My method of operating is as follows: Avery small, arch-like incision is made above or below the umbilicus, not more than cm. distant from the umbilical tumor, around which it passes in the shape of a semicircle, half the circumference of the hernial neck being exposed and the little flap turned up. The other half of the hernial neck is loosened up with a blunt instrument, so that the entire neck may be placed between the blades of an open pair of artery clamps (Fig. 35a). The hernial sac is opened peripherally from the artery for ceps and near the skin; the top of the sac, which is always adherent to the skin, is left attached; the peritoneal margins are ligated with clamps; any contents that may be present are reduced, the sac is drawn tight, and the artery clamps which were applied first are closed (Fig. 25b). The sac is ligated peripherally from the clamp, the latter is taken off, and the hernial sac sutured over the ligature, either longitudinally or transversely. Large herniae, which are generally associated with a dias tasis of the rectus muscles, are treated by closing the raphc of the rectus muscles, turning down the skin flap and closing the skin wound with a few Michel clamps (Fig. 35c). The wound will heal in four days. In six months the cicatrix will be so far retracted, together with the umbilicus, as to be scarcely noticeable.
Extirpation of the umbilicus is in my opinion a grave error which violates the principles of conservative and cosmetic surgery. It can easily he dispensed with and prevents the unaesthetic appearance pro duced by absence of this cosmetically important part.
Ligation of the hernial sac, without opening it, involves great danger, because, as previously mentioned, a portion of the omentum, adhering to the top of the sac, may have been the cause of preventing spontaneous closure of the ring. Ligation would certainly cause it to adhere again and, besides, might induce a number of complications resulting from intestinal fixation in the hernial sac.
Complicated methods of closure (Biondi, Brenner, Bier) are needed only in extensive hernhe of older children and do not essentially differ from operations on adults, to which reference may here be made (Wullst ein).
The method described above is applicable to the youngest infant and can lie carried out in a few minutes. The inhalation of a few drops of ether while opening the peritoneum is sufficient to prevent prolapse of the intestines; in older children local anesthesia (novneain, 1 per cent.) is employed. The injury to the child is the least possible, the prognosis for the wound is more favorable on account of the few sutures employed, which are buried. The dressing is kept in place by a piece of adhesive plaster, which is applied over the sterile gauze covering the wound. To prevent the dressing getting wet or soiled, the child is placed on a frame which will be described in detail when dealing with inguinal hernia.
If necessary, this operation may be performed on out-patients, although I prefer to keep infants in the hospital until the clamps are removed on the fifth day.
The mortality is nil (in ninety-two eases), notwithstanding that many atrophic and poorly developed children were treated.
In small umbilical hernim the closure may be effected by injection of paraffin (Escherich), unless the diameter of the umbilical ring exceeds cm. In such eases the method is dangerous, owing to the possibility of paraffin flowing into the abdominal cavity, and cannot therefore be recommended non would the paraffin splint be able to retain more extensive hernife.
In raro cases children may have a small hernia in the linen, alba (Klausner). Generally, however, these are associated with a deformity in the umbilical region, and are likewise of congenital origin in so far that they are always associated with a congenital diastasis of the rectus muscles.
For their radical relief in children, it is sufficient to dissect out the hernial sac and to close with a purse-string suture any fascial gap that may be present.