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The UF Division of Pediatric Surgery specializes in evaluating and treating:

• Epigastric Hernia
• Inguinal Hernia
• Umbilical Hernia

The division also specializes in:

• Neonatal surgical care in coordination with the regional perinatal care center.

• Emergency surgical care of high-risk, premature infants with life-threatening illness
• Reconstructive surgery of congenital abnormalities of the abdominal wall, intestinal tract and lungs.

• Surgical care for severe injuries. As a component of the state-designated Level I Regional Pediatric Trauma Referral Center, we have an international reputation for excellence in management of all aspects of childhood injury.

• Rapid assessment of injured children of all ages to identify and treat serious and life-threatening injuries
• Comprehensive critical care management of severe traumatic brain injury
• Reconstruction of soft tissue injuries
• Coordination of multidisciplinary care of polysystem injury

• Elective surgical care of infants and children, including body wall hernia as described below.

Inguinal Hernia

Inguinal hernia is the most common congenital anomaly seen in healthy children. Unlike adult hernias that represent a weakening of the abdominal wall, an inguinal hernia in a child occurs when the inguinal canal does not close completely after birth, leaving a path for intestines to enter.

Both girls and boys can develop hernias, although it is approximately nine times more common in little boys. An inguinal hernia appears as a bulge in the scrotum or groin area. Little girls will frequently demonstrate a bulge in the area of the groin or the labia majora. It is usually worse when the child cries or does anything that increases pressure in the abdomen.

Commonly, the bulge comes and goes and causes little or no discomfort to the child. However, it provides a risk that a loop of intestine might become entrapped outside of the abdominal cavity. If the intestine is tightly trapped, it will be cut off from its blood supply and quickly develop an infection that could be life-threatening.

If a child suddenly develops a tender mass in the groin or genital region that does not go away with gentle pressure, a physician should be consulted to determine whether surgical evaluation and often immediate operative intervention is required. Ninety-five percent of hernias are harmless bulges that may come and go, but these too represent potential risk. For this reason, every bulge in the groin or genitals should be evaluated by a pediatric surgeon to determine the type of hernia that may be present.

What can I expect regarding care?
The first inclination that a hernia is present often comes from the parent, who observes the bulge during diaper change or bathing, or the pediatrician who evaluates it during a routine well-baby physical. This usually requires referral to the pediatric surgeon, who, on initial examination, will review the child's medical history, especially in regard to whether the child was born prematurely. Premature babies have a slightly higher incidence of developing inguinal hernias and may also have a higher incidence of having the hernia on both sides at the same time, even though only one side is visible or has symptoms.

After a brief physical examination, the pediatric surgeon will describe to the family what the presence of a hernia means, as well as the process of repair, which, for the majority of infants, is done in an outpatient surgical center. The process usually involves evaluation by an anesthesiologist on the day of surgery, as well as review of the methods for pain control so that the baby has minimal or no pain after the operation.

How is the hernia corrected surgically?
The actual process of surgical correction does not change the strength or integrity of the abdominal wall. The opening in the inguinal canal simply needs to be closed with stitches. The part that extends into the scrotum is frequently removed to avoid postoperative or future swelling. The risks of the procedure are a very low possibility of significant bleeding and an even lower incidence of wound infection, which almost always spontaneously resolves within days. The vas deferens, which conducts sperm from the testis to the base of the penis, and the vessels that nourish the testis are very closely attached to this area and are potentially at risk for injury during the course of the procedure. For this reason, the operation is performed by fully-trained teams who recognize these anatomic relationships.

One question that continually arises is whether or not the opposite side should be considered for a surgical intervention at the time the original hernia is being repaired. Objective clinical evidence clearly indicates that if the opposite side has no symptoms of an inguinal hernia, it should not be considered for operative intervention. The chance that the other side will develop a hernia later on, requiring yet another visit to the surgeon and operative intervention, is extraordinarily low, occurring in about one in every 4,000-5,000 cases. For babies born prematurely or those in which there is concern that a hernia might be present on the other side, this may be addressed through surgical exploration or looking at the site through a laparoscope. Both of these options would be thoroughly reviewed and discussed with the patient's family before proceeding with any surgical care.

What kind of follow-up care is required?
Fortunately, once the inguinal hernia is repaired, the chances of further problems are less than 1 percent. The majority of children go home within hours of their procedure. The tiny incision in the groin is closed with sutures that gradually dissolve. In many cases today, this incision is closed by absorbable glue. After two or three days of keeping the area clean and dry, the baby can resume normal activity with the expectation of no further problems. Sometimes, there is brief swelling of the scrotum or testicle as the result of the surgery. This routinely disappears within weeks to months after the procedure.

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Umbilical Hernia

An umbilical hernia is a bulge at the umbilicus, known as the belly button. This occurs because that area of the abdominal wall must remain open to allow the blood vessels of the umbilical cord to pass in and out of the abdominal cavity. When the baby is born, a process begins that usually stimulates that hole to contract to a point that ultimately results in its disappearance. Failure of this process to complete results in a persistent hole in the abdominal wall through which abdominal contents can protrude and create a very unsightly bulge.

Six out of ten umbilical hernias with a diameter of less than 1 cm (approximately the width of a normal adult's index finger) will close within the first two years of the baby's life. The most worrisome complication is when a piece of intestine gets trapped and cut off from its blood supply (a strangulated, incarcerated hernia). This is a rare occurrence. The usual presenting symptom is a relatively large bulge in the umbilical area that comes and goes.

What can I expect regarding care?
When pediatricians identify babies with umbilical hernias, they usually recommend operative repair only if the lesion persists after the baby has reached 2½-3 years of age. There are two reasons for this. First, the likelihood of ongoing contraction with gradual decrease in the size of the defect continues for the first two years of life. Second, the area around the defect is a very active metabolic area and is not as strong as the more mature fascia of the abdominal wall of an older child or adult. Placement of the sutures necessary to close that fascial defect may result in the sutures lacerating the fascia, causing a recurrence of the hernia that would be even more complex than the original problem. Thus, the majority of pediatric surgeons routinely consider surgical repair on children who have reached at least 2½ years of age and have no other significant problems.

Like an inguinal hernia, once this is identified, it usually results in referral to a pediatric surgeon, who, after examination and review of the child's medical history, will discuss much of what has been described above, as well as the procedure.

How is it corrected surgically?
The basic defect of an umbilical hernia is the persistent gap in the abdominal wall under the skin in the area of the umbilicus. Repair is accomplished through an incision in the skin overlying the umbilicus and placement of strong, non-absorbable sutures to close the fascia. The overlying skin is then loosely tacked to the fascia so that the umbilicus becomes an "inny" as the process of healing continues. The actual skin incision is closed with an absorbable suture. The area should be kept clean and dry for two to three days, after which the suture will dissolve automatically.

One question that frequently arises relates to the extra tissue that is produced as a result of the large bulge through the fascial defect. The greater majority of pediatric surgeons strongly recommend that this tissue be left alone rather than removing it surgically in an attempt to create a new umbilicus. The new umbilicus is never as normal looking as the native umbilicus. Moreover, the extra tissue gradually remodels and forms a normal appearance as the child continues to grow and develop. Thus, the actual repair of the umbilical hernia may have very little outside change other than the absence of the bulge and the persistence of extra skin that will gradually resolve.

The operation usually takes less than one hour in an outpatient procedure and, as with all procedures done by the University of Florida Division of Pediatric Surgery, involves the careful use of anesthetics so that the child's postoperative care is pain free. Currently, 96 percent of our patients experience no pain after their operation.

What kind of complications should I expect?
The most significant complication, as with any operative procedure, is infection. The other problem relates to the issue of recurrence, which can occur if the sutures (stitches) used to close up the hole in the tissue (fascia) come loose or if the tissue becomes weakened during the healing process.

What kind of follow-up care is required?
Care for these children is very similar to those who undergo inguinal hernia repair and usually require one to two follow-up visits to confirm complete healing of the incision. The repair should last for a lifetime and have no further problems.

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Epigastric Hernia

Most babies have a relatively wide space between the muscles that run up and down the anterior abdominal wall (rectus muscles). This space consists of a type of tissue that gradually continues to strengthen and ultimately results in these muscles coming together in the middle of the abdominal wall. As this process continues, there is occasionally a weak point in this fascia, known as the linea alba, that may result in a piece of fatty tissue underneath popping through and causing a lump. The lump is always in the middle of the abdominal wall and often is completely free of any symptoms. It usually does not change in size and, under most circumstances, is found by the mother or father during bathing or by a pediatrician during a well-baby visit.

What can I expect regarding care?
These masses usually result in referral to a pediatric surgeon for evaluation. After a simple office examination and the child's medical history, process of the development of this particular problem, as well as other options as to what might actually be causing the bulge, are usually reviewed. In most circumstances, especially when the size doesn't change and the bulge is not tender to the baby, the recommendation is either observing the bulge for gradual resolution or a brief operative procedure. In cases where the bulge changes in size or causes the baby pain, surgical repair is considered the most appropriate course.

How is it corrected surgically?
The process is simply a matter of a small incision over the area of the bulge once it is localized and then removal of the piece of fat with closure of the defect through which the fat protruded.

What complications should I expect?
As with all operative procedures, the most common complication is potential for infection of the surgical site. While bleeding is a possibility, there are no blood vessels in and around this area that if cut would cause bleeding or any potential threat to the child's life. The other problem is persistence of a palpable lump that is the result of the fascial repair causing some scarring or the possibility of a second bulge occurring in the nearby area. Occasionally, parents become concerned by a bulge caused by the suture used to close the defect. This gradually goes away as the suture begins to dissolve.

What kind of follow-up care is required?
These children are very similar to those who undergo umbilical hernia repair and usually require a single postoperative visit to confirm complete healing of the skin incision.

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