Background
Umbilical hernias account 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, [2] multiple pregnancies, and large abdominal tumors) contribute to the development of umbilical hernias. [3]
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. [4]
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%). [5] Complications such as irreducibility, obstruction, strangulation, skin ulceration, and rupture are more common in paraumbilical hernias than in other abdominal hernias.
Indications
All adult umbilical hernias should be repaired, owing to the high risk of complications. [3] Indications for operative repair include the following:
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Pain
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Incarceration
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Strangulation
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Defect larger than 1 cm
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Skin ulceration
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Hernia rupture
Incarceration or strangulation is a particular concern in pregnant patients. [6]
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.
Contraindications
Cirrhosis and uncontrolled ascites have been considered 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, [7] 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. [8]
In a study examining the outcomes of elective and emergency umbilical hernia repair in veterans with cirrhosis, Shahait et al found that emergency surgery yielded worse outcomes, suggesting that diagnosis should be followed by medical optimization and elective repair in many cases. [9] A study by Snitkjaer et al cited similar findings regarding emergency vs elective repair in cirrhotic patients. [10]
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.
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. [5] Ascites should be controlled with medical management, diuretics, and dietary changes before elective repair.
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%). [11] 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%. [12]
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.
In a propensity score–matched (age, sex, body mass index [BMI]) multicenter study that assessed mesh repairs (n = 590) and suture repairs (n = 590) for small umbilical hernias (≤1 cm in diameter), rates of pain on the Numerical Rating Scale-11 (1.1% for mesh repair, 2.6% for suture repair) and surgical-site occurrences (2.2% for mesh repair, 1.4% for suture repair) were similar at the 30-day follow-up. [13] At the 2-year follow-up, the mesh repair group had fewer reoperated recurrences (0.2% vs 1.7%) and no more pain or discomfort than the suture repair group.
A study using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database demonstrated decreased overall morbidity in laparoscopic umbilical hernia repair as compared with open repair. [14] 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. [15] 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%.
In a systematic review and meta-analysis aimed at comparing the outcomes of laparoscopic repair of umbilical and paraumbilical hernias with those of open repair, Hajibandeh et al found that laparoscopic repair appeared to be associated with reductions in wound infection, wound dehiscence, recurrence rate, and length of stay, albeit at the cost of a longer operating time. [16] They noted, however, that the best available evidence was of only moderate quality and that selection bias was a concern, given that most of the studies examined were nonrandomized.
