Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Umbilical Hernia Repair

  • Author: Dana Taylor, MD, FACS; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Oct 19, 2015
 

Background

Umbilical hernias acccount for 10% of abdominal wall hernias.[1] Conditions that lead to increased intra-abdominal pressure and weakened fascia at the level of the umbilicus (eg, obesity, ascites, multiple pregnancies, and large abdominal tumors) contribute to the development of umbilical hernias.

Umbilical hernias are typically small with a narrow neck, a configuration that increases the risk of strangulation and incarceration. Omentum, small bowel, and colon can be found within the sac. A direct or true umbilical hernia consists of a symmetric protrusion through the umbilical ring and is seen in neonates or infants. Indirect umbilical (paraumbilical) hernias protrude above or below the umbilicus and are the most common type of umbilical hernia in adults.[2]

Infantile umbilical hernias result from failure of the umbilical ring to close. The umbilical cord structures fail to fuse with the umbilical foramen, therefore leaving a patent umbilical ring. In contrast, anterior abdominal wall defects such as gastroschisis and omphalocele result from disruption in the development of the abdominal wall structures. The distinction should be made between these two entities because of the difference in management. Umbilical hernias are managed with observation; these defects typically close by age 4 or 5 years. Any defects that persist beyond this age should undergo surgical repair.

The most common symptom of umbilical hernias is pain at the umbilicus (44% of cases). Other complaints include pressure (20%) and nausea and vomiting (9%).[3] Complications such as irreducibility, obstruction, strangulation, skin ulceration, and rupture are more common in paraumbilical hernias than in other abdominal hernias.

Next

Indications

All adult umbilical hernias should be repaired, owing to the high risk of complications. Indications for operative repair include pain, incarceration, strangulation, defect larger than 1 cm, skin ulceration, and/or hernia rupture.

With infantile umbilical hernias, parents should be reassured; these typically close spontaneously by age 5 years. If a hernia persists beyond this age or the defect is larger than 2 cm, operative repair is indicated.

Previous
Next

Contraindications

Cirrhosis and uncontrolled ascites are relative contraindications for elective open umbilical hernia repair. Owing to the increased surgical risk, elective repair is generally avoided in patients with Child-Pugh class B and C cirrhosis. In a literature review by McKay et al,[4] small retrospective studies showed decreasing morbidity and mortality in patients with ascites and cirrhosis, to 2.7% and 21%, respectively. A small retrospective single-institution study by Yu et al suggested that early elective umbilical hernia repair can be safely carried out in cirrhotic patients with minimally invasive aproaches and appropriate perioperative care.[5]

Unfortunately, no consensus exists on the timing of repair in patients with cirrhosis. However, it is recommended to obtain preoperative control of ascites via medical management or peritoneal drainage.

Previous
Next

Technical Considerations

Treatable conditions such as ascites and obesity should be addressed and treated in advance of elective repair. Obese patients should be counseled on weight loss before surgery. The mortality associated with repair in patients with uncontrolled ascites is reportedly 2%, and the recurrence rate is high.[3] Ascites should be controlled with medical management, diuretics, and dietary changes before elective repair.

Previous
Next

Outcomes

A nationwide prospective study of umbilical and epigastric hernias demonstrated that complications necessitating readmission included hematoma (46% of cases), seroma (19%), and pain (77%).[6] This study also found an overall rate of readmission rate of 5%, mostly due to the aforementioned complications. A retrospective analysis of 150 veterans found an overall recurrence rate of 6%, with 1.5% in the nonmesh group; this study also found an infection rate of 19%.[7]

Recurrence rates associated with primary tissue repair have been reported to range from 15% to 40%.[1] A systematic review and meta-analysis by Aslani and Brown[1] showed a 10-fold decreased risk of recurrence in mesh repair as compared with primary suture repair. An increased risk of recurrence is seen in obese patients and defects larger than 3 cm. Other factors associated with an increased recurrence rate include smoking and diabetes.

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database demonstrated decreased overall morbidity in laparoscopic umbilical hernia repair as compared with open repair.[8] Laparoscopic repair has been found to result in fewer complications, decreased length of stay, and decreased risk of recurrence. However, the disadvantages associated with laparoscopic surgery, such as increased cost, operating time, and the risk of a general anesthetic, should be considered.

In an analysis using NSQIP data to evaluate perioperative outcomes for three general surgery procedures, Zielsdorf et al found that the Model for End-Stage Liver Disease (MELD) score was predictive of an increased risk of postoperative complications after umbilical hernia repair.[9] For every 1-point increase over the mean MELD score (8.5), the risk of postoperative complications in patients who underwent umbilical hernia repair rose by 13.8%.

Previous
 
 
Contributor Information and Disclosures
Author

Dana Taylor, MD, FACS Assistant Professor of Surgery, University of Tennessee Health Science Center College of Medicine; Consulting Surgeon, University General Surgeons, PC

Dana Taylor, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Southeastern Surgical Congress, Eastern Association for the Surgery of Trauma, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Camille Blackledge, MD Resident Physician, Department of Surgery, University of Tennessee Health Science Center College of Medicine

Camille Blackledge, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

References
  1. Aslani N, Brown C J. Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis. Hernia. July 2010. 14:455-462.

  2. The Umbilical Hernia. Schumpelick V, Fitzgibbons R J. Recurrent hernia Prevention and treatment. Springer: Verlag Berlin Heidelberg; 2007. 359-364.

  3. [Guideline] Rodriguez JA, Hinder RA. Surgical management of umbilical hernia. Operative techniques in general surgery. 2004. 6:156-164. [Full Text].

  4. McKay A, Dixon E, Bathe O, Sutherland F. Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia. October 2009. 13:461-468. [Full Text].

  5. Yu BC, Chung M, Lee G. The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute. Ann Surg Treat Res. 2015 Aug. 89 (2):87-91. [Medline].

  6. Bisgaard T, Kehlet H, Bay-Nielsen M, et al. A nationwide study on readmission, morbidity, and mortality after umbilical and epigastric hernia repair. Hernia. May 3, 2011. 15:541-546. [Full Text].

  7. Farrow B, Awad S, Berger DH. More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical center. The American Journal of Surgery. November 2008. 196:647-651. [Full Text].

  8. Mason RJ, Moazzez A, Sohn HJ, Berne TV, Katkhouda N. Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database. Annals of Surgery. October 2011. 254:641-652. [Full Text].

  9. Zielsdorf SM, Kubasiak JC, Janssen I, Myers JA, Luu MB. A NSQIP Analysis of MELD and Perioperative Outcomes in General Surgery. Am Surg. 2015 Aug. 81 (8):755-9. [Medline].

  10. Harrell AG, Novitsky YW, Kercher KW, Heniford BT. Ventral Herniation in Adults. Yeo CJ, Dempsey DT, Klein AS, Pemberton JH, Peters JH, eds. Shackelford’s Surgery of the Alimentary Tract. 6th ed. Philadelphia: W.B. Saunders; 2007. Vol 1: Chapter 47 671-686. [Full Text].

  11. Muschaweck U. Umbilical and epigastric hernia repair. Surgical Clinics of North America. October 2003. 83 (5):1207-1221.

  12. Solomon TA, Wignesvaran P, Chaudry MA, Tutton MG. A retrospective audit comparing outcomes of open versus laparoscopic repair of umbilical/paraumbilical herniae. Surgical Endoscopy. May 2010. 24:3109-3112.

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.