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An Atlas of Lumps and Bumps: Part 24

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Alexander Leung
Alexander Leung
Alexander Leung
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Benjamin Barankin at Toronto Dermatology Centre
Benjamin Barankin
  • Toronto Dermatology Centre
Joseph Lam at University of British Columbia
Joseph Lam
Andrew Leung
Andrew Leung
Andrew Leung
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An Atlas of Lumps and Bumps: Part 24
consultant360.com/photo-essay/atlas-lumps-and-bumps-part-24
Photo Essay
Alexander K.C. Leung, MD —Series Editor • Benjamin Barankin, MD • Joseph M Lam,
MD • Andrew A. H. Leung, BSc • Alex H.C. Wong, MD
AFFILIATIONS:
Clinical Professor of Pediatrics, the University of Calgary; Pediatric Consultant, the Alberta
Children’s Hospital, Calgary, Alberta, Canada
Dermatologist, Medical Director and Founder, the Toronto Dermatology Centre, Toronto,
Ontario, Canada
Associate Clinical Professor of Pediatrics, Dermatology and Skin Sciences, the University of
British Columbia, Vancouver, British Columbia, Canada.
Faculty of Medicine, St. George’s University, Grenada
Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
CITATION:
Leung AKC, Barankin B, Lam JM, Leung AAH, Wong AHC. An atlas of lumps and bumps,
part 24. Consultant. 2023;63(2):e11. DOI: 10.25270/con.2023.02.000002.
DISCLOSURES:
Dr Leung is the series editor. He was not involved with the handling of this paper, which was
sent out for independent external peer review.
CORRESPONDENCE:
Alexander K. C. Leung, MD, #200, 233 16th Ave NW, Calgary, AB T2M 0H5, Canada
(aleung@ucalgary.ca)
EDITOR’S NOTE:
This article is part of a series describing and differentiating dermatologic lumps and bumps.
To access previously published articles in the series, visit
https://www.consultant360.com/resource-center/atlas-lumps-and-bumps.
Umbilical Hernia
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An umbilical hernia results from imperfect closure or weakness of the umbilical
ring. Umbilical hernias are found in 15% to 23% of newborn infants. The incidence is
affected by gestational age, birth weight, age of the child, race, and coexisting disorders.
Umbilical hernias are about six to 10 times more common in Black individuals than White
individuals. They are also more common in low-birth-weight and premature infants. The
sex incidence is approximately equal.
Most umbilical hernias are sporadic and occur as isolated findings in otherwise healthy
infants. Umbilical hernias occur with increased frequency in patients with Beckwith-
Wiedemann syndrome, Down syndrome, trisomy 13, trisomy 18, congenital hypothyroidism,
mucopolysaccharidosis, and cirrhosis of the liver with ascites.
Classically, an umbilical hernia presents as a soft, skin-covered swelling that protrudes
through the fibrous ring at the umbilicus.2 (Figure 1)
Figure 1 An umbilical hernia in an infant is shown.
The umbilical bulge becomes more apparent during episodes of crying, coughing, or straining
and is easily capable of being reduced. The content usually consists of a piece of small
intestine and, sometimes, omentum. The condition is usually asymptomatic and recognized
in the neonatal period.
Complications, such as incarceration of intestine or omentum, strangulation, perforation of
the intestine, and rupture with evisceration, are rare in children. The risk of
complications varies greatly between populations worldwide and is much higher in adults.
For young women with persistent umbilical hernia, the umbilical defect may enlarge and
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become symptomatic during pregnancy.2 Most umbilical hernias resolve spontaneously,
usually within the first 2 years of life, if not the first year. Of the umbilical hernias not
repaired in childhood, approximately 10% persist into adulthood.
Paraumbilical Hernia
A paraumbilical hernia is due to a defect in the linea alba close to the umbilicus. Unlike an
umbilical hernia, a paraumbilical hernia does not protrude through the umbilical area.
Rather, it protrudes just above or below the umbilicus (Figure 2). Unless complicated, a
paraumbilical hernia can be reduced manually and asymptomatic.
Figure 2. A paraumbilical hernia in an adult male is shown.
Although the defect in the linea alba is congenital, a paraumbilical hernia may not be
noticeable until later in life when abdominal contents herniate through the defect and
presents with a visible lump on the abdominal wall. Paraumbilical hernias are more common
in adults than in children.
The female to male ratio is about 5:1. The condition is more common in White individuals,
those with obesity, and in those with weak abdominal muscles.12 A paraumbilical hernia
poses a risk of incarceration and strangulation. Omentum, small bowel, and large bowel
are the usual content. Occasionally, the content consists of an appendix or a Meckel’s
diverticulum.
The diagnosis of paraumbilical hernia can usually be made clinically unless the hernia sac is
small or the patient’s body habitus interferes with adequate palpation. High-resolution
ultrasonography is an efficient tool for detecting the presence of a paraumbilical hernia and
accurately verifies not only its content but also possible associated complications. A recent
onset of a paraumbilical hernia in the elderly is a possible sign of internal malignancy.
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A paraumbilical hernia does not close spontaneously. Elective herniorrhaphy is advisable
because of the recognized risk of complications.
References
1. Halleran DR, Minneci PC, Cooper JN. Association between age and umbilical hernia
repair outcomes in children: A multistate population-based cohort study. J Pediatr.
2020;217:125-130.e4. doi: 10.1016/j.jpeds.2019.10.035.
2. Leung AK. Umbilical hernia. In: Leung AK. Ed. Common Problems in Ambulatory
Pediatrics: Specific Clinical Problems, Volume 1. New York: Nova Science Publishers,
Inc. 2011, pp23-26.
3. Zens TJ, Rogers A, Cartmill R, Ostlie D, Muldowney BL, Nichol P, et al. Age-dependent
outcomes in asymptomatic umbilical hernia repair. Pediatr Surg Int. 2019;35(4):463-
468. doi: 10.1007/s00383-018-4413-3.
4. Almeflh W, AlRaymoony A, AlDaaja MM, Abdullah B, Oudeh A. A systematic review of
current consensus on timing of operative repair versus spontaneous closure for
asymptomatic umbilical hernias in pediatric. Med Arch. 2019;73(4):268-271. doi:
10.5455/medarh.2019.73.268-271.
5. Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surg Clin North Am.
2013;93(5):1255-1267. doi: 10.1016/j.suc.2013.06.016.
6. Sherman SC, Lee L. Strangulated umbilical hernia. J Emerg Med. 2004; 26(2):209-211.
doi: 10.1016/j.jemermed.2003.06.007.
7. Ekwunife OH, Osuigwe AN. Spontaneous rupture of an umbilical hernia. Afr J Paediatr
Surg. 2011;8(2):257-8. doi: 10.4103/0189-6725.86081.
8. Ireland A, Gollow I, Gera P. Low risk, but not no risk, of umbilical hernia complications
requiring acute surgery in childhood. J Paediatr Child Health. 2014;50(4):291-293.
doi: 10.1111/jpc.12480.
9. Ginsburg BY. Sharma AN. Spontaneous rupture of an umbilical hernia with
evisceration. J Emerg Med. 2006; 30(2):155-157. doi:
10.1016/j.jemermed.2005.05.017.
10. Durakbasa CU. Spontaneous rupture of an infantile umbilical hernia with intestinal
evisceration. Pediatr Surg Int. 2006; 22(2):567-569. doi: 10.1007/s00383-006-1661-4.
11. Daoud FS. Incarcerated endometriotic ovarian cyst within paraumbilical hernia. J
Obstet Gynaecol. 2005; 25(8):828-829. doi: 10.1080/01443610500338347.
12. Sinha SN, Keith T. Mesh plus repair for paraumbilical hernia. Surgeon. 2004; 2(2):99-
102. oi: 10.1016/s1479-666x(04)80052-0.
13. Bedewi MA, EI-Sharkawy MS, AI Boukai AA, AI-Nakshabandi N. Prevalence of adult
paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based
study. Hernia. 2012; 16(1):59-62. doi: 10.1007/s10029-011-0863-4.
14. Yau KK, Siu WT, chan KL. Strangulated appendix epiploica in paraumbilical hernia:
preoperative diagnosis and laparoscopic treatment. Surg Laparosc Endosc Percutan
Tech. 2006; 16(1):49-51. doi: 10.1097/01.sle.0000202199.82193.84.
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15. Zormpa A, Alfa-Wali M, Chung A. Appendicitis within the contents of an incarcerated
paraumbilical hernia. BMJ Case Rep. 2019 Aug 10;12(8):e228915. doi: 10.1136/bcr-
2018-228915.
16. Kong V, Parkinson F, Barasa J, Ranjan P. Strangulated paraumbilical hernia - An
unusual complication of a Meckel's diverticulum. Int J Surg Case Rep. 2012;3(6):197-
198. doi: 10.1016/j.ijscr.2012.02.001.
17. Kenig J, Richter P, Barczyński M. An umbilical/paraumbilical hernia as a sign of an
intraabdominal malignancy in the elderly. Pol Przegl Chir. 2014;86(4):189-93. doi:
10.2478/pjs-2014-0034.
ResearchGate has not been able to resolve any citations for this publication.
A Systematic Review of Current Consensus on Timing of Operative Repair Versus Spontaneous Closure for Asymptomatic Umbilical Hernias in Pediatric
Article
Full-text available
  • Aug 2019
Introduction: Umbilical hernia is a common pediatric disorder that pediatric surgeons are usually asked to manage. Most cases will be closed spontaneously during the first 4-5 years of life. Low number of studies regarding umbilical defects in children does not allow a definitive guideline to be drawn about their natural history, indications and optimal timing for repair. In this systematic review, we evaluated the existing literature where pediatric umbilical hernias are addressed in regards to watchful waiting versus recommendations on timing of operative repair and we compared our institutional results with current literature. Aim: The aim of our study is to review and evaluate the current guidelines in management of umbilical hernias in children and to compare the results with our experience in management of umbilical hernia in our institution. Methods: Online literature search for studies that published about umbilical hernias in pediatric using literature's search of ACP Journal Club, Clinical Evidence, Dynamed, Cochran Controlled Trial Register (1945-2015), UpToDate, and PubMed. We reviewed the recommendations of these studies regarding conservative treatment, rule and time of surgery, complications, and its natural history trend to close spontaneously. We compared the literature results and recommendations to our institutional results. We also conducted a retrospective medical charts review of 520 children aged between 1 month and 14 years presented to our institution for surgical consultation for asymptomatic umbilical hernia between 2007 and 2017. We only included children with umbilical hernia who are less than 14 years old and without other associated disorders. Results: A Total of 7 studies that met the inclusion criteria were reviewed. These studies examined the possibilities of spontaneous closure of hernia defect in pediatric, incidence of complications from watchful waiting and current recommendations for surgery timing. In general, spontaneous resolution were unlikely to be seen beyond the age of 5 years. Our institutional results found that of 442 cases treated conservatively between 2007 and 2017, 85% are closed spontaneously by 1-5 years of age. Conclusion: There is minimal top-notch clinical data guiding pediatric surgeons on management protocols in regards to umbilical hernias in children. Current published studies and our institutional retrospective study recommend that conservative management of asymptomatic, uncomplicated umbilical hernias until age 4-5 years is both safe and practical.
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Age-dependent outcomes in asymptomatic umbilical hernia repair
Article
Full-text available
  • Apr 2019
  • PEDIATR SURG INT
Purpose Umbilical hernias are common in young children. Many resolve spontaneously by age four with very low risk of symptoms or incarceration. Complications associated with surgical repair of asymptomatic umbilical hernias have not been well elucidated. We analyzed data from one hospital to test the hypothesis that repair at younger ages is associated with increased complication rates. Methods A retrospective chart review of all umbilical hernia repairs performed during 2007–2015 was conducted at a tertiary care children’s hospital. Patients undergoing repairs as a single procedure for asymptomatic hernia were evaluated for post-operative complications by age, demographics, and co-morbidities. Results Of 308 umbilical hernia repairs performed, 204 were isolated and asymptomatic. Postoperative complications were more frequent in children < 4 years (12.3%) compared to > 4 years (3.1%, p = 0.034). All respiratory complications (N = 4) and readmissions (N = 1) were in children < 4 years. Conclusions Age of umbilical hernia repair in children varied widely even within a single institution, demonstrating that timing of repair may be a surgeon-dependent decision. Patients < 4 years were more likely to experience post-operative complications. Umbilical hernias often resolve over time and can safely be monitored with watchful waiting. Formal guidelines are needed to support delayed repair and prevent unnecessary, potentially harmful operations.
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An Umbilical/Paraumbilical Hernia as a Sign of an Intraabdominal Malignancy in the Elderly
Article
Full-text available
  • Apr 2014
Unlabelled: The umbilical area can present with a variety of signs associated with an intra abdominal malignancy. An umbilical/paraumbilical hernia might itself be a sign of an internal malignancy. The correlation between the presence of an umbilical/paraumbilical hernia and an intra abdominal malignancy has been previously based only on case reports. The aim of the study was to evaluate the significance of an umbilical/paraumbilical hernia as a symptom of an intraabdominal malignancy. Material and methods: A retrospective analysis was performed; review of the medical records of 145 patients (113 female and 32 male; mean age 66.4±11.9) with an umbilical/paraumbilical hernia treated during the period of 2005-2013. Twenty-three patients (15.9%) were diagnosed with an intra abdominal malignancy; 34% were in the age group over 75 years of age. Results: The most common malignancies were: colorectal cancer, followed by pancreatic cancer, and cancers of the adnexa and kidneys. The patients with a concomitant malignancy identified were significantly older than those without a malignancy. In 65% of patients, the diagnosis was made postoperatively. Logistic regression analysis demonstrated that age, the presence of preoperative symptoms, anemia, and weight loss were independent risk factors for concomitant abdominal cancer. Conclusion: The findings of this study support intensive preoperative diagnostic evaluation of elderly patients that are qualified for surgery for an umbilical/paraumbilical hernia. This is particularly important because most of these patients had a small/medium hernia orifice, which did not allow for accurate manual abdominal exploration. Currently, the routine preoperative diagnostic evaluation is often insufficient for an accurate diagnosis.
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Strangulated paraumplical hernia - An unusual complication of a Meckel’s diverticulum
Article
Full-text available
  • Feb 2012
Meckel's diverticulum is the commonest congenital abnormality of the gastrointestinal tract. Most are asymptomatic but can rarely present with varies forms of intestinal obstruction. We present an unusual case of an elderly African woman with a massive strangulated paraumbilical hernia as a complication from a Meckel's diverticulum. Meckel's diverticulum presenting as a strangulated paraumbilical hernia is uncommon and can be difficult to diagnose. It is often only found intraoperatively. Delay in referral due to poor access can potentially lead to adverse outcome. Although uncommon, a through clinical assessment is of paramount importance and timely operative intervention must occur in order to provide the best outcome for these patients.
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Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: A hospital-based study
Article
Full-text available
  • Jul 2011
  • Hernia
Abdominal wall hernias are a common imaging finding in the abdomen. Ultrasonography (US) is noninvasive and allows the examination of the patient in a physiological manner. High-frequency annular US probes have become an increasingly important diagnostic tool for detecting pathological lesions in superficial organs. To determine the prevalence of paraumbilical hernias among adult patients by abdominal sonography in a tertiary care hospital and to describe the sonographic technique and findings. During the 2-year period between January 2008 and December 2009, we performed high-resolution US of the anterior abdominal wall on 302 patients who were referred for different reasons other than the examination of the anterior abdominal wall. The images were taken by a radiologist with 12 years of experience in US, and the images were reviewed by three consultant radiologists with expertise in body imaging. A total of 302 patients [169 females (56.0%) and 133 males (44.0%)], ranging in age from 17 to 85 years, with a mean age of 53.5 years, were enrolled in the study. The number of positive cases among females was 42 (24.9%) and that among males was 31 (23.3%). High-resolution US is an efficient tool for detecting the presence of paraumbilical hernias and accurately verifying not only their content, but also the possible associated complications.
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Association between Age and Umbilical Hernia Repair Outcomes in Children: A Multistate Population-Based Cohort Study
Article
  • Nov 2019
  • J Pediatr
Objective: To evaluate whether patient age or other sociodemographic and clinical characteristics are associated with recurrence or unplanned related hospital revisits after pediatric umbilical hernia repair. Study design: We performed a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases of 7 states. Pediatric umbilical hernia repairs performed at any hospital or surgery center in 2010-2014 were included. Hernia recurrences and occurrences of unplanned and related hospital revisits within 30 days were evaluated. Results: Of 9809 included patients, 52.0% were female and 50.5% were black. The 3-year hernia recurrence rate was 0.57% (95% CI 0.42, 0.73). In multivariable analysis, the recurrence rate was higher in children <4 years of age than in children 4-10 years of age (hazard ratio [HR] 1.93, 95% CI 1.09, 3.44). Unplanned related hospital revisits within 30 days occurred in 2.5% of patients. Patient characteristics associated with the risk of an unplanned related hospital revisit included age <4 years (HR 2.17, 95% CI 1.70, 2.77) or >10 years (HR 2.11, 95% CI 1.46, 3.05), public insurance (HR 2.10, 95% CI 1.58, 2.79), asthma (HR 1.74, 95% CI 1.32, 2.29), and initial presentation to the emergency department (HR 2.46, 95% CI 1.08, 5.61). Conclusions: Rates of recurrence and unplanned related hospital revisits following pediatric umbilical hernia repair are higher in children younger than 4 years of age. These findings support delaying the repair of asymptomatic umbilical hernia in children until 4 years of age.
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Appendicitis within the contents of an incarcerated paraumbilical hernia
Article
  • Aug 2019
A 30-year-old woman known to have a paraumbilical hernia presented with central abdominal pain and vomiting. On examination, she was tender around the umbilical area, and a lump was felt on the umbilicus with associated skin changes. A CT scan was performed which showed an inflamed appendix within an incarcerated paraumblical hernia.
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Low risk, but not no risk, of umbilical hernia complications requiring acute surgery in childhood
Article
  • Dec 2013
  • J Paediatr Child Health
Umbilical hernias are a common finding in the paediatric community, with a preponderance to affect Afro-Caribbean and premature children. The rate of incarceration varies greatly between populations. Therefore, it is valuable to obtain some Australian data on this topic. We undertook a retrospective study of the records of all patients who underwent umbilical hernia repair over a 12-year period of between October 1999 and May 2012 at Princess Margaret Hospital. From this group, all patients that had an umbilical hernia repair for reason of acute complication were identified and analysed for age, ethnicity and co-morbidities. Between October 1999 and May 2012, 433 umbilical hernias were repaired at Princess Margaret Hospital, five of which were as the direct result of an acutely complicated umbilical hernia. The mean age of hernia repair was 5 years old, and the mean age of acute complication was 5 years old. Out of the patients with acutely complicated umbilical hernia, there were no Afro-Caribbean patients, and one was premature complicated by hyaline membrane disease and broncho-pulmonary dysplasia. Western Australia has an incidence of acutely complicated umbilical hernia requiring operative intervention of 1:3000 to 1:11 000. On an international scale, this is low, and studies with similar incidence do not advocate for immediate repair of all identified umbilical hernias. The authors believe repair should be guided by patient and guardian, but if there is an episode of incarceration, acute repair is advised.
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Pediatric Abdominal Wall Defects
Article
  • Oct 2013
This article reviews the incidence, presentation, anatomy, and surgical management of abdominal wall defects found in the pediatric population. Defects such as inguinal hernia and umbilical hernia are common and are encountered frequently by the pediatric surgeon. Recently developed techniques for repairing these hernias are aimed at improving cosmesis and decreasing pain while maintaining acceptably low recurrence rates. Less common conditions such as femoral hernia, Spigelian hernia, epigastric hernia, lumbar hernia, gastroschisis, and omphalocele are also discussed. The surgical treatment of gastroschisis and omphalocele has undergone some advancement with the use of various silos and meshes.
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