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Anatomy; Umbilical hernia; Senegalese children; Redundant umbilical skin

Abbreviations

RUS: Redundant Umbilical Skin; UH: Umbilical Hernia

Introduction

Umbilical Hernias (UH) have long been of interest to health professionals and researchers due to their impact on quality of life and aesthetics [1]. The umbilicus marks the origin of our lineage, a lasting scar and a symbol of life itself. As the first anatomical imprint of our intrauterine existence, it carries both physiological and symbolic significance. This intimate and personal structure results from the obliteration and retraction of four embryonic elements: the left umbilical vein, the urachus, and the two umbilical arteries. These structures gradually regress and transform into fibrous cords, anchoring to the inferior margin of the umbilical ring. Following birth and the clamping of the umbilical cord, the residual segment undergoes desiccation and eventually detaches, leaving behind the umbilical scar [2]. UH results from a delay or an abnormality in the closure of the umbilical musculoaponeurotic orifice [1]. The prevalence and characteristics of this condition vary according to factors such as age, sex, and ethnic background. Its incidence is reported at 42.5% in black children and 18.5% in caucasian children [2]. This condition is frequently encountered in African pediatric practice [1]. Although generally considered benign, studies reveal a higher incidence of complications associated with umbilical hernias in Africa [3]. Only a few studies have been done in Africa on the morphology of umbilical hernias in children [2]. Given the significant differences in prevalence and complication rates across populations, along with the scarcity of data in the literature regarding the specific characteristics of UH in children from sub-Saharan Africa, it remains challenging to establish appropriate and consensual medical protocols. A detailed analysis of the anatomical variations of UH could make a major contribution to understanding their morphological diversity and distribution within the African pediatric population. Such data would also be essential for developing evidence-based management strategies tailored to local contexts. This study aims to investigate the anatomical features of umbilical hernias in Senegalese children aged 1 to 24 months.

Patients and Methods

We conducted a descriptive and analytical prospective study over six months from March 2023 to august 2023, in the pediatric surgical units of Pikine National Hospital Center and Ziguinchor Regional Hospital. It involves senegalese patients living in Dakar and Ziguinchor, aged between 1 and 24 months. All children who came for pediatric surgery consultation were included unless they had a pathology that could distort the measurements. All measurements were taken by the same person to reduce inter-observer bias. The parameters studied were sociodemographic aspects (frequency, age, sex, geographical origin), clinical measurements of the umbilical hernia (average longitudinal and vertical diameters of the umbilical swelling, average diameter of the defect), umbilical morphology, ultrasound measurements of the defect (average longitudinal diameter, average vertical diameter), and Bivariate analysis (defect size and age class) (defect size measured clinically and by ultrasound). Anthropometric measurements were performed following standardized protocols to minimize measurement errors. Clinical measurements of the umbilicus and hernia neck were taken using a calibrated digital caliper (Figure 1,2) to ensure precision.

Figure 1: Digital caliper.

Figure 2: Measurement of longitudinal umbilical diameter.

Data were collected using a survey form and recorded in an Excel database. We processed and analyzed these data using appropriate statistical methods, including descriptive statistics (means, standard deviations, medians) and comparison tests between age groups using R software version 4.3.0. Correlation tests were performed with Pearson's chi-square test or Fisher's test according to their applicability conditions. Statistical significance was set at p-value <0.05.

Our study received authorization from our Institutional Ethics Committee, and informed consent was obtained from each patient's parents.

Results

This study collected 63 cases of umbilical hernia out of 125 children seen; corresponding to a frequency of 50.4% the mean age was 7.3 months. Infants less than 6 months were the most represented (63.5%), as reported in Table 1. The sex ratio was 1.2. The mean defect diameter measured during physical examination was 12.3 mm (Range 4-40 mm). For ultrasound measurements, the mean horizontal diameter was 13.5 mm (range 4-27 mm) and the mean vertical diameter was 13 mm (Range 4.7-20.2 mm). Table 2 shows the distribution of patients according to Lassaletta's classification with clinical measurements.

Table 1: Distribution of patients according to age group.

Table 2: Distribution of patients according to Lassaletta's classification.

Clinically, the mean horizontal (longitudinal) diameter of the umbilical swelling was 24.5 mm (Range: 10-58.6 mm), while the mean vertical diameter was 20 mm (Range: 6.8-50 mm). Fifty-three patients had redundant umbilical skin (RUS) (84.1%). The mean RUS was 21 mm (Range 5-53.6 mm). In Table 3, the appearance of the umbilicus according to Gandiaye classification is reported (Figure 3).

Table 3: Shape of the umbilical hernia accordind to Gandiaye classification

Figure 3: The different aspects of umbilical hernia. (A)Conical shape, (B) Ellipsoidal shape, (C) Ovoidal shape, (D) Spherical shape.

Bivariate analysis did not reveal any significant correlation between the size of the defect and age group (p > 0.05). Comparison between the clinical and ultrasonographic measurements of the umbilical defect diameter showed a statistically significant difference (p < 0.05).

Discussion

The incidence of umbilical hernias varies according to race and age. In Caucasians, it is estimated at 20% at birth and 5% at 6 years. It is more frequent in African children, where it is estimated between 25 to 58% [4,5]. According to several studies conducted in Africa [6,7,8,9], the prevalence of umbilical hernia may reach 50% in children from sub-Saharan Africa, consistent with the findings of our study, which reported a rate of 50.4%. This elevated prevalence may be attributed to genetic predisposition, in addition to common risk factors observed in the African population, including prematurity and low birth weight. The high prevalence of umbilical hernia in children, affecting nearly half of Senegalese children, raises questions about its pathological significance. It may be considered an evolving anatomical and physiological process of the umbilical region, with a course that varies depending on the individual, ethnic background, and certain contextual factors. In some children, spontaneous closure of the umbilical defect occurs early, while in others, it is delayed. In certain cases, the defect persists, becomes symptomatic, and ultimately acquires a pathological status. The incidence of umbilical hernia in children decreases with age [8]. Indeed, more than 2/3 of the patients in our study were under 6 months of age, and only 1/10 was older than 18 months. The age-based distribution of umbilical hernias shows an increased prevalence among the youngest age groups. This supports the hypothesis that the umbilical orifice may close spontaneously in the months following birth. At the time of diagnosis, initial monitoring of umbilical hernias is generally recommended to allow for the possibility of spontaneous closure of the defect [1].

Most authors report a male predominance, as was the case in our study, without a cause being identified [9-11].

Umbilical hernia in Sub-Saharan African children presents with a wide range of types, often with impressive defect diameters [1]. According to Lassaletta et al. [12], umbilical hernia defects are classified into three categories based on size. Our study highlights a predominance of medium-sized defects, followed by large defects. This finding is consistent with data from other African studies [13]. It is important to note that hernias with large or medium-sized defects are less likely to close spontaneously compared to those with small defects [6,9,14].

The amount of redundant skin is proportional to the size of the umbilical defect; the larger the defect, the greater the redundancy of the skin [13,16]. To improve the characterization of umbilical hernia morphology and associated skin redundancy, a recent classification, the Gandiaye classification, has been proposed. It defines four distinct types based on geometric shape: conical, ovoid, spherical, and ellipsoidal [13]. In the series reported by Ngom [13], as in our study, redundant umbilical skin was observed in most patients. This finding is associated with the predominance of conical, ellipsoidal, and ovoid shapes in our series, which are typically characterized by redundant umbilical skin. This may reflect a morphological trait specific to children of Sub-Saharan African origin.

Our study did not reveal any significant correlation between defect size and age group. This suggests a homogeneous distribution of defect sizes across the different age classes. Comparison between clinical and ultrasonographic measurements of the umbilical defect diameter revealed a statistically significant difference, highlighting the clinical measurements as a reliable tool in routine practice. Therefore, performing an ultrasound is not necessary for diagnosis or assessment of the defect. However, in cases of small umbilical hernias, diagnosis can be challenging, particularly in infants who do not tolerate examination well. It is essential to calm the child in order to detect a defect that is often not palpable with the fingertip [1]. In such cases, ultrasound may be required to confirm the diagnosis.

This preliminary study provides insight into the characteristics of the pediatric umbilicus and the various types of umbilical hernias encountered, along with their anatomical particularities, in Sub-Saharan African children. In African populations, symptomatic umbilical hernias and their often unsightly appearance, which may lead to social stigma, constitute a common source of parental concern. Therefore, it is essential to provide parents with reassurance and education regarding the various potential clinical courses, enabling a personalized approach to hernia management.

Study limitations

Nevertheless, our study has certain limitations, notably the lack of consideration of factors such as nutritional status, prematurity, as well as medical and environmental influences that may impact umbilical development. To address these limitations and further this work, a follow-up study will be conducted on the same patient cohort, with biannual evaluations of hernia progression, incorporating relevant clinical and environmental factors, and placing particular emphasis on the evolution of the defect.

Conclusion

Umbilical hernias in children are a very common condition in surgical practice in Africa. The high prevalence of umbilical hernia in children, affecting nearly half of Senegalese children, raises questions about its pathological significance. It may reflect an evolving anatomical and physiological process whose course varies with individual, ethnic, and contextual factors. While spontaneous closure occurs early in some cases, it may be delayed or persist, becoming symptomatic and pathological. We observed a predominance of hernias with medium to large defects, which are less likely to close spontaneously. Forms with redundant umbilical skin may reflect a distinctive morphological trait in Sub-Saharan African children.

Declarations

Funding

This study did not benefit from any funding.

Competing Interests

The authors declare that they have no competing interests.

Ethics Approval and Consent to Participate

This study complies with all the good clinical practices used in clinical research in accordance with the Declaration of Helsinki.

Consent for Publication

Authors declared taking informed written consent for the publication of clinical photographs/material, from the legal guardian of the patient with an understanding that every effort will be made to conceal the identity of the patient, however it cannot be guaranteed.

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