Umbilical Hernia in Children: Are the Complications Seasonal?

Globally, umbilical hernia is not uncommon especially among black children worldwide [1]. The estimated incidence of umbilical hernia is 85% in blacks and 15% in Caucasian children. Size of the umbilical ring and skin type of the umbilicus are two inherited physiological characteristics seen in Africans that may explain this increased incidence of umbilical hernias. However, it is difficult to say if the incidence of complicated umbilical hernia is more common in Africans. High incidence of occurrence of umbilical hernia has been documented in premature and small for gestational age neonates, in patients with congenital hypothyroidism, Down syndrome, and in patients undergoing peritoneal dialysis [1,2]. Umbilical hernia results from failure of closure or congenital weakness of the umbilical ring after separation of the umbilical cord [3,4]. In majority of cases, umbilical hernia resolves spontaneously during the first few years of life and active surveillance management is recommended until the age of 5 years of life [2,3,5]. Complications such as incarceration, obstruction and strangulation are common in children who have umbilical hernia. However, these complications are rarely reported and may be more common at certain times of the year [6]. The aim of this study was to evaluate the demographic characteristics, presentation of children that presented with complicated umbilical hernia relative to their occurrence at certain times of the year.

This was a retrospective study of children aged 15 years and below who presented with complicated umbilical hernia between January 2020 and December 2024 at the pediatric surgery unit of Enugu State University Teaching Hospital (ESUTH) Enugu, Nigeria. The complications were in the forms of incarceration, obstruction and/or strangulation and the time of these complications are related to the time/month of the year in which they happened. Patients who have paraumbilical hernias and other ventral wall hernias were excluded from this study. Patients who have had umbilical herniorrhaphy in a peripheral hospital before referral to us for reoperation were also included in the study. ESUTH is a tertiary hospital located in Enugu, South East Nigeria. The hospital serves the whole of Enugu State, which according to the 2016 estimates of the National Population Commission and Nigerian National Bureau of Statistics, has a population of about 4 million people and a population density of 616.0/km².

The hospital also receives referrals from its neighboring states. Information was extracted from the case notes, operation notes, operation register, and admission-discharge records. The information extracted include the age, gender, duration of symptoms before presentation, month/year of onset of symptoms, intra-operative finding, complications of treatment, duration of hospital stay and outcome of treatment. The period of follow up was for 2 months. Ethical approval was obtained from the ethics and research committee of ESUTH. Statistical Package for Social Science (SPSS) version 21 was used for data entry and analysis. Data were expressed as percentages, mean, median and range.

Patient’s Demographics

A total of 122 cases of umbilical hernias were repaired during the study period, out of this number, 52 cases were for complicated umbilical hernia which accounted for 42.6 % of the total hernia repaired. These complications were in the form of incarceration, obstruction and/or strangulation. There were 30 males (57.7%) and 22 females (42.3%), with a male to female ratio of 1.4:1. The mean age of the patients was 34 months (range: 12-168 months). The median duration of symptoms prior to presentation to the hospital was 3 days (range: 1-5) and the mean duration of hospital stay was 7 days (range: 3-12 days).

Month of Onset of Symptoms

Table 1:Month/year of presentation and number of patients (n=52).

Intra-operative finding

The commonest content of the umbilical hernia sac was omentum. The omentum in the hernia sac was found to be viable in 25 (48.1%) patients while 5 (9.6%) patients had gangrenous omentum that required excision. Viable small bowel was found in the hernia sac in 20 (38.5%) patients. Two (3.8%) patients had gangrenous small bowel that required resection and anastomosis.

Complications of Treatment

Complications were not documented in 40 (76.9%). There was surgical site infection in 9 (17.3%) patients. Three (5.8%) patients had abnormal healing scars.

Outcome of Treatment

Fifty (96.2%) patients did well and were discharged home. Two (3.8%) patients, in the immediate post-operative period, was discharged against medical advice. Mortality was not reported.

Paediatric umbilical hernia also known as ruptures in the past were described in earliest surgical literatures dating back to 500 BC. Hippocrates wrote about hernias around the belly button area indicating that the pathology has been recognized for millennia. Umbilical hernia is a common pathology of the anterior abdominal wall in children. Although complication of the umbilical hernia can occur, it is rare [4]. Some authorities have advocated operative treatment of all umbilical hernias especially in black children [4,7]. Other researchers recommend operative treatment of umbilical hernia if it is symptomatic or when complications develop [8,9]. In the index study, about half of the paediatric umbilical hernias repaired during the study period were due to complications. Other umbilical hernias were repaired due to parental request, cosmesis and non-specific abdominal pain. The large number of complicated umbilical hernia witnessed in this study could be due to late presentation and lack of parental awareness.

Brown et al and Fall, et al reported incidences of 5% and 15% respectively [4,9]. These discrepancies in the number of umbilical hernia repaired may be due to the setting of the study because umbilical hernias are more common in black children. Incarceration, obstruction and strangulation are the complications experienced in abdominal wall hernias generally. Abdominal pain due to incarceration of the omentum is a consistent symptom in children who have umbilical hernia. More males are affected in the current study and this is in line with the report of other studies on umbilical hernias [7,8,10]. Howbeit, this is in contrast to the publications of other series that recorded female dominance [11,12]. The reason for this gender difference in the reports is unknown. Variations occur regarding the mean age of published works of paediatric complicated umbilical hernia. The mean age of 34 months reflected in our patients is consistent with the mean age of most published studies [4,6,9].

However, a study in Asia recorded an average age of 30 months in their research [13]. Delayed and late presentation of patients is a consistent fact in patients presenting to the hospital in developing countries like Nigeria. This is reflected in the mean duration of 3 days before patient presentation to our facility. The mean period of hospital stay of 7 days recorded in our patients is the period required for return of bowel function and adequate healing. However, when bowel resection is done, the duration of hospitalization may be longer. During the period of the study, majority of the cases of umbilical hernia were repaired in the months of December, January, February and March. These are periods of dry season. The exact justification to explain this may not be known. However, the higher incidence of gastroenteritis, with the associated bowel hypermotility, during these months may explain the herniation of the bowel into the umbilical defect causing symptoms. An umbilical hernia can contain any of the intraabdominal organs.

Omentum was the commonest content in the present study. This is similar to the reports of Sinopodis et al and Brown et al [9,11]. The hernia content of the complicated umbilical hernia may be viable or non-viable. This may be related to the duration of symptoms before intervention. Regarding the content of the umbilical hernia, reports from northern Nigeria and Senegal documented 6.7% and 12.2% respectively, of non-viable bowel that required intestinal resection [4,6]. Non-classical/atypical structures such as the vermiform appendix has been found in the umbilical hernia [14]. In the present study, the complications witnessed are comparable to the reports of other series on umbilical hernias [4,6]. Two of our patients had abnormal scars (hypertrophied scars) and this was noticed during the follow up period.

Umbilical hernia complications are not uncommon and can occur at any time of the day, week or month. However, it may more common at certain times of the year especially during the dry season. This is what this study has established.

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