Journal Article: Management of asymptomatic pediatric umbilical hernias: a systematic review

Reasoning:

• Patient never knew that she has an umbilical hernia until we diagnosed her with it during her visit
• Many infants are born with umbilical hernias or they can be acquired during adulthood, more often in females than in males
• Umbilical hernias may close as the patient ages but large hernias that do not close may require surgical repair
• Even though patient is asymptomatic currently, it is important to teach her the management of umbilical hernias

Purpose:

• This systematic review aims to postulate guidelines for the optimal timing and indications for umbilical hernia repair since there are no formal guidelines as of now
• It also looks into the complications of repair umbilical hernias, in addition to looking into non-operative approaches for management recommendations

Methods:

• The authors and reference librarian performed a literature search of Cochrane Review, EMBASE, PubMed, and Web of Science and identified 776 initial articles, resulting in 10 final articles for review.
• Inclusion criteria composed of studies describing complications from umbilical hernias that were not surgically repaired and the likelihood of pediatric umbilical hernias to close spontaneously without surgical intervention
• Most of the studies included were prospective or retrospective cohorts in nature that followed patients over the span of several years from the United States and all over the world

Key Points:

• There is a consensus for surgical intervention for symptomatic or complicated umbilical hernias. However, there are no guidelines for asymptomatic and uncomplicated umbilical hernias
• 10% of the reason for operative intervention for all umbilical hernia repairs is parental concern. It is difficult for pediatric surgeons to education families that watchful waiting is reasonable in pediatric patients with asymptomatic umbilical hernias
• There is low incidence of any complications with significant morbidity or mortality without surgical intervention (mean age of complication was between 4-7 years old)
• There is no significant increase risk of complication based solely on the size of the hernia. Despite these findings, most children hospitals recommend early operative repair for larger or enlarging hernias without clear rationale
• Complications of surgical repair include superficial surgical site infection, hematoma, seroma, and keloid, granuloma, or abscess formation
• Delaying surgical intervention minimizes neurocognitive anesthetic risks and the risk of adverse respiratory events
• Only Australia and the United States took cosmetic appearance into consideration for determining the timing of operative repair

Conclusion:

• Early closure of umbilical hernias result in unnecessary and expensive expenditure since many hernias close naturally with time. In addition, children are exposed to surgical and anesthetic complications at a young age that are not warranted
• By age 4, PCPs should refer patients for a surgical consult. Patients should undergo surgical repair before they reach adulthood

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