Year : 2023 | Volume
: 28 | Issue : 3 | Page : 212--217
Management of umbilical hernia in African children: The experience of 2146 cases
Gabriel Ngom1, Florent Tshibwid A. Zeng1, Aloise Sagna1, Doudou Gueye1, Ndeye Aby Ndoye1, Papa Alassane Mbaye1, Cheikh Ndiaye1, Mbaye Fall2, Oumar Ndour2,
1 Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
2 Department of Pediatric Surgery, Aristide Le Dantec University Teaching Hospital, Cheikh Anta Diop University, Dakar, Senegal
Correspondence Address:
Florent Tshibwid A. Zeng
52x65 Streets, Gueule Tapee, Dakar
Senegal
Abstract
Aims: Umbilical hernia (UH) is common in African and African-descent children. In high-income countries (HICs), it is considered benign, which is not the case in Sub-Saharan ones. Through this study, we aimed to share our experience.
Materials and Methods: A descriptive review was conducted from January 01, 2012 to December 31, 2017 at Albert Royer National Children's Hospital Center. Among the 2499 patients, 2146 cases were included in the review.
Results: UH had a frequency of 6.5%, with patients having a mean age of 2.6 years, with a male preponderance of 63%. Emergency consultation occurred in 37.1%. The symptomatic hernia was present in 90.9%. The congenital type was found in 96%, a history of painful episodes was reported in 46%, and medical and surgical comorbidities were found in 30.1% and 16.4%, respectively. Multimodal anesthesia was used in 93.1%. A lower umbilical crease incision was made in 83.2%, the sac was not empty in 16.3%, and additional umbilicoplasty was performed in 16.3%. During a 14-month follow-up, a complication occurred in 6.5% and mortality in 0.05%.
Conclusion: In our region, the pediatric UH was predominantly symptomatic, with its natural evolution leading to more complications than in HICs. Its management carried acceptable morbidity.
How to cite this article:
Ngom G, A. Zeng FT, Sagna A, Gueye D, Ndoye NA, Mbaye PA, Ndiaye C, Fall M, Ndour O. Management of umbilical hernia in African children: The experience of 2146 cases.J Indian Assoc Pediatr Surg 2023;28:212-217
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How to cite this URL:
Ngom G, A. Zeng FT, Sagna A, Gueye D, Ndoye NA, Mbaye PA, Ndiaye C, Fall M, Ndour O. Management of umbilical hernia in African children: The experience of 2146 cases. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Sep 27 ];28:212-217
Available from: https://www.jiaps.com/text.asp?2023/28/3/212/375514 |
Full Text
Introduction
The umbilicus is the only natural scar of the human body; it plays a cosmetic role on the anterior abdominal wall. After birth, the umbilical ring represents a congenital weakness on the linea alba and will progressively close.[1] The failure of this process allows abdominal viscera contents to herniate, resulting in an umbilical hernia (UH).[2] The latter is a congenital malformation that occurs in 15%–25% of live births,[2] with a higher incidence in the African and African-descent population.[1],[2],[3] Therefore, valuable studies on this subject were done in Africa in general,[4],[5],[6],[7],[8] as well as in Senegal particularly.[9],[10],[11],[12],[13],[14],[15]
Different from other pediatric hernias, UH has the particularity of possible spontaneous closure, which determinants are not yet fully understood.[1],[2],[16] This happens around 4–5 years but can still happen around 13 years.[1],[5] Seeing this possibility, and since complication rarely occurs in children of high-income countries (HICs), UH is considered a benign disease, and most parents consult for cosmetic reasons and rarely for pain or complication in those countries.[1],[2],[16] This is not the case in African countries, where UHs are frequently symptomatic, with multiple reports supporting a higher occurrence of complications such as incarceration[4],[6],[17] and strangulation[9],[11],[13],[14],[18],[19],[20],[21] or spontaneous rupture,[22] which seriously endangers patient's (omit vital) prognosis.
When the diagnosis is clinically made, a management plan should be decided. For symptomatic UH, the approach is the same in HICs and Africa, with emergent or semi-elective repair, depending on whether the UH is strangulated or incarcerated.[6],[11],[23],[24],[25] In the case of asymptomatic UH, HICs' guidelines recommend conservative management until 4 years old.[23],[24],[25] In Africa, seeing the high incidence of complications and their potential threat to patients' life, some authors advocate for the systematic repair of asymptomatic UH.[12],[21],[26] However, some controversies still exist.[27]
Our study aimed to report patients' sociodemographic characteristics, clinical presentation, management, and outcome of UH at our institution in Senegal.
Material and Methods
We conducted a descriptive retrospective study for 6 years, from January 01, 2012 to December 31, 2017, at the Department of Pediatric Surgery of Albert Royer National Children's Hospital Center in Dakar, Senegal. It is a university teaching hospital, the main department of pediatric surgery in Senegal and regularly receives patients from neighboring countries such as Mauritania, Gambia, and Guinea.
We considered patients managed for UH within the study period. Among the files of the 2499 patients, 353 lacked demographic data such as sex, age, size of the hernia, and outcome. These 353 patients were excluded. We collected data from the outpatient department (OPD) registry, patients' medical files, and the operating room registry. Studied parameters were sociodemographic (age at admission, sex, and admission mode), clinical (main complaint, period of apparition of the hernia, past painful episodes, comorbidities, and hernia size), therapeutic (type of anesthesia, surgical exposure, content of the hernia sac, technique of fascial closure, kind of used sutures, and type of umbilicoplasty), and evolutionary (length of stay and outcome). These data were first collected on a predesigned printed sheet and secondarily encrypted and analyzed using Epi InfoTM version 3.2.2 (Atlanta, Center of Diseases Control, Georgia, US). The quantitative data are presented as mean, and the qualitative ones are presented as frequencies.
The institutional board of ARNCHC allowed the study, which was in accordance with the Helsinki Declaration. For all patients who benefited from surgery, consent was obtained from the legal tutor.
Results
During the study period, our department received 38,451 patients, of whom 2499 were diagnosed with UH, which shows a 6.5% inhospital frequency of UH, and an annual frequency of approximately 416 cases. Our study included 2146 cases.
For sociodemographic characteristics, the mean age was 2.6 years, with extremes ranging from 2 weeks to 15 years, with details in [Figure 1]. Infants were more represented, followed by preschool and school-aged children. Neonates and adolescents were less represented. There were 1352 males and 794 females, which gave a sex ratio of 1.7. Among our patients, 1350 (62.9%) presented to the OPD, whereas 796 (37.1%) presented to the Emergency Department (ED).{Figure 1}
In our population study, 194 (9.1%) consulted for cosmetic reasons, whereas 1952 patients (90.9%) consulted for symptomatic UH. Among the latter, 987 (50.6%) had abdominal pain with umbilical tumefaction, 622 (31.8%) had a painful irreducible umbilical swelling (strangulated UH), and 343 (17.6%) had a painful reducible umbilical swelling (incarcerated UH). Among symptomatic patients, digestive complaints were vomiting in 179 (9.2%) patients, no stool and flatus (obstruction) in 28 (1.4%) patients, and diarrhea in 7 (0.3%) patients.
Two thousand and sixty patients (96%) had a congenital hernia, whereas 86 (4%) had an acquired one. Nine hundred and eighty-seven (46%) patients had a history of a painful episode. As detailed in [Table 1], medical comorbidities were found in 646 patients (30.1%), whereas surgical ones were reported in 352 patients (16.4%). Concerning the size of the fascial defect, 966 patients (45%) had a mean-sized one (1–1.5 cm), as represented in [Figure 2].{Table 1}{Figure 2}
For the surgical repair, all patients were operated under general anesthesia, using the laryngeal mask in 2058 (95.9%) and orotracheal intubation in 88 patients (4.1%). In the laryngeal mask group, 1815 patients benefited from periumbilical block (PUB), 95 from the caudal block, and 148 from general anesthesia alone. In the orotracheal intubation group, all patients benefited from the PUB. In general, 1998 patients (93.1%) benefited from multimodal anesthesia and 148 patients (6.9%) from general anesthesia alone.
The surgical exposure used the lower umbilical crease in 1785 patients (83.2%). The hernia's sac was not empty in 350 patients (16.3%), with the great omentum being the most common herniated viscera, found in 150 of these 350 patients (42.9%). The fascial closure was done by simple approximation using X stitches in 1713 patients (79.8%), with a nonabsorbable suture (Ethylene polyterephthalate) in 1345 patients (62.7%). An additional umbilicoplasty was performed in 350 patients (16.3%), with 251 (71.7%) benefiting from the horseshoe umbilicoplasty. The data on surgical treatment are detailed in [Table 2].{Table 2}
Postoperatively, hospitalization was required in 92 patients (4.3%) as the remaining 2054 benefited from ambulatory surgery. All patients were followed for 14 months, and no complication was detected in 2006 patients (93.5%), whereas 140 (6.5%) patients had variable complications, of which a recurrence was found in 77 patients, as presented in [Table 3]. Mortality occurred in a patient (0.05%) due to complications of evisceration in the early postoperative period; he had UH associated with an inguinal hernia.{Table 3}
Discussion
An UH is common in the African and African-descent population, while authors from HICs report an inhospital frequency of nine cases per year.[2],[3],[28] At our institution, 416 cases present per year, approximately one in 20 patients attending our department, similar to other Senegalese authors' reports.[14] However, our inhospital frequency is higher than other African authors, who found a variation from 11 to 39 cases per year.[17],[29],[30],[31] The reasons may be that Senegalese studies were conducted in regional and national referral hospitals. Differences in consultation habits may also be a reason for this difference, as some authors conducted their general surgery department studies.[17] Population-based studies would help to determine if UH and its complications have a higher incidence in Senegalese children. The mean age was 2.6 years, similar to other authors' findings, ranging from 2 to 3.8 years.[17],[26],[28],[29],[31] In our study, the presentation was nearly double in males as compared in females, as reported by other African authors.[26],[31] However, some HICs' studies reported equal frequency in both sexes.[16],[28],[32]
A third of our patients were admitted through the ED due to a complication (incarceration or strangulation), findings similar to the results of the majority of African authors (34.4%–73.2%),[17],[20],[26],[29],[31] which is higher than frequencies encountered in HICs (1.1%–7%).[1],[3],[28],[33] However, South African and, recently, Nigerian authors reported a lower frequency (7.2% and 7.9%, respectively), similar to HICs.[30],[34] Both countries have the two highest gross domestic products in Africa,[35] which suggests socioeconomic level might play a role in the frequency of UHs' complications. The higher frequency of complications is related to seasonal variation too, with higher incidence during the dry season. The difference in morphology between populations of different regions of the world would also play a role in difference of the occurrence of complications in pediatric UH.
Nine of ten patients in our study had a symptomatic UH, with pain being the most common symptom. In these children, pain occurs as an isolated symptom of UH or as a part of complications such as incarceration or strangulation. Other African authors report this predominance of symptomatic UH[17],[26],[29],[31] when those of HICs found the inverse situation.[3],[28],[33] This difference may be linked to the high inhospital frequency of complicated UH in African studies. Furthermore, 1.3% of our patients presented with obstruction, which was also described by other African authors.[6],[13],[20],[31] In a Togolese study on pediatric intestinal obstruction, authors reported obstructed hernias as the third most common etiology, with UH representing approximately 5% of all causes of children's intestinal obstruction.[36]
In our population study, a third of patients had medical comorbidity, of which respiratory ones (Bronchopneumopathy and asthma) were the commonest. In Central Africa, authors found the same proportion of medical comorbidities, but the most common were malaria and typhoid fever.[31] This difference is mainly attributable to geographical differences, with their consequences on some endemic diseases. In our context, these respiratory diseases were frequently found during the dry season due to a dry, cold wind, the Harmattan. The latter brings dust and other biologic particles, which increases respiratory tract infections or allergic reactions. This leads to cough, with the frequent episodes of incarceration, finally leading to strangulation.[13] Surgical comorbidities were found in a sixth of patients, similar to findings of other reports.[10] They were primarily found in males, as the most frequent were inguinal hernia and cryptorchidism, as shown in a previous report.[10] These surgical comorbidities can be presented as the chief complaint, and then UH is discovered during the physical examination or the inverse situation. For the latter, the pediatric surgeon needs to perform an exhaustive physical examination, carefully looking for surgical comorbidities, which, if present, should be treated concomitantly with the UH.
Surgical management of UH presents differences between HICs and African ones. In HICs, UH is not as common as in Africa, and most patients are asymptomatic.[3],[28],[33] In most patients, the UH will spontaneously close by 4–5 years without experiencing complications.[2] After 5 years, 50% of UH will close spontaneously by 11 years.[37] This has justified the conservative management of pediatric UH, supported by HICs' authors.[1],[2],[16] In Africa, UH is frequent, with a proportion of symptomatic UH far more significant than in HICs, which lead to a high proportion of surgical repair compared to HICs, as reported by many African authors.[7],[9],[11],[14],[17],[20],[26],[27] Taking into account the high complication risk, some authors even suggest systematic repair of asymptomatic UH.[12],[21],[26] Reports on Senegalese and Beninese children concluded that strangulation was more frequent in UH (20%–53%) compared to inguinal hernia (6%–24%).[12],[20] However, in countries without experienced pediatric anesthetists, systematic surgical repair in newborns should not be attempted.[38]
The most of our patients benefited from PUB, which significantly reduces postoperative analgesic and shortens the length of stay.[39] Furthermore, this technique is safe for incarcerated UH too, as previously reported in the literature.[40] Four-fifths of our patients benefited from an incision in the lower skin crease, the classical exposure, as shown by other authors.[2],[16],[25] This exposure is mainly chosen for cosmetic purposes. However, depending on the surgeon's preference, other exposure can be used, which were less represented in our study. The contents of the hernia sac vary widely and are often reported in strangulated UH, as it spontaneously reduces in asymptomatic UH or after induction of general anesthesia for incarcerated ones. In our study, the omentum or the small bowel or both were by far the most common, similar to the results of other reports.[9],[11],[14],[20],[21],[30] This is mainly due to the proximity of these viscera (omentum and small bowel) with the umbilicus. The fascia was closed by simple approximation in almost our patients, mainly using X stitches. This is the classical closure; however, simple interrupted or continuous sutures can be used with the same results.[41] In approximately 70% of our patients, nonabsorbable sutures were used. Other authors report the otherwise, with absorbable sutures being the most used.[28] This difference can be attributable to the surgeon's preference. A fifth of patients benefited from umbilicoplasty, which is high compared to reports of other African authors (6.5%–9%).[26],[31] This may be linked to the surgeon's experience with umbilicoplasty techniques, as well as their preference to perform or not an umbilicoplasty, as the redundant skin tends to reduce as the child grows. At our institution, the horseshoe technique[15] was the most used as residents are primarily trained to, but many other techniques are suggested,[42],[43],[44],[45] all with similar results.
Postoperative complications occurred in 6.5% of patients, similar to reports of African and HICs' authors, with a frequency ranging from 4% to 6.1%.[26],[28] In a local study, complications were shown to be more common in complicated UH (15%) than uncomplicated ones (4.5%).[46] This was confirmed by reports finding 16%–20% of complications after complicated UH repair.[14],[21] The most encountered complication was a recurrence, found in 3.5% of patients, which is higher than 2% found by other authors.[26],[28] Formally identified risk factors of recurrence were patients who were operated on before 4 years, admitted to the ED, and needing hospitalization beyond one day.[47] All these three factors are commonly found in African children, as complicated UH is frequent in our context. This may explain the difference. Mortality was reported in our study. Contrary to studies from HIC studies where no mortality occurs, other African authors have reported mortality linked to UH, ranging from 0.6% to 1.9%.[17],[20],[21] This highlights why UH in African children should not be taken lightly.
Conclusion
Umbilical hernia in the Senegalese child primarily occurs in males and is mainly symptomatic, with a high proportion of complicated presentation. Respiratory comorbidities are frequently encountered and may play a role in the high proportion of complicated presentations in our population study. Provided the availability of a competent pediatric anesthetist, an asymptomatic umbilical hernia in the African child should be operated on, seeing the rate of complication. Postoperative complications are mainly recurrence, happening in a higher proportion compared to HICs. Mortality is still encountered, however rare.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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