Umbilical Hernia Repair 

Updated: Oct 03, 2019
Author: Dana Taylor, MD, FACS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS 

Overview

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.[2]

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.[3]

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%).[4] 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.[2] Indications for operative repair include the following:

  • Pain
  • Incarceration
  • Strangulation
  • Defect larger than 1 cm
  • Skin ulceration
  • Hernia rupture

Incarceration or strangulation is a particular concern in pregnant patients.[5]

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 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,[6] 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.[7]

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.[4] 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%).[8] 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%.[9]

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 (ACS) National Surgical Quality Improvement Program (NSQIP) database demonstrated decreased overall morbidity in laparoscopic umbilical hernia repair as compared with open repair.[10] 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.[11] 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.[12] 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.

 

Periprocedural Care

Preprocedural Evaluation

Umbilical hernias are typically diagnosed with a detailed history and physical examination. Patients generally complain of pain or a lump at the umbilicus. On physical examination, a protrusion at the umbilicus can be seen. Paraumbilical hernias are more common in women than in men. Findings are confirmed by palpating a fascial defect or by visualizing the hernia with increasing intra-abdominal pressure by straining. The fascial defect is usually smaller than the sac.

Computed tomography (CT) is not required but can be used to diagnose defects that are difficult to appreciate on physical examination.

Equipment

A general surgery tray with basic surgical instruments should be used. The type of mesh used is typically based on the individual surgeon's preference, but polypropylene or polytetrafluoroethylene (PTFE) mesh is a common choice.

Patient Preparation

Anesthesia

General endotracheal anesthesia or intravenous sedation with local anesthesia[13] can be used for open repair.

Positioning

The patient should be placed in the supine position with arms out at 90°.

Monitoring & Follow-up

Patients should be instructed to avoid heavy lifting for 2-4 weeks postoperatively. Obese patients should be counseled on strategies for weight management. Continued medical control helps to decrease the risk of recurrence in patients with ascites.

 

Technique

Approach Considerations

Hernia repair with mesh should be considered for patients with defects larger than 4 cm. The type of mesh to be used is selected on the basis of the surgeon's preference and experience. Open mesh repair of umbilical hernia appears to be associated with significantly lower recurrence rates than suture repair in adults.[14]  

Laparoscopic repair should be considered for obese patients, patients with defects larger than 4 cm, and patients with recurrent hernias. Robotic assistance has facilitated this approach.[15, 16, 17, 18]

Repair of Umbilical Hernia

The traditional Mayo repair consists of a vertical overlap with adjacent aponeurotic structures. A curvilinear transverse incision is made in a natural skin crease and should not exceed 180°. Additionally, an elliptical incision can be used for large hernias that require excision of excess skin.

With a fine-tipped instrument and electrocautery, abundant skin overlying the hernia is excised to clear fat from the hernia sac and to clear the abdominal wall circumferentially from the edges of the defect.

The incision in the aponeurosis is extended longitudinally on either side of the hernia defect. The hernia sac is encircled and excised from the edges of the fascia. The sac is transected from the base of the umbilicus. The contents of the hernia sac are reduced, and the sac is opened to allow inspection of the contents. All adhesions and scar tissue are lysed.

The contents are inspected for viability, and any compromised adherent omentum is resected.

The peritoneum is closed with an absorbable running suture. Flaps of fascia are raised off the peritoneum and overlapped with a 3-cm overlap. The flaps are closed with a monofilament nonabsorbable or long-acting absorbable 0 horizontal mattress suture. Relaxing incisions are placed 5 cm lateral to the defect. The overlying fascia is fixed to the anterior abdominal wall, and the umbilicus is inverted by fixing the undersurface to the fascia.

For defects larger than 4 cm, a mesh onlay, sublay, or underlay should be used. Sublay mesh should be placed between the rectus muscle and the posterior sheath. For a mesh underlay, adhesions to the peritoneum should be excluded. Nonabsorbable 0 sutures are used to secure the mesh to the anterior abdominal wall.

The peritoneum is then closed with interrupted or running absorbable suture. The undersurface of the umbilicus is fixed to the fascia. If large skin flaps have been raised, the subcutaneous space can be closed with absorbable suture or closed suction drains.

The wound is then closed with a running subcuticular suture. The onlay mesh is sutured to the fascia above the peritoneum with a 3-cm overlap on all sides.

The use of a tentacle-shaped mesh implant (with a central body and integrated radiating arms at its edge) for fixation-free repair of umbilical hernias has been described.[19]

Complications

Potential complications of umbilical hernia repair include the following (see Outcomes):

  • Seroma
  • Hematoma
  • Wound infection
  • Bowel injury
  • Paralytic ileus
  • Hernia recurrence

A retrospective study by Shankar et al identified the following factors as predictors of umbilical hernia recurrence[20] :

  • Ascites
  • Liver disease
  • Diabetes
  • Obesity
  • Primary suture repair without mesh

A study by Donovan et al (N = 979) found the following factors to be predictive of recurrence after open umbilical hernia repair[21] :

  • Higher body mass index (BMI)
  • Concurrent laparoscopic inguinal hernia repair
  • Current smoking
  • Diabetes
  • Primary closure repair of hernias ≥1.5 cm
  • Postoperative infection