Types:
1. Exomphalos.
2. Congenital U. H.
3. Umbilical hernia in infants and children
4. Adult U.H.
(1) EXOMPHALOS
Aetiology: Due to persistence of physiological hernia of the foetal life
Pathology:
Sac: Fold of peritoneum
Content:
1- Whole midgut ® exomphalos major. The cord attached below the mass.
2- Caecum, appendix ® exomphalos minor. (The cord end to the center of the sac)
- Covering: Amniotic membrane & Wharton's jelly.
- Descent: Directly anterior.
Treatment:
Immediate operation is done to prevent peritonitis which result from spread of infection through thin peritoneal covering.
(I) Exomphalos minor: The defect is less than 4 cm. It can be termed hrniation of umbilical cord. Ligation of what was thought to be umbilical cord may lead to transection of the intestine.
It is easy to excise the small sac and repair the defect of anterior abdominal wall in layers.
(II) Exomphalos major: It is difficult to reduce the content due to small sized coelomic cavity.
So, there are four techniques have been described
1. Non operative therapy.
Ä Indications:
· Premature infants with huge intact sac.
· Those who have other congenital anomalies and cann’t withstand surgery.
Ä Technique:
The intact sac is painted daily with discicating antiseptic solution. Granulisation grows from the periphery and subsequent ventral hernia can be treated later.
2. Skin flap closure:
· 1stly we cover the hernia by skin flap by undermined skin of the flanks.
· Then; if the baby survive ® the coelomic cavity will enlarge and reduction of the hernia and repair of the defect can be done later on.
3. Staged closure:
· The sac is excised and replaced by prosthetic material (Expanded polytetrafluro-ethelene or polyprolene mesh).
· The mesh is sutured to the edge of the excised sac by interrupted sutures.
· The top of the mesh is tied at its center with umbilical tape to perform permanent compression to push the intestine to the abdomen.
· At daily interval the mesh is opened under strict aseptic conditions the content is examined for infection and small of intestine part is reduced.
· The mesh is then tied at lower level and the cycle is repeated until the sac is flushed with the anterior abdominal wall. At this stage the closure can be easily done
4. Primary closure:
· It can be achieved by evacuation of the meconium, nasogastric suction and manual dilatation of the quadrants of abdomen. Monitoring of the intragastric pressure can prevent inferior undue vena caval compression.
F N.B. There is some debate as to whether gastrochisis represent a separate entity or is simply an exomphalos with ruptured membranes. This debate has little practical importance as the principles of treatment are similar.
(2) CONGENITAL UMBILICAL HERNIA
Rarely a fully developed umbilical hernia is present at birth due to intra-uterine epithelisation of small exomphalos.

(3) UMBILICAL HERNIA IN INFANTS AND CHILDREN
Aetiology : Weak umbilical scar acted upon by ­ I.A.P.
1- The defect is weak umbilical fascia of Piorier which is an extension of transversalis fascia at the umbilical region .
2- Increase I.A.P. mostly due to phimosis .
Pathology:
Sac: fold of peritoneum with wide neck.
Content: omentum, intestine.
Coverings: Stretched umbilical scar.
· Lax fascia of piorier. · Extra peritoneal fat.
· The fascia of Piorier undergoes condensation with the growth of the child and may lead to spontaneous cure.
Treatment:
(1) Expectant treatment: in small hernia less than 1/2 inch, only admit the tip of the little finger. We wait for spontaneous cure within 2 years.
(2) Surgical treatment:
Indications:
a- Big hernia. b- Failure of spontaneous closure in 2 years.
c- If strangulation occurs ( very rare)
The umbilicus is elevated by curved incision around umbilicus. Then do excision of the sac and repair of the defect.
FN.B. In expectant treatment; strapping is not preferred as it delays the
condensation of Piorier's fascia.

(4) Adult U.H. ( Para-umbilical H.)
Aetiology: Defect in the midline. Very rare to be true umbilical as the umbilical cicatrex is the strongest part in the cress-cross meshwork of linea alba .
Ÿ It is usually supra-umbilical as the previous meshwork is wider and more weak above than below .
Ÿ It may result in any case with increase intro-abdominal pressure So, it is more common in female due to repeated pregnancy.

Pathology:
Sac: - Fold of peritoneum with narrow neck, So, strangulation is common.
- Multiple loculation may occur.
- Adhesion may occurs at the fundus with the content.
Content: Omentum, transverse colon, intestine.
Covering: Skin, fascia, stretched linea alba.
Descent: Forward then downward when became big making skin fold liable to infection & ulceration.
Clinical Picture:
Usually female, women are affected five times more frequent than men. (female, fatty, forty, fertile)
The hernia can be felt with ease if it is protruded but reduction may be difficult due to adhesions at the fundus.
Treatment: (Surgical only) (Narrow neck ® common to strangulate):
1- Small hernia ® excision of the sac & repair of the defect.
2- Moderate H ® Mayo's repair = double breasting of the 2 edges.
3- Large hernia ® hernioplasty using synthetic mesh.
FN.B.: The sac here is opened at the neck due to adhesions at the fundus and multiple loculations.