What is the management plan for an infant with a periumbilical hernia and a palpable thrill?

Management of an Infant with a Periumbilical Hernia and Palpable Thrill

Urgent surgical referral is required for an infant with a periumbilical hernia and palpable thrill, as this presentation suggests potential intestinal strangulation requiring immediate intervention to prevent serious morbidity and mortality. 1

Pathophysiology and Clinical Significance

• Periumbilical hernias result from incomplete involution of the processus vaginalis, creating a patent processus vaginalis (PPV) through which intra-abdominal structures can herniate 1
• The presence of a palpable thrill is concerning for vascular compromise and potential strangulation, which significantly increases the risk of bowel necrosis and other life-threatening complications 1, 2
• Inguinal hernias are repaired in infants to avoid the risk of bowel incarceration and gonadal infarction/atrophy, with periumbilical hernias carrying similar risks 3, 1

Immediate Management Steps

• Emergency surgical consultation should be obtained without delay 1, 2
• Avoid activities or interventions that might increase intra-abdominal pressure, which could worsen the hernia or accelerate strangulation 1
• Monitor for signs of Systemic Inflammatory Response Syndrome (SIRS), which are common indicators of strangulated obstruction 1, 2
• Assess for additional concerning findings such as:
  • Erythema or edema at the hernia site 2
  • Abdominal distention 4
  • Bilious vomiting 4
  • Bloody stool, which may indicate intestinal ischemia 4

Diagnostic Evaluation

• Physical examination should focus on assessing the reducibility of the hernia and signs of intestinal obstruction 2
• If the clinical situation permits, imaging may be considered:
  • CT scan with contrast can help predict intestinal strangulation 2
  • Ultrasound may help evaluate blood flow and identify potential complications 1
• Laboratory studies to assess for signs of inflammation, infection, or metabolic derangements 2

Definitive Management

• Surgical repair is the definitive treatment for all periumbilical hernias in infants, especially those with signs of complications 3, 1
• Delayed treatment (>24 hours) is associated with significantly higher mortality rates 1, 2
• The surgical approach may include:
  • Reduction of the hernia contents 5
  • Repair of the mesenteric defect 5
  • Possible bowel resection if strangulation has led to necrosis 2
• Tension-free mesh repair techniques may be considered for larger defects, though this is more commonly used in older patients 6

Important Considerations and Pitfalls

• Internal hernias can be mistaken for other more common conditions in infants, such as necrotizing enterocolitis, potentially leading to inappropriate medical management instead of necessary surgical intervention 4
• Symptomatic periods lasting longer than 8 hours significantly affect morbidity rates 1
• The physical features of the hernia (size of defect, amount of herniating intestine) do not consistently predict the risk of incarceration, so all concerning signs should prompt urgent evaluation 3, 1
• Prophylactic antibiotics may be indicated if there is concern for intestinal compromise 2

Follow-up Care

• Close monitoring for recurrence is necessary, as periumbilical hernias can recur after repair 7, 8
• Serial examinations should be performed to assess for complications such as wound infection or mesh migration (if mesh was used) 7
• Parents should be educated about warning signs that would necessitate immediate medical attention 1