**7.1. Umbilical hernia**

behind post reduction of hernia sac, such as hematomas and seromas. Henceforth, experts recommend placement of closed suction drainage; which by itself along with mesh will

The aim of enhanced recovery after surgery protocols is to improve outcomes, lower health cost, while harnessing the benefits by standardizing the medical care [59, 60]. Such protocols are evidence-based guidelines that include minimizing surgical trauma, post-operative pain, reduce complications, and improve outcomes by decreasing the expected length of hospital stay and fasten the patient recovery [61]. Such approach to patient care should be a multidisciplinary approach including surgeon, anesthesiologists or pain specialists, nursing staff, physical rehabilitation service, and most importantly patient cooperation [62, 63]. Patients who are followed with an enhanced recovery protocol will have the same discharge criteria but will reach these milestones sooner. This approach will usually contain 15–20 elements and will span through the full patient hospital stay; preoperatively, intra-operatively, and postoperatively (**Table 3**) [64]. Before surgery, patient education and counseling about current treatment options and best approach should be discussed. After that, a meticulous overview of the patient general health condition and management of any comorbidities such as renal, cardiac, or respiratory should be done. Intra-operatively prophylactic antibiotics are recommended

• Medical comorbidities optimization

• Avoid drains and nasogastric tube

• Early removal of urinary catheter

• Bowel preparation

• Antibiotic prophylaxis • Thermal regulation • Fluid maintenance

• Multimodal analgesia • Antiemetic prophylaxis

• Early mobilization

increase the risk of infection post-operatively [57, 58].

100 Hernia Surgery and Recent Developments

**6. Enhanced recovery after hernia surgery**

**Period Criteria**

Pre-operative • Patient education

Intra-operative • Thromboprophylaxis

**Table 3.** Main criteria for enhanced recovery after surgery protocol [66].

Post-operative • Enteral nutrition from day one post-operative

An umbilical hernia is usually seen in the pediatric population with an incidence of 10–30% at birth in infants of Caucasian ethnicity and higher in those of African-American ethnicity, for unknown reasons [1]. It is also more common in premature infants of all races, and some report a tendency for familial inheritance. While the cause is yet to be identified in most of the cases, an umbilical hernia usually will regress and close on its own by 2–3 years of age with less than 10% needing surgical intervention.

Meanwhile, umbilical hernias in adults have a different clinical presentation, most being acquired not congenital with a male to female ratio of 3:1. The adult-type umbilical hernia usually will need surgical intervention for it to close and usually are symptomatic at time of presentation. A typical presentation will be of an exquisitely tender peri-umbilical mass overlying the skin; long-standing untreated umbilical hernia might result in thinning of covering skin and ulceration due to pressure necrosis of the adjacent skin. While small umbilical hernias could pass unnoticed and discovered incidentally. This type of hernia is associated usually with recurrence in the setting of high intra-abdominal pressure. For this reason, surgical repair is offered for incarcerated hernia or a progressively symptomatic type [3, 11, 70].

### **7.2. Inguinal hernias**

Although the overall incidence of inguinal hernia in the pediatric population is low when compared with adults, the complication that might arise is almost the same. In the age group, bowel incarceration is incidence is low, but should this be the case, bowel infarction would happen within 2–3 hours. With bowel infarction, it is not uncommon to get testicular blood supply compromise leading to ischemic necrosis and testicular atrophy with an incidence around 9% according to some studies [71–73]. While in girls, ovarian torsion is reported to happen with inguinal hernia strangulation in about third of patients with incarcerated hernia that contain an irreducible ovary. For this reason, some experts recommend not to delay surgical intervention in this population [74].

### **7.3. Congenital diaphragmatic hernia**

The congenital diaphragmatic hernia is caused by a diaphragmatic defect resulting abdominal viscera herniating to the chest. It usually presents in the first few hours of life with respiratory distress so severe that it could be incompatible with life [75]. In many cases, this condition can be diagnosed in utero via ultrasound, and for those not diagnosed prenatally, this condition should be suspected in neonates with respiratory distress and absent breath sounds soon after delivery and can be easily diagnosed by chest X-ray [76]. Congenital diaphragmatic hernia complications are categorized into acute, and late-onset complications, the most serious acute complication is persistent pulmonary hypertension of the new born other complications include chylothorax, hemorrhage, and recurrent infection. Furthermore, the spectrum of late complications includes chronic respiratory disease, recurrent hernia, spinal/chest wall abnormalities, neurological, and gastrointestinal complications [77, 78].

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