CONGENITAL UMBILICAL HERNIA.—In this variety the contents can often be seen through the hernial coverings, owing to the thinness of the layers. The hernia, though usually very small, is sometimes quite large from the first, and contains the greater part of the abdom inal organs.
Strangulation may occur at the neck through compression of the surrounding tissues, but it has also been caused trau matically by means of the cord applied around the funis at birth, leading to a fatal issue if much intestine is involved.
A acal fistula results if but a small por tion of gut is lost.
Treatment.— Immediate reduction should be practiced if possible, and re tention of intestine insured by the appli cation of adhesive strips over a small pad placed over the opening. Many surgeons advise the immediate closure of the edges of the ring by catgut sutures. The oper ation is simple and effective.
An operation for the radical cure of umbilical hernia is performed as follows: 1. Transverse elliptical incisions are made surrounding the umbilicus and hernia: this is deepened to the base of the hernial protrusion. 2. The surfaces of the aponeurotic structures are care fully cleared an inch and a half in all directions from the neck of the sac. 3. The fibrous and peritoneal coverings of the hernia are divided in a circular man ner at the neck, exposing its contents. If intestinal viscera are present, the ad hesions are separated and made. The contained omentum is ligated and removed with the entire sac of the hernia. 4. With forceps the of
the ring are grasped and approximated: whichever way the overlapping is more easy of accomplishment suggests the di rection of closure. 5. For this approxi mation an incision is made through the aponeurotie and peritoneal structures of the ring. extending one inch or more tran&versely to each side, and the peri toneum is separated from the under sur face of the upper of the two flaps thus formed. 6. Beginning from one to one and one-half inches above the margin of the upper flap, three or four silver wire mattress sutures are introduced, the loop firmly grasping the upper margin of the lower flap; sufficient traction is made on these sutures to enable peri toneal approximation with running su ture of catgut. The mattress sutures are then drawn into position, sliding the entire lower flap into the pocket previ ously formed between the aponeurosis and the peritoneum above. 7. The free margin of the upper flap is fixed by catgut sutures to the surface of the aponeurosis below, and the superficial incision closed in the usual manner. The later approximation is carried out by sliding one side under the other in the same In the larger hernia. the incision through the fibrous coverings of the sac may he made somewhat above the base, thereby increasing the amount of tissue to be used in the overlapping process. W. J. Mayo (Annals of Sur gery. Aug.. 1901).