Embryonic hernia of the umbilical cord. Omphalocele Conservative treatment of omphalocele

Fetal umbilical hernias occur in early period development of the embryo, when the abdominal wall is underdeveloped, and the intestines and liver are located outside the abdominal cavity, covered with a transparent membrane (amnion), Wharton's jelly and inner shell, which corresponds to the parietal peritoneum. In fact, with this type of hernia there is eventration of the abdominal organs with underdevelopment of the anterior abdominal wall, white line and often in combination with splitting of the sternum and underdevelopment of the pubic joint (Fig. 24).

These defects can be combined with defects of the diaphragm, ectopia of the heart, ectopia Bladder. Due to such severe developmental defects, the child is not viable and surgical intervention is inappropriate.

Diagnosis of umbilical embryonic hernias is easy. Peristalsis is visible through the translucent transparent shell.

tingling loops of intestines, liver, dislocating during breathing. When the child screams, the protrusion increases.

The membrane covering the insides released into the embryonic hernia sac is thin and can easily rupture during childbirth or in the first hours of the child’s life. Observation of spontaneous rupture of the membrane of an embryonic hernia is given by V.V. Gavryushov (Fig. 24, b). The entire protrusion, covered with an outer membrane, is adjacent to the skin with the formation of a well-defined skin ridge. During the first day, the transparent outer shell begins to dry out, wrinkle, and become covered with a fibrinous coating. An associated infection with subsequent suppuration leads to the development of peritonitis, from which the child dies, usually on the 3rd day of life. Dimensions hernial orifice with embryonic hernias are different [up to 10x8 cm (M. P. Postolov)], hernias are usually located in the supra-umbilical region. Protrusions are also observed, which at their base have some narrowing, corresponding to the neck of a given hernial sac. The umbilical cord is most often located to the left of hernial protrusion, less often - at the top of it. The abdominal organs located in the hernial sac (liver, intestines) may have fusions with each other and with the wall of the sac. The liver is often enlarged ( congestion) or atrophic, its lacing in the form of an hourglass is observed.

Fetal hernias are rare. M. S. Simanovich (1958) reports 2 cases of embryonic hernias per 7000 births.

Newborns with embryonic hernias die from pneumonia, peritonitis, and sepsis. Cases of survival are rare. V.V. Gavryushov (1962) provides an observation of a girl aged 1 year 4 months with a spontaneously healed embryonic hernia (Fig. 24, c).

a - embryonic umbilical hernia; b - rupture of the membranes of the embryonic hernia 3 hours after birth; c - embryonic (unoperated) gryn; and in a girl 1 year 4 months old (V.V. Gavryushov).

Operations for embryonic hernias. To treat the surgical field, it is recommended to use 5% tincture of iodine, wipe the surgical field with alcohol, 5% alcohol solution tannin.

S. D. Ternovsky (1959) performs the operation according to the following plan: removal of the membrane covering the hernial protrusion, reduction of the viscera and layer-by-layer suturing of the abdominal wall. The peritoneum is sutured with interrupted sutures along with the aponeurosis, and sometimes with the edge of the muscles; a second row of sutures is placed on the skin. At small hernias the operation is easy and can be performed under local anesthesia. With large liver prolapses, the operation becomes much more complicated, especially in cases where the wall of the sac is tightly sealed to the liver. Separation of adhesions causes significant bleeding and leads to ruptures of the liver, which does not have a capsule in this place, so it is recommended to leave the area soldered to the liver on it and, lubricated with iodine tincture, immerse it in the abdominal cavity. During surgery in early dates, as long as there is no infection, this technique is safer than forced isolation

shells. For more convenient repositioning of the viscera, it is useful to cut up and down the opening of the abdominal wall defect. If the tissue tension of the aponeurosis of the abdominal muscles is high, the defect is sutured only in the lower part of the wound, and in the upper part above the liver only the skin is sutured. This technique significantly reduces intra-abdominal pressure and facilitates wound closure.

When the entire liver and intestines prolapse, partial suturing of the abdominal wall is practiced: after the intestines and part of the liver are reduced into the abdominal cavity, the unreduced part is left in the wound. The edges of the abdominal wall wound are sutured to the liver with separate sutures. This technique protects the abdominal cavity from infection. The part of the liver lying in the wound is covered with granulation tissue, followed by healing under a bandage.

Muscle plasticity is performed in more late dates, and the operation is thus divided into two stages. I J. Kossakovsky (Poland, 1949) makes a section within healthy skin at the base of the hernial protrusion. In case of bleeding, which may occur during the separation of membranes that have adhered to the released organs, part of the membrane is not removed. When repositioning the viscera into the abdominal cavity, it is recommended to lift the edges of the skin incision, which facilitates their gradual insertion. To facilitate the repositioning of the released viscera, a thread glove is put on the hand. If it is impossible to tighten the edges of the skin incision, two lateral loosening incisions are made, the surfaces of which are healed by subsequent granulation.

Hernias of the umbilical cord - umbilical, germinal (HERNIA FUNICULI UMBILICALIS, OMPHALOCELE)

Umbilical or embryonic hernias as a defect in fetal development are formed after the 3rd month of intrauterine life. At normal development in this period, the abdominal wall is close to its design, the umbilical cord and umbilical ring adopt anatomical relationships that ensure normal development of the fetus and its usefulness at the time of birth.

By 3 months, the fetal peritoneum is formed as an anatomical layer, covering the navel area; the delay in the development of the peritoneum favors the formation of a hernial protrusion.

The integument of an embryonic hernia has three layers: amnion, Wharton's jelly and peritoneum (Fig. 25). The outer shell of the hernial protrusion passes to the umbilical cord with the formation of a noticeable groove at the transition site, which is not observed in all cases. The hernial protrusion can enter the umbilical cord between the vessels, below them, and also be located to the right or left of them.

Rice. 25. Hernia of the umbilical cord (Kossakowski).

Rice. 26. Surgery for embryo-

nal hernia. Skin incision

at a distance of a few millimeters from the bag, dressing umbilical arteries and umbilical vein (Duhamel).

The hernial orifice usually has a round shape. The umbilical cord outside the hernial protrusion has its usual appearance. The hernial protrusion at its base may have a narrowed neck, and the umbilical opening is a hernial orifice. An increase in hernial protrusion occurs when the child cries. With hernias of the cord, as well as with embryonic hernias, maceration of the outer membrane occurs, its wrinkling with the gradual rejection of individual sections. Rupture of the protrusion membranes with prolapse of the abdominal viscera and subsequent development of peritonitis is also possible.

According to P.I. Tikhov, one hernia of the umbilical cord occurs in 3000-5000 births. Conservative treatment does not produce results and the only justified action is urgent surgery in the first hours after birth; at a later date, the outcome of the operation is unfavorable.

N.V. Schwartz (1935) proposed for hernias of the umbilical cord large sizes refuse surgery and use conservative treatment to achieve healing of the abdominal wall defect through scarring. Although there is information in the literature about isolated cases self-healing of embryonic hernias and hernias of the umbilical cord (embryonic), in this period of development of surgery it is impossible to talk about conservative treatment as a method, and the opinion of S. D. Ternovsky (1959) that protection conservative method is the “wrong direction”, quite justifiably.

Indications and contraindications for operations for embryonic hernias and hernias of the umbilical cord in each case should be made taking into account general condition newborn and associated developmental defects. A significant defect in the abdominal wall, which precludes the possibility of closing the abdominal wound, underdevelopment of the diaphragm, protrusion into the heart wall defect, and prematurity of the newborn are contraindications for surgery.

If surgery is indicated, prompt intervention is necessary within the next few hours after the birth of the child.

Before the operation, the mother is informed about the condition of the child and the indications for surgery, which is the only measure that can correct the birth defect.

At the suggestion of J. Kossakovsky, the newborn is placed on a specially prepared cruciform plate, the limbs are fixed with soft bandages.

Surgery for umbilical cord hernias is performed from an oval incision surrounding the base of the hernial protrusion. Next, the tissues are separated layer by layer, the hernial sac is opened, and the existing adhesions are separated. If bleeding occurs when separating membranes that have adhered to the removed organs, some of the membranes may not be removed. bandaged umbilical vein and arteries; the peritoneum and aponeurosis are sutured separately if possible (Fig. 26). When introducing organs into the abdominal cavity, it is recommended to raise the edges of the skin incision. If it is impossible to tighten the edges of the skin incision, two lateral loosening incisions are made, the surfaces of which are healed by granulation (J. Kossakovsky).

In our time, fetal hernia has been well studied. This disease has become quite common. If we take into account the statistics, then 20% of newborns and 35% of children who were not born have it. A particularly important question now is how to prevent the problem and recurrence of the disease.

What is a fetal hernia?

Fetal hernia is called (it is also called a hernia of the umbilical cord) a developmental defect when, at the moment of the birth of a child, some of the organs that are located in the abdominal cavity are located outside it, i.e. protruded in the navel area (umbilical ring). The navel ring is located on a strip that runs down the middle of the abdomen and is made up of ligaments. This is the connection between the fetus and the umbilical cord. When a baby is born, the umbilical cord is cut off, and over time the remaining part falls off. It will take some time before the vessels are tightened with connective tissue, which will block the hole in the umbilical ring. Over time it will close and heal. The muscles that make up the abdominals will also tighten and strengthen the ring. Of course, it will take some time to independently strengthen and fill the umbilical cord with vessels.

At the very beginning, the umbilical ring is too weak, it has not yet had time to tighten. The muscles that are located on the abdomen form a hollow ring and are located at a short distance. If the pressure in the abdominal cavity increases, intestinal loops may protrude through the ring. This phenomenon is called an embryonic hernia. It can be easily felt when touched; it looks like a small subcutaneous ball. When intrauterine pressure increases, there is a chance to see the baby's internal organs. After the pressure drops to normal, the internal organs will return to their original position.

Reasons why illness may occur

The reasons why an umbilical hernia appears have been studied at a low level. A hernia may appear hereditary predisposition and external negative influence on the fetus during pregnancy. Under these circumstances, the impact on connective tissue the fetus causes a delay in its normal development. Due to the slow development of collagen fibers of connective tissues, the structure of the umbilical ring is formed incorrectly. There are a huge number of reasons that can delay the overgrowth of the umbilical ring, which is why after the navel is overgrown, there is an empty space behind it, which was previously occupied by vessels that provide the child with blood.

Main symptoms of the disease

nausea
enlarged umbilical ring
convex bump in the area of the umbilical ring
for any physical activity there is a feeling of pain in the abdomen

A fetal ulcer can appear in a baby even before birth. It can be identified by an increased amount of alpha-fetoprotein during the second trimester or when abnormalities occur, such as a defect in the abdominal area, which are noticed during an ultrasound examination.

Classification of hernias

The main differences between hernias are the size (small, medium and large) and the condition of the membranes (complicated or uncomplicated).

Various ways to treat hernias

By medical statistics in 99% of cases, a congenital embryonic hernia resolves without the help of doctors. But this is only if the hernia is small. If the child develops correctly, his intestines work normally, then the hernia will disappear. Self-healing is possible until the child reaches three years of age.

You can strengthen the muscles in the baby’s abdominal area with massages or therapeutic physical activities with a coach.

An important point is the nutrition of the baby and his mother while she is breastfeeding. You will need to exclude from your diet all foods that may cause digestion problems.

Positional therapy can also be used to treat a fetal hernia. You need to put the baby on your stomach. In this position, the process of passing gases is easier, it becomes possible to move the limbs, and the protrusion of the hernia is inhibited.

Do not forget that in the presence of such a disease complications may occur. In most cases you will have to resort to surgical intervention. Therefore, until the hernia completely disappears, you will need to visit the doctor regularly.

Also, surgical intervention may be prescribed if the hernia exceeds small size or the umbilical ring is not tightened for execution one year old. The operation will help eliminate defects in the umbilical ring.

Embryonic umbilical hernias occur in the early period of embryonic development, when the abdominal wall is underdeveloped, and the intestines and liver are located outside the abdominal cavity, covered with a transparent membrane (amnion), Wharton's jelly and an internal membrane that corresponds to the parietal peritoneum. In fact, with this type of hernia, there is eventration of the abdominal organs with underdevelopment of the anterior abdominal wall, linea alba, and often in combination with splitting of the sternum and underdevelopment of the pubic joint (Fig. 24).

These defects can be combined with defects of the diaphragm, ectopia of the heart, and ectopia of the bladder. Due to such severe developmental defects, the child is not viable and surgical intervention is inappropriate.

Diagnosis of umbilical embryonic hernias is easy. Peristalsis is visible through the translucent transparent shell.

tingling loops of intestines, liver, dislocating during breathing. When the child screams, the protrusion increases.

The membrane covering the insides released into the embryonic hernia sac is thin and can easily rupture during childbirth or in the first hours of the child’s life. Observation of spontaneous rupture of the membrane of an embryonic hernia is given by V.V. Gavryushov (Fig. 24, b). The entire protrusion, covered with an outer membrane, is adjacent to the skin with the formation of a well-defined skin ridge. During the first day, the transparent outer shell begins to dry out, wrinkle, and become covered with a fibrinous coating. An associated infection with subsequent suppuration leads to the development of peritonitis, from which the child dies, usually on the 3rd day of life. The size of the hernial orifice in embryonic hernias varies 5; hernias are usually located in the supra-umbilical region. Protrusions are also observed, which at their base have some narrowing, corresponding to the neck of the hernial sac. The umbilical cord is most often located to the left of the hernial protrusion, less often - at its apex. The abdominal organs located in the hernial sac (liver, intestines) may have fusions with each other and with the wall of the sac. The liver is often enlarged (congestion) or atrophic, and its ligation in the form of an hourglass is observed.

Fetal hernias are rare. M. S. Simanovich (1958) reports 2 cases of embryonic hernias per 7000 births.

Rice. 24.

a - embryonic umbilical hernia; b - rupture of the membranes of the embryonic hernia 3 hours after birth; c - embryonic (non-operated) grain; and the girl is 1 year 4 months old (V.V. Gavryushov).

Operations for embryonic hernias. To treat the surgical field, 5% tincture of iodine, wiping the surgical field with alcohol, and a 5% alcohol solution of tannin are recommended.

S. D. Ternovsky (1959) performs the operation according to the following plan: removal of the membrane covering the hernial protrusion, reduction of the viscera and layer-by-layer suturing of the abdominal wall. The peritoneum is sutured with interrupted sutures along with the aponeurosis, and sometimes with the edge of the muscles; a second row of sutures is placed on the skin. For small hernias, the operation is easy and can be performed under local anesthesia. With large liver prolapses, the operation becomes much more complicated, especially in cases where the wall of the sac is tightly sealed to the liver. Separation of adhesions causes significant bleeding and leads to ruptures of the liver, which does not have a capsule in this place, so it is recommended to leave the area soldered to the liver on it and, lubricated with iodine tincture, immerse it in the abdominal cavity. When operating early, while there is no infection, this technique is safer than forced extraction

Muscle plastic surgery is performed at a later date, and the operation is thus divided into two stages. I J. Kossakovsky (Poland, 1949) makes an incision within healthy skin at the base of the hernial protrusion. In case of bleeding, which may occur during the separation of membranes that have adhered to the released organs, part of the membrane is not removed. When repositioning the viscera into the abdominal cavity, it is recommended to lift the edges of the skin incision, which facilitates their gradual insertion. To facilitate the repositioning of the released viscera, a thread glove is put on the hand. If it is impossible to tighten the edges of the skin incision, two lateral loosening incisions are made, the surfaces of which are healed by subsequent granulation.

Omphalocele (umbilical cord hernia, umbilical hernia, fetal hernia) is a protrusion of abdominal organs through a midline defect at the base of the umbilicus.

Omphalocele is a developmental anomaly in which, as a result, early violation organogenesis, the organs of the abdominal cavity, to one degree or another, develop outside the body of the embryo, which entails not only the incorrect development of these organs, but also defects in the formation of both the abdominal cavity and chest. The hernial protrusion is covered with a hernial sac, consisting of the amnion on the outside, the peritoneum on the inside, with mesenchyme (Vargan's jelly) between them.

In an omphalocele, the protrusion of organs is covered by a thin membrane and may be small (only a few loops of intestine) or may contain most of the abdominal organs (intestines, stomach, liver). The immediate danger is drying out internal organs, hypothermia and dehydration due to water evaporation, as well as infection of the peritoneum. Infants with omphalocele have a very high incidence of other congenital malformations, including intestinal atresia; chromosomal abnormalities such as Down syndrome; and cardiac and renal abnormalities that should be identified and evaluated before surgical correction.

ICD-10 code

Q79.2. Exomphalosis.

What causes omphalocele?

Ideas about the ethology and pathogenesis of omphalocele still remain controversial. It is believed that two factors play a major role in the genesis of embryonic hernia of the umbilical cord - impaired intestinal rotation in the first period of rotation and underdevelopment of the anterior abdominal wall. Impaired intestinal rotation manifests itself in the form of preservation of temporary “physiological” umbilical hernia, which forms in a 5-week embryo due to a discrepancy between the growth rates of the intestine and the abdominal cavity and disappears independently by the 11th week of development.

According to another theory, omphalocele is “persistence of the trunk stalk in the area normally occupied by somatopleura.” This idea of a violation of the lateral mesodermal replacement of the peritoneum, amnion and stalk mesoderm explains the variety of anomalies noted in omphalocele - from cloacal exstrophy to Cantrell's pentad.

How does omphalocele manifest?

Children with omphalocele often have multiple combined defects of other vital signs. important organs and systems, as well as chromosomal abnormalities. Most often these are congenital heart defects, kidney malformations, orthopedic defects, etc. Small omphalocele is often combined with a patent vitelline duct.

A combination of omphalocele with Down's disease and trisomy of chromosomes 13 and 18 is possible.

Omphalocele is a component of Beckwith-Wiedemann syndrome, also called OMG syndrome (omphalocele-macroglossia-gigantism). This syndrome, in addition to omphalocele, is characterized (as the name suggests) by the presence big tongue, sometimes causing difficulty breathing, and gigantism, most often realized in gigantism of parenchymal organs (hepatosplenomegaly, pancreatic hyperplasia), which can manifest itself as hyperinsulinism and hypoglycemia, which is especially dangerous in the neonatal period. Partial skeletal gigantism is less commonly found.

Omphalocele is sometimes a component of such severe anomalies as Cantrell's pentad and cloacal exstrophy, the treatment of which is extremely difficult and still has disappointing results in most clinics. It is the severity of combined lesions and their curability that determine the severity of the patient’s condition with omphalocele and the prognosis, and in thanatogenesis or disability: the patient’s leading role often belongs not to the omphalocele, but to combined malformations or genetic syndromes. All of the above dictates the need early detection omphalocele in the antenatal period for a timely decision on the issue of maintaining or terminating the pregnancy.

Classification

According to the working classification of omphalocele, depending on the size of the defect of the anterior abdominal wall (hernial orifice) and the volume of the contents of the hernial sac, omphaloceles are divided into small, medium and large sizes. The contents of small and medium hernias are talc intestinal loops (in small ones - one or several). A large omphalocele always contains not only intestinal loops, but also the liver.

Based on the shape of the hernial protrusion, hemispherical, spherical and mushroom-shaped hernias are distinguished.

How to recognize an omphalocele?

Visualization of omphalocele is possible with ultrasound from the 14th week of pregnancy. A test for maternal alpha-fetoprotein (AFP) levels is very informative; its levels are elevated in congenital malformations. In this case (with an increase in the amount of AFP), it is necessary to carefully examine the fetus for the presence of combined congenital malformations. If an omphalocele is detected in combination with incurable malformations or genetic abnormalities future parents may be advised to terminate the pregnancy.

The birth of children with a small or medium omphalocele can occur naturally if there are no other indications for a cesarean section. For large GPCs, the method of delivery is chosen individually in each specific case. It is usually advisable to do C-section due to the danger of rupture of the thin membranes of the hernia.

Prenatal diagnosis of omphalocele

Diagnosis of omphalocele after the birth of a child, as a rule, does not cause difficulties. However, with a small omphalocele, when processing the umbilical cord in the maternity hospital, errors may be made that have severe consequences. Usually in the hernial membranes with this type of anomaly there are one or two loops of intestine, i.e. the volume of the formation is small, and such an omphalocele often looks like a thickened umbilical cord. If a doctor or midwife does not recognize a small omphalocele and a crush clamp or ligature is applied to the border between the umbilical cord and the skin, and the remainder of the umbilical cord is cut off, the intestinal wall may be damaged. Therefore, in doubtful cases (with a thick umbilical cord, umbilical cord vascular dysplasia), it is important to remember about small omphaloceles and apply a ligature at a distance of at least 10-15 cm from the skin edge. Such a newborn needs immediate transfer to a surgical hospital for examination. The diagnosis of small omphalocele can be confirmed or excluded x-ray examination in lateral projection. With an omphalocele outside the anterior abdominal wall, intestinal loops (gas bubbles) are identified in the umbilical cord membranes, while in the absence of communication between the abdominal cavity and the umbilical cord membranes, the integrity of the anterior abdominal wall on the radiograph is not broken. Considering the fact that with omphalocele there are often combined malformations, the mandatory protocol for examining the patient, in addition to radiography of the chest and abdominal cavity, vertical position, includes ultrasonography of the brain, abdominal cavity and retroperitoneal space, as well as ultrasound of the heart of large vessels.

Treatment of omphalocele

When giving first aid to a child with omphalocele in the maternity hospital, the main attention should be paid to maintaining his body temperature, protecting the hernial sac from adverse external influences. Patients with omphalocele need emergency care.

The choice of treatment method for omphalocele depends on the size of the hernia, the patient’s condition and the capabilities of the hospital where this treatment takes place. It can be conservative or surgical and take place in one or several stages.

Conservative treatment of omphalocele

Conservative treatment in last years With the development of resuscitation and improvement of resuscitation support, it is used in extremely limited cases when, for one reason or another, it is proposed to postpone surgical intervention. Similar tactics can be used for huge hernias of the umbilical cord or their combination with multiple severe malformations. Most often, tanning solutions such as povidone-iodine, merbromine, and 5% potassium permanganate solution are used for these purposes. The hernial sac is fixed over the patient by the umbilical cord in a vertical position, the hernia membranes are treated several times a day with one of the listed solutions, achieving the formation of a dense crust, under which a scar gradually forms, forming a large ventral hernia. However, this method has many serious disadvantages (infection of the membranes, their rupture, a long period healing, expressed adhesive process etc.), therefore it should be used only in extraordinary cases.

Surgical treatment of omphalocele

Surgical treatment can be radical (layer-by-layer suturing of all layers of the abdominal wall after immersing the organs in the abdominal cavity) or staged. The second option involves the gradual formation of the anterior abdominal wall using auto- or alloplastic materials at intermediate stages.

Radical intervention is the operation of choice, performed in cases where the viscero-abdominal disproportion (the ratio between the volume of the hernia formation and the capacity of the abdominal cavity) is moderate, and layer-by-layer suturing of the anterior abdominal wall does not cause a significant increase in intra-abdominal pressure. Accordingly, radical surgery is usually performed for small and medium-sized omphaloceles, and less often for large omphaloceles.

If a small omphalocele is combined with a vitelline duct, radical intervention is supplemented with resection of the vitelline duct. It should be remembered that a component of almost any omphalocele, with rare exceptions for small hernias, is malrotation, a common mesentery of the small and large intestines, therefore, when organs are immersed in the abdominal cavity, the large intestine should move to the left flank, and the small intestine should be in the right flank and center abdominal cavity. After completion of the intraperitoneal stage of the operation, layer-by-layer suturing of the wound of the anterior abdominal wall is performed to form a “cosmetic” navel.

The greatest difficulties arise in the treatment of large omphaloceles with a significant degree of viscero-abdominal disproportion, when radical surgery is impossible due to a sharp increase in intra-abdominal pressure. In such cases it is necessary to use different kinds staged surgical treatment.

In 194S, Robert Gross from Boston described a method of staged surgical treatment of large hernias of the umbilical cord. The first stage consisted of removing the hernia membranes, immersing the organs as far as possible into the abdominal cavity, wide separation of skin flaps of the abdominal wall up to lumbar region and suturing the skin with the formation of a ventral hernia. The second stage was the elimination of the ventral hernia (at the age of L-2 years). Currently, this technique is practically not used, since it has many disadvantages (pronounced adhesions, large sizes of the ventral hernia, lack of conditions for increasing the volume of the abdominal cavity, since almost all organs are located in the skin hernial sac).

A breakthrough in the treatment of large omphaloceles was made in 1967 when Schuster described a method of temporarily applying a plastic covering to reduce the size of the fascial defect.

Then in 1969, Allen and Wrenn proposed the use of a single-layer silastic covering sutured to the edges of the fascial defect, followed by a gradual reduction in the volume of the hernia formation using manual compression, which allows for delayed primary closure of the abdominal wall. As soon as after the first stage of the intervention, intestinal motility is restored, it empties and decreases in volume, the second stage follows (usually after 3-14 days) - removal of the sac and radical plastic surgery of the anterior abdominal wall or the formation of a now small ventral hernia. This method remains the main one in the treatment of this pathology to this day.

Operation technique for staged treatment large omphaloceles. The operation begins with a skin incision around the hernial formation. After making sure that it is impossible to immerse all the organs, a silicone bag with a silastic coating is sutured to the muscular aponeurotic edge of the defect of the anterior abdominal wall. This bag covers that part of the hernia contents that was able to be placed in the abdominal cavity. The bag is tied over the organs and fixed over the patient in a vertical position. As the organs from the sac spontaneously descend into the abdominal cavity, the sac is ligated lower and lower (relative to the abdominal wall), reducing its volume, while allowing some degree of compression. The second stage consists of removing the sac after 7-14 days and radical layer-by-layer suturing of the anterior abdominal wall to form a small ventral hernia. In this case, the last stage of surgical treatment (liquidation of the ventral hernia with layer-by-layer suturing of the abdominal wall) is performed at the age of 6 months.

There are and successfully used methods for using allotransplantations of synthetic or biological origin, sewn into the fascial defect of the anterior abdominal wall in the form of a patch with a pronounced degree of visceroabdominal disproportion.

Postoperative management

In the early postoperative period it is carried out artificial ventilation lungs, pain relief, antibacterial therapy. The decisive component of treatment is total parenteral nutrition throughout the entire period of healing of the abdominal wall and restoration of intestinal functions. In children with combined severe anomalies in the postoperative period, the issue of timely correction of these anomalies should be resolved, which requires the participation of doctors of these specialties in the treatment. Special attention should be given to patients with Besquit-Wiedemann syndrome who are prone to severe hypoglycemia. Careful control of blood sugar can prevent this condition and prevent the development of encephalopathy in such patients.

Prognosis of omphalocele

All patients with omphalocele who do not have lethal malformations of other organs and systems survive. However, when omphalocele is combined with various anomalies their timely diagnosis, as well as cooperation with doctors of other specialties, make it possible not only to cure children with severe birth defects heart, kidney. central nervous system, musculoskeletal system, but to provide them with an acceptable quality of life, which is only possible in a multidisciplinary children's hospital, all of whose specialists and services have extensive experience in caring for newborns with this complex pathology. Clinical observation of patients should be carried out until rehabilitation is completed for several years.

Hernia of the umbilical cord, or umbilical hernia(omphalocele) is a developmental defect in which, by the time the child is born, part of the abdominal organs is located outside the peritoneum - in the umbilical cord membranes, consisting of amnion, Wharton's jelly and primary primitive peritoneum (Fig. 149). Occurs in 1 in 5000-6000 newborns.

Rice. 149. Hernia of the umbilical cord (diagram).

The origin of the hernia is associated with a violation of the development of embryogenesis in the first weeks of intrauterine life. At that time abdomen cannot accommodate rapidly expanding intestinal loops. Located extraperitoneally, in the umbilical cord membranes, they go through a temporary stage of “physiological embryonic hernia”, and then, after completing the process of rotation, they return to the expanding abdominal cavity. If, as a result of a violation of the process of intestinal rotation, underdevelopment of the abdominal cavity, or a violation of the closure of the anterior abdominal wall, some organs remain in the umbilical cord membranes, the child is born with a hernia of the umbilical cord.

Depending on the time of stopping the development of the anterior abdominal wall, two main types of umbilical hernias are distinguished - embryonic and fetal. In embryonic hernias, the liver does not have a Glissonian capsule and fuses with the membranes of the umbilical cord, which plays an important role during surgical intervention.

By clinical signs umbilical cord hernias are divided into in the following way:

by hernia size: small - up to 5 cm, medium - up to 10 cm, large - more than 10 cm;
according to the condition of the hernial membranes: uncomplicated (with unchanged membranes), complicated (rupture of membranes, purulent melting, intestinal fistulas).

Approximately 65% of children with umbilical cord hernias have combined malformations (heart, gastrointestinal tract, genitourinary system).

Clinical picture. When examining the child, it is discovered that part of the abdominal organs is located in the umbilical cord membranes. The hernial protrusion is located in the projection of the navel, above the defect of the anterior abdominal wall. The umbilical cord extends from the upper pole of the hernial protrusion. If developmental arrest occurs early, then a significant part of the liver is located outside the abdominal cavity and most of intestines. In cases of more late delay development, only part of the intestinal loops remains extraperitoneally. In practice, the contents of an embryonic hernia can be all organs except the rectum. With a defect in the diaphragm, ectopia of the heart is observed.

In the first hours after birth, the puovine membranes that form the hernial sac are shiny, transparent, and whitish. However, by the end of the first day they dry out, become cloudy, then become infected and covered with fibrinous deposits. If measures are not taken to prevent and treat infected membranes, peritonitis and sepsis may develop. When the membranes become thinner and rupture, eventration occurs.

Rice. 150. Treatment of umbilical cord hernia (diagram). a - radical surgery with layer-by-layer suturing of the tissues of the abdominal wall; b - Gross operation (suturing the skin over the unopened hernia membranes); c - alloplastic method; d - conservative treatment.

Treatment . Children with umbilical cord hernias begin to be treated immediately after diagnosis. Two treatment methods are used: surgical and conservative (Fig. 150).

Absolute contraindications To operative method treatments are congenital heart disease, severe prematurity and severe birth traumatic brain injury. For these children, conservative treatment is used, which consists of daily treatment of the umbilical cord membranes with 2% tincture of iodine and alcohol. After the coagulation crusts have separated and granulations have appeared, they switch to ointment dressings (Vishnevsky ointment, Shostakovsky balm). Antibiotics and physical therapy are prescribed ( ultraviolet irradiation, electrophoresis with antibiotics), restorative and stimulating therapy. The hernial sac is slowly covered with epithelium and, shrinking, becomes smaller. Complete epithelization is observed after 2-3 months.

Relative contraindication Large hernias are considered for surgery if they clearly do not correspond to the volume of the abdominal cavity, since the simultaneous reduction of internal organs into the underdeveloped abdominal cavity leads to sharp increase intra-abdominal pressure, limited mobility of the diaphragm and the development of sudden respiratory failure, which often causes death.

However, in these children, if they were born full-term and without severe concomitant malformations and diseases, a two-stage Gross operation or closing the defect with alloplastic material can be successfully used. According to the method proposed by Gross, only the excess part of the umbilical cord is excised. The membranes are treated with 5% tincture of iodine, the skin is widely mobilized to the sides. The selected edge of the muscular aponeurotic defect is sutured to the membranes of the hernial sac as close as possible to the upper pole. The skin is sutured over the hernial sac using interrupted silk sutures. To reduce tension, skin incisions are made in a checkerboard pattern. Muscular aponeurotic plasty is performed in the second stage in children older than one year.

When using alloplastic material, the hernial sac is covered with Dacron, Teflon, suturing it along the edge of the muscular aponeurotic defect. In the next few days postoperative period the capacity of the hernial sac is reduced with the help of collecting sutures, which makes it possible to gradually immerse the organs in the abdominal cavity and perform delayed plastic surgery of the anterior abdominal wall on the 7-10th day after the birth of the child.

Radical surgical intervention Newborns with small and medium hernias with a well-formed abdominal cavity are eligible.

Radical operation comes down to excision of the umbilical membranes, reduction of the viscera and plastic surgery of the anterior abdominal wall. The operation is performed under endotracheal anesthesia. The use of muscle relaxants is undesirable, since it is not possible to timely diagnose the increase in intra-abdominal pressure that occurs with large hernias.

At the border of the skin and umbilical cord membranes, a 0.25% solution of novocaine is injected and carefully, without opening the abdominal cavity, a bordering incision is made around the hernial protrusion. The contents of the hernial sac are inserted into the abdominal cavity. The membranes are gradually excised, starting from the upper pole, and at the same time plastic surgery of the anterior abdominal wall begins. The peritoneum is sutured together with the aponeurosis, and sometimes with the edge of the muscles, using interrupted sutures. A second row of sutures is placed on the skin. If there is tension when suturing the aponeurosis, two rows of sutures (U-shaped and interrupted silk) are applied to the skin. If the hernia membranes are tightly sealed to the liver, they are left, treated with tincture of iodine and immersed together with the liver into the abdominal cavity. This is necessary due to the fact that separation of the membranes from the liver, deprived of the Glissonian capsule, leads to damage to the organ and persistent bleeding.

After Gross's operation and conservative treatment, a ventral hernia is formed (Fig. 151). For prevention severe forms for ventral hernias, after the child is discharged from the hospital, wearing a bandage, massage, and gymnastics are necessary.

Rice. 151. Ventral hernia.

Ventral hernia is eliminated surgically in children older than one year. Preliminarily carried out functional test, allowing you to find out how much the increase in intra-abdominal pressure is compensated. Blood gases are examined before and after hernia repair. The simplest tests are to determine heart rate and breathing. If after reduction of the hernia they remain within normal limits, elimination of the hernia is possible. If increased heart rate and shortness of breath are observed, surgery is postponed until the abdominal cavity has reached sufficient volume and surgery is possible.

The most common are two methods of plastic surgery of the anterior abdominal wall for ventral hernias.

One of them involves muscular aponeurotic plastic surgery of the defect: flaps are cut out from the outer layers of the aponeurosis, which are sutured along the midline. During surgery using the Shilovtsev method, the deep-epidermalized skin flap covering the ventral hernia is displaced under the skin.

Inguinal hernia which often accompany ventral hernias, eliminate surgically 3-6 months after surgery for a ventral hernia.

Prognosis for umbilical cord hernias always serious. Mortality during surgical treatment of umbilical cord hernias remains high and ranges from 30% for small hernias to 80% for large and complicated hernias. Children successfully operated on during the neonatal period subsequently grow and develop normally.

Isakov Yu. F. Pediatric surgery, 1983