Page 9 - 67 abdominal-wall56-58_opt

356 Disorders of the Umbilicus
Stoma at umbilicus preventing many children with umbilical hernias from unnecessarily
Some paediatric surgeons in the West have advocated placing intestinal undergoing the risk of a surgical procedure and anaesthesia? Or did
or urinary stomas in the umbilicus primarily for aesthetic consider- the current recommendations arise out of necessity, due to the wide
ations. Experience with this in Africa has been limited, and no papers prevalence of umbilical hernias, in an effort to strategically utilise
adopting its use have been published in Africa to date. surgical resources and time? If the latter is true, and umbilical hernias
Gastroschisis and omphalocele should be repaired by using the same criteria as those used in developed
These problems are discussed in Chapter 56. countries, there may be other creative solutions. For instance, just as
health care workers have been specifically trained to suture lacerations
Ethical Issues or to perform caesarean sections, perhaps consideration should be given
As previously discussed, most African surgeons do not use the same to specifically training them to perform simple, straightforward surgical
indications for umbilical hernia repair as are used in developed procedures such as umbilical hernia repairs.
countries. Instead, they recommend repairing only those umbilical Evidence-Based Research
hernias that are symptomatic in children. However, the incidence of
Table 57.2 presents the results of a trial involving application of chlorhex-
incarceration or strangulation seems to be higher in Africa than in
idine to the umbilical cord to prevent omphalitis and neonatal mortality.
developed countries. Because of this, some African surgeons have
21
recommended repairing all umbilical hernias in children. Others, Table 57.2: Evidence-based research.
however, continue to recommend conservative treatment in spite of Title Topical applications of chlorhexidine to the umbilical cord
the risk of incarceration. 16,22 Part of the rationale given is the wide for prevention of omphalitis and neonatal mortality in
prevalence of umbilical hernias. southern Nepal: a community-based, cluster-randomised
trial
Even using selective criteria, Meier et al. have estimated that if all
umbilical hernias >1.5 cm were repaired in young children in Africa, Authors Mullany LC, Darmstadt GL, Khatry SK, et al.
about 6–8% of children younger than 4 years of age would require Institution DNepal Nutrition Intervention Project, Sarlahi, Kathmandu,
16
repair; the volume of cases would likely outstrip available surgical Nepal; Institute of Medicine, Tribhuvan University, Kath-
mandu, Nepal; Department of International Health, Johns
resources. The exact criteria for elective repair on which Meier et al.
Hopkins Bloomberg School of Public Health, Baltimore,
based their estimates were females older than 2 years of age and males Maryland, USA
older than 4 years of age with a fascial defect ≥1.5 cm in diameter; they
Reference Lancet 2006; 365:910–918
estimated that 6% of 2-year-old females and 8% of 4-year-old males
would need repair. 16 Problem Prevention of omphalitis and neonatal death related to
umbilical cord care in southern Nepal.
If hernias with large (>1.5 cm) fascial defects are indeed the most
22
likely to incarcerate in Africa, as reported by Chirdan et al., one Intervention Topical application of chlorhexidine to the umbilical cord.
Comparison/
could argue that they should be repaired, as they are the most likely to
control (quality Prospective, community-based, cluster-randomised trial.
incarcerate and the least likely to spontaneously close. Consideration
of evidence)
should also be given to closing umbilical hernias in patients who live
Outcome/effect Compared to dry cord care, chlorhexidine reduced severe
more than one hour away from surgical resources. More research
omphalitis by 75% and neonatal mortality by 24%.
is necessary to determine the actual incidence of incarceration or
Historical
strangulation, and to clearly define which umbilical hernias are at Recent recommendations by the World Health
significance/ Organization for dry umbilical cord care may be
greatest risk.
comments inappropriate in developing countries, where the risk of
Perhaps it is time to re-examine how current recommendations for omphalitis and death related to umbilical cord care is
umbilical hernia repair in Africa were developed or became generally higher than in developed countries.
accepted. Are the current recommendations truly the best for the patient,
Key Summary Points
1. Appropriate umbilical cord care is important in preventing 6. In Africa, proboscoid umbilical hernias are common, well-
omphalitis, which can be a life-threatening infection. accepted, and treated conservatively.
2. The presence of a remnant of the urachus or 7. Incarceration or strangulation of umbilical hernias is uncommon
omphalomesenteric duct should be considered if there is an but has been reported more often in Africa than in developed
umbilical sinus, persistent drainage, or remnant tissue. countries. Complications remain the general indication for
umbilical hernia repair in Africa.
3. Ultrasonography can be useful in investigating umbilical
disorders when the diagnosis is uncertain. 8. An omphaloplasty may be indicated for cultural reasons.
4. Any irreducible umbilical mass or persistent umbilical lesion 9. After umbilical surgery, the prognosis is excellent and
needs surgical exploration and resection. complications are rare.
5. Umbilical hernias are more common in children in Africa than
in the rest of the world, and the incidence of incarceration
appears to be higher than in the West.