identified by the corresponding set of clinical signs.

Purulent melting of the superficial membranes of the hernial sac inevitably occurs in cases where the child was not operated on in the first day after birth. In such children, the hernial protrusion is a dirty gray purulent wound with mucous discharge and areas of necrosis in the form of dark clots.

In the first days, inflammatory changes are distributed only to the superficial layers of the hernial sac (amnion, Wharton's jelly), and the phenomena of peritonitis are not detected. The general condition of the newborn is usually severe, the body temperature is elevated, and symptoms of intoxication are pronounced. Blood tests show significant leukocytosis with a neutrophilic shift to the left and anemia.

X-ray examination

X-ray examination of a newborn with a hernia of the umbilical cord is carried out in order to clarify the nature of the contents of the hernial protrusion and identify associated anomalies.

In the survey pictures taken with the child in the vertical position in two mutually perpendicular projections, intestinal loops and the size of the edge of the liver protruding into the hernial protrusion are clearly visible.

Uniform filling of intestinal loops with gas eliminates congenital obstruction. The revealed horizontal levels in the stomach and duodenum give grounds to diagnose high congenital obstruction. The presence of wide multiple levels suggests low obstruction. To clarify the diagnosis, irrigography is performed.

Treatment

The main treatment for a hernia of the umbilical cord is immediate surgery. The child should be transferred directly from the hands of the obstetrician to the surgical department. In the first hours after birth, the hernia shells are not inflamed, thin, tender - they are easier to surgically treat, the intestines are not distended with gases and its reduction into the abdominal cavity is less traumatic.

Delay in hospitalization causes a deterioration in the general condition of the child, significant infection of the hernial membranes, their adhesion to the underlying organs, primarily the liver.

Operative treatment. The main purpose of the operation is to reduce organs into the abdominal cavity, excise the membranes of the hernial sac and close the defect of the anterior abdominal wall. The choice of a rational method of surgical intervention depends on the size of the hernia, the existing complications and the presence of such combined malformations that simultaneously need urgent correction.

Preoperative preparation should begin from the moment the child is born. Immediately after the newborn's usual toilet, wipes moistened with a warm antibiotic solution are applied to the hernial protrusion.

In cases of congenital rupture of the membranes with eventration of the internal organs, the latter are closed with a multilayer gauze compress, abundantly moistened with a warm 0,25% solution of novocaine with antibiotics.

The child is wrapped in sterile diapers and covered with heating pads. Vitamin K and antibiotics are injected subcutaneously. Upon admission to the surgical department, the patient is placed in a heated incubator with a constant supply of humidified oxygen. Before the operation, the stomach is washed through a thin tube. A gas tube is placed in the rectum.

The duration of preparation should not exceed 1-2 hours. During this time, the necessary studies are carried out, the patient is warmed up, antibiotics and cardiac agents are re-introduced. Children with hernias complicated by rupture of the membranes, or with an identified fecal fistula, require immediate delivery to the operating room and an urgent start of the operation. Before the intervention, all children are prescribed appropriate drug preparation for anesthesia and an intravenous drip infusion device is installed. In this group of patients, all intravenous infusions, both during surgery and after it, should be carried out only in the vessels of the basin of the superior vena cava due to the fact that during the intervention outflow from the inferior vena cava may be disturbed.

Anesthesia is always an endotracheal method. The greatest difficulties arise when administering anesthesia during the period of immersion of the hernial contents into the abdominal cavity. An attempt to switch to spontaneous breathing at the time of increased intra-abdominal pressure during hernia reduction should not be made, as this worsens the child’s condition and does not allow assessing his adaptation to the new situation.

Surgical treatment of uncomplicated hernias of the umbilical cord has its own characteristics, which depend on the size of the hernial protrusion and its shape.

In newborns with hernias of the umbilical cord, the abdominal cavity is developed normally, and the reduction of the viscera from the hernial protrusion during surgery cannot cause complications, just like suturing a relatively small defect in the anterior abdominal wall. These children undergo a one-stage radical operation.

Newborns with medium-sized hernias are mostly subject to one-stage radical surgery. However, in some of them (especially in premature II degree), the reduction of internal organs and especially the suturing of the aponeurosis defect is accompanied by an excessive increase in intra-abdominal pressure due to the relatively small size of the abdominal cavity and the presence of a part of the liver in the hernial sac.

An objective criterion for the possibility of simultaneous correction of a hernia can only be a comparison of the dynamics of pressure in the superior and inferior vena cava.

If, in the process of immersion of organs, the pressure in the inferior vena cava progressively increases (to measure the pressure before surgery, the child undergoes a venesection of the great saphenous vein of the thigh with the introduction of a catheter by 5-6 cm), and in the superior vena cava (Seldinger catheterization) drops to zero or also increases to the level of pressure in the inferior vena cava, then the depth of immersion of the intestines and liver into the abdominal cavity should be minimized.

The surgeon needs to change the operation plan, ending it with the first stage of the two-stage technique.

Surgical treatment of newborns with large hernias of the umbilical cord presents significant difficulties and the prognosis remains extremely difficult until recently. This is due to the fact that the abdominal cavity in such children is very small, and the contents of the hernia (part of the liver, intestinal loops, sometimes the spleen) cannot be reduced into it during a radical operation.

Forced immersion of the viscera inevitably causes an increase in intra-abdominal pressure and is accompanied by severe complications:

1) respiratory failure due to displacement of the diaphragm and mediastinal organs;

2) compression of the inferior vena cava with subsequent difficulty in blood outflow;

3) compression of the intestinal loops and stomach, causing partial obstruction.

These complications for the newborn are so severe that they usually lead to death within a few hours to two days after surgery.

In this regard, in the treatment of children with large hernias of the umbilical cord, only a two-stage operation can be used, which avoids the listed complications.

Premature newborns weighing up to 1,5 kg (III degree), with medium and large hernias, are subject to conservative treatment methods. Only in case of complications with rupture of the membranes and eventration of the internal organs should an attempt be made to surgically correct the defect.

Surgical treatment of complicated hernias of the umbilical cord is an extremely difficult task. Newborns with intrauterine rupture of the hernia membranes and eventration of the internal organs are admitted to the surgical clinic, as a rule, in the first hours after birth. The condition of children in this group is extremely difficult due to developing peritonitis and cooling of prolapsed intestinal loops.

The volume of surgical intervention changes in connection with the combined defects revealed in the child. The operation may be complicated due to the presence of incomplete reverse development (non-closure) of the vitelline duct.

In rare cases, with large hernias of the umbilical cord, there are multiple combined malformations of the digestive tract, creating extreme difficulties in planning surgical intervention.

The choice of the method of operation is carried out individually, however, the main and mandatory principle is the primary elimination of the malformation that is incompatible with the life of the child.

postoperative treatment. The nature of postoperative treatment depends on the general condition of the child, his age and the method of surgical intervention.

In the first 2-3 days after the operation, all children are given prolonged epidural anesthesia, an elevated position is created.

Humidified oxygen is constantly supplied to the flask. Prescribe broad-spectrum antibiotics (5-7 days), cardiac drugs (according to indications) and physiotherapy. Produce 1-2 times a week transfusion of blood or plasma.

Children with small and medium-sized hernias begin to be fed orally 6 hours after surgery (in more severe cases - after 10-12 hours), dosed at 10 ml every 2 hours, adding 5 ml with each feeding. The fluid deficiency is replenished by intravenous drip. By the end of 2 days, the child should receive a normal (in terms of body weight and age) amount of breast milk; apply to the breast on the 3-4th day. Skin sutures are removed on the 8-10th day.

Children with large hernias after stage I of a two-stage operation are given parenteral nutrition for 48 hours. From the beginning of day 3, they begin to give 5-7 ml of a 5% glucose solution through the mouth, then expressed breast milk every 2 hours, 10 ml.

The total daily amount of fluid administered intravenously should not exceed the age-specific dosage, taking into account the child’s body weight. Gradually increasing the amount of breast milk, by the 8th day the baby is transferred to normal feeding (expressed milk). It is applied to the mother's breast on the 12-14th day.

Children are given daily control dressings and careful wound care. The sutures are removed on the 9-12th day, depending on the degree of tension of the edges of the surgical wound.

In cases of surgical interventions on the intestine, the child is prescribed a diet indicated after resection of the intestine in a newborn.

The most significant problem in the management of the postoperative period during stage I of a two-stage intervention or radical correction is the child's adaptation to high intra-abdominal pressure. This adaptation is facilitated by a set of measures, which includes oxygen barotherapy, prolonged epidural blockade and a late start of feeding the child. In premature infants after the first stage of correction of large hernias, if signs of circulatory disorders in the lower extremities appear on the operating table, it is advisable to use prolonged nasotracheal intubation for 2 days. It reduces dead space and reduces ventilation disturbances due to the high standing of the diaphragm and the restriction of its mobility. Oxygen therapy should be carried out in the same cases with repeated sessions every 12-24 hours for 12 days.

Complications in the postoperative period. Damage at the time of surgery of the inner plate of the hernia membranes (avascular peritoneum) can lead to adhesions and the development of obstruction (usually 3-4 weeks after surgery).

Such a complication can be prevented by prescribing anti-adhesion therapy from the first days after surgery. The complication is manifested by periodic mild anxiety of the child. Vomiting occurs, which is persistent. Through the skin of the abdominal wall (hernial protrusion) the peristalsis of the intestinal loops is visible. There may be stool, but it is scanty, then the passage of feces stops. Characteristic is a gradual increase in symptoms of obstruction. Contrast examination of the gastrointestinal tract helps establish the diagnosis: a long delay (4-5 hours) of iodolipol administered orally indicates obstruction. In such cases, laparotomy and elimination of obstruction are indicated.

Conservative treatment. The conservative technique consists of general strengthening measures and local treatment.

Reinforcing activities. Feeding expressed breast milk strictly according to the norm. From the 8-10th day of life, when the child is strong enough, they are applied to the mother's chest (control weighing is required). If the child sluggishly sucks or vomits, the fluid deficiency is replenished by intravenous administration of solutions of glucose, blood plasma, and vitamin albumin.

From the day of admission, broad-spectrum antibiotics begin to be administered. A change of antibiotics is necessary after 6-7 days, depending on the results of sowing the purulent discharge and the sensitivity of microbes (starting from the 2nd course, nystatin is administered). Antibiotics are canceled after the appearance of granulations and cleansing of the wound from necrotic deposits (15-20 days).

local treatment. The child is daily changed ointment dressings and toilet hernial protrusion. Removing the dressing and treating the wound requires great care because of the danger of rupture of the membranes. Areas of superficial necrosis of the amniotic membrane depart spontaneously, and then granulations begin to appear, going from the periphery to the center. Cleansing of the wound is facilitated by electrophoresis with antibiotics and irradiation of the wound during dressings with ultraviolet rays.

After the appearance of granulations (7-10th day of treatment), daily hygienic baths are used. Marginal epithelialization and scarring lead to a decrease in the size of the hernial protrusion. This is facilitated by tight bandaging used in the treatment process. The wound heals by the 40-50th day after the birth of the child.

The ventral hernia formed as a result of conservative treatment is eliminated surgically, as well as in a two-stage operation, after the age of the first year.

Authors: Drozdov A.A., Drozdova M.V.

<< Back: Diaphragmatic hernia. Phrenico-pericardial hernia (Hernias of the diaphragm proper. Complicated false hernias of the diaphragm proper. Complicated true hernias of the diaphragm proper. Hiatal hernias. Hernias of the anterior part of the diaphragm. Complicated phrenico-pericardial hernias)

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