Hernias: why are some watched while others are repaired?

The most common thing that I see as a pediatric surgeon is a child with a lump that is thought to be a hernia. A hernia is a bulging of tissue through an opening in the muscle layers that isn’t normally present. In children, these openings are usually the result of a developmental process that just didn’t quite reach completion. Some hernias need surgery emergently, while others are observed for years with the expectation that they will close on their own.

Here are some pointers to help understand this wide range of approaches to hernias:

Location is very important in considering how aggressive to be with hernias. Belly button (umbilical) hernias are most often watched with the expectation that they will close on their own within the first few years of life. A small number will eventually require surgery to prevent problems as an adult. There are some hernias just above or below the belly button (ventral or epigastric hernias), and these typically require a surgery to fix. Similarly, groin (inguinal) hernias do not close on their own and so will require surgical repair.

Any hernia that is “stuck out” (incarcerated) needs to be seen immediately by a medical professional. This is because a hernia may be squeezing or strangulating intestines or other vital structures which might soon lose their circulation. In this situation a child is distressed, inconsolable, may be vomiting, and the lump is tender, swollen and/or red. This is more likely to occur in inguinal or groin hernias versus umbilical (belly button) hernias, and so we recommend repairing inguinal hernias soon after they are detected. Thankfully, incarceration is an unusual event and so if a groin lump is seen but comes and goes, this merits a visit but not emergently.

If a hernia needs to be surgically repaired, this is typically done as a day surgery with a quick recovery and fast return to full activities.

Figure 1 shows two hernias: a ventral hernia just below the belly button and an inguinal hernia which occurs in the groin and can extend down into the scrotum. Both of these hernias require surgery.

Figure 2 shows a typical belly button (umbilical) hernia. These can look quite large, but the size of the opening at the muscle layer is what predicts spontaneous closure, and this is usually small.