CORRESPONDENCE
1258
REFERENCES 1. Soucy P, Bass J, Evans M: The muscle-sparing thoracotomy in infants and children. J Pediatr Surg 26:1323-1325, 1991 2. Goh DW, Brereton RJ: Thoracotomy through the triangle of auscultation in neonates. J Thorac Cardiovasc Surg (in press)
3. Goh DW, Brereton RJ: Success and failure with neonatal trachea-oesophageal anomalies. Br J Surg 78834~837,1991
To the Editor:
the examination. This produced a desired effect and the hernia was clearly noted. Our office long ago gave up handing out balloons as gifts for children because of the risk of aspiration and airway occlusion. We now, however, have a smaller quantity of balloons available to help the surgeons detect inguinal hernias.
I have always chosen not to operate for inguinal hernia unless I could definitely detect a mass on examination. This is often difficult to do in young children. In infants one can examine the ears to induce screaming; but in the toddler, it is hard to think of maneuvers that will increase intraabdominal pressure. Somehow or other they just won’t cough. A mother recently introduced me to the balloon test. She knew that the hernia might not reveal itself on examination, so she brought with her a balloon and had the child blow this up during
To the Editor: Congenital lumbar hernia is rare and is said to be one of the rarest of abdominal parietal hernias.’ Its association with ipsilatera1 congenital inguinal hernia and proximal jejunal pancreatic heterotopia, to the best of our knowledge, has not been reported. A male infant born following an uneventful pregnancy and labour was noted to have easily reducible right flank protrusion and a right inguinal bulge soon after birth (Fig 1). Both these lesions tended to become tense and larger in the erect position, had impulse on crying and were tympanic to percussion. Examination proved them to be congenital right inferior lumbar and inguinal hernias. Plain abdominal x-ray showed intestinal gas pockets in the right flank and scrotum with hemivertebra of Lz. Chest radiograph was normal except for hemivertebra of T5. Ultrasound confirmed intestinal loops as contents of these hernias. As the size was increasing and parents were very apprehensive, high ligation of
Michael D. Klein Children’s Hospital of Michigan Detroit, MI
inguinal hernia and Dowd’s fascial flap repair* of inferior lumbar hernia were performed at the age of 1 month. At the time of surgical repair of lumbar hernia, a well defined, 2.5cm fascial defect was found at the level of inferior lumbar triangle. Ileocecal region with appendix was found as content of this hernial sac and an incidental appendectomy was carried out. Postoperative period was uneventful except for a small stich abscess. Two months following surgery, the infant was readmitted with features of acute intestinal obstruction and, at exploration, an adhensive omental band obstruction of terminal ileum was found with the band attached to the mesoappendix ligature. Incidentally, a nodular elevated mass lesion was found in the proximal jejunum subserosally over the antimesenteric border, which was excised. Histological examination proved it to be heterotopic pancreatic tissue. Congenital hernias in the lumbar region are quite rare and may occur in two locations. Superior lumbar triangle (GrynfeltLesshaft) and inferior lumbar triangle (Petit), the former being more common than the latter and only 30 cases have been reported in the world literature.3,4 Acquired lumbar hernias outnumber congenital hernias by 10 to 15. Previously published materials suggest an association between congenital lumbar hernias and lumbocostal vertebral deficiency syndrome$ the present case had two additional congenital lesions in the neonatal period, which lends support to congenital origin also. We recommend early operative repair, because the hernial defect may enlarge with growth, making primary closure with surround tissue difficult.’ However, we feel that incidental appendectomy should be avoided, at least in neonates, even if the appendix is the content of the sac, to avoid postoperative wound infection and adhesive intestinal obstruction. M.H. Mehta R.T/ Pate1 S.G. Mehta KT Children Hospital Gujarat, India
.,._ . . Fig 1.
lpsilateral lumbar and inguinal hernias in an infant.
REFERENCES 1. Talukdar BC: Congenital 9:419-420. 1974
lumbar hernia. J Pediatr Surg
2. Dowd CN: Congenital lumbar hernia at the triangle of Petit. Ann Surg 45:245-248,1907
1258
REFERENCES 1. Soucy P, Bass J, Evans M: The muscle-sparing thoracotomy in infants and children. J Pediatr Surg 26:1323-1325, 1991 2. Goh DW, Brereton RJ: Thoracotomy through the triangle of auscultation in neonates. J Thorac Cardiovasc Surg (in press)
3. Goh DW, Brereton RJ: Success and failure with neonatal trachea-oesophageal anomalies. Br J Surg 78834~837,1991
To the Editor:
the examination. This produced a desired effect and the hernia was clearly noted. Our office long ago gave up handing out balloons as gifts for children because of the risk of aspiration and airway occlusion. We now, however, have a smaller quantity of balloons available to help the surgeons detect inguinal hernias.
I have always chosen not to operate for inguinal hernia unless I could definitely detect a mass on examination. This is often difficult to do in young children. In infants one can examine the ears to induce screaming; but in the toddler, it is hard to think of maneuvers that will increase intraabdominal pressure. Somehow or other they just won’t cough. A mother recently introduced me to the balloon test. She knew that the hernia might not reveal itself on examination, so she brought with her a balloon and had the child blow this up during
To the Editor: Congenital lumbar hernia is rare and is said to be one of the rarest of abdominal parietal hernias.’ Its association with ipsilatera1 congenital inguinal hernia and proximal jejunal pancreatic heterotopia, to the best of our knowledge, has not been reported. A male infant born following an uneventful pregnancy and labour was noted to have easily reducible right flank protrusion and a right inguinal bulge soon after birth (Fig 1). Both these lesions tended to become tense and larger in the erect position, had impulse on crying and were tympanic to percussion. Examination proved them to be congenital right inferior lumbar and inguinal hernias. Plain abdominal x-ray showed intestinal gas pockets in the right flank and scrotum with hemivertebra of Lz. Chest radiograph was normal except for hemivertebra of T5. Ultrasound confirmed intestinal loops as contents of these hernias. As the size was increasing and parents were very apprehensive, high ligation of
Michael D. Klein Children’s Hospital of Michigan Detroit, MI
inguinal hernia and Dowd’s fascial flap repair* of inferior lumbar hernia were performed at the age of 1 month. At the time of surgical repair of lumbar hernia, a well defined, 2.5cm fascial defect was found at the level of inferior lumbar triangle. Ileocecal region with appendix was found as content of this hernial sac and an incidental appendectomy was carried out. Postoperative period was uneventful except for a small stich abscess. Two months following surgery, the infant was readmitted with features of acute intestinal obstruction and, at exploration, an adhensive omental band obstruction of terminal ileum was found with the band attached to the mesoappendix ligature. Incidentally, a nodular elevated mass lesion was found in the proximal jejunum subserosally over the antimesenteric border, which was excised. Histological examination proved it to be heterotopic pancreatic tissue. Congenital hernias in the lumbar region are quite rare and may occur in two locations. Superior lumbar triangle (GrynfeltLesshaft) and inferior lumbar triangle (Petit), the former being more common than the latter and only 30 cases have been reported in the world literature.3,4 Acquired lumbar hernias outnumber congenital hernias by 10 to 15. Previously published materials suggest an association between congenital lumbar hernias and lumbocostal vertebral deficiency syndrome$ the present case had two additional congenital lesions in the neonatal period, which lends support to congenital origin also. We recommend early operative repair, because the hernial defect may enlarge with growth, making primary closure with surround tissue difficult.’ However, we feel that incidental appendectomy should be avoided, at least in neonates, even if the appendix is the content of the sac, to avoid postoperative wound infection and adhesive intestinal obstruction. M.H. Mehta R.T/ Pate1 S.G. Mehta KT Children Hospital Gujarat, India
.,._ . . Fig 1.
lpsilateral lumbar and inguinal hernias in an infant.
REFERENCES 1. Talukdar BC: Congenital 9:419-420. 1974
lumbar hernia. J Pediatr Surg
2. Dowd CN: Congenital lumbar hernia at the triangle of Petit. Ann Surg 45:245-248,1907
