From the Guidelines
Surgical repair of umbilical hernias in patients with ascites is recommended due to the high risk of complications, including ulceration, incarceration, strangulation, and rupture, with mortality rates ranging from 60-88% with non-operative management 1.
Umbilical Hernia Management
Umbilical hernias are a common complication in patients with ascites, with an incidence of 16% in cirrhotic patients and 24% in those with ascites 1. The management of umbilical hernias in these patients is crucial to prevent complications and reduce morbidity and mortality.
- Key factors associated with mortality in hernia repair include emergency surgery, Child-Pugh-Turcotte class C, American Society of Anaesthesiologists (ASA) score ≥3, and MELD score ≥20 1.
- A recent retrospective series of 102 patients who underwent surgical repair of umbilical hernias in the presence of ascites reported morbidity and mortality rates of 37.2% and 3.9%, respectively 1.
- Optimizing management of ascites, including large volume paracentesis (LVP) and transjugular intrahepatic portosystemic shunt (TIPSS) perioperatively, can reduce the risk of wound dehiscence and recurrence of hernia 1.
Surgical Approach
The standard treatment for umbilical hernias in adults is umbilical herniorrhaphy, which involves pushing the protruding tissue back into place and closing the abdominal wall defect, often using mesh reinforcement 1.
- The use of mesh in hernia repair is safe and effective, with low rates of wound infection, mesh infection, and recurrence 1.
- A prospective study of 202 patients with acutely incarcerated groin hernias reported extremely low rates of wound infection, mesh infections, and recurrence with the use of mesh 1.
From the Research
Umbilicus Hernia Overview
- Umbilical hernias are common and surgery is often indicated in symptomatic patients 2
- The size of umbilical hernia defects can vary from small to large and complex, requiring tailored treatment options 2
Treatment Options
- Open, laparoscopic, and robotic options are available for umbilical hernia repair, each with its advantages and disadvantages 2
- The use of mesh in repair has been shown to decrease recurrence rates, even in small hernias 2
- A transumbilical repair technique has been developed, which involves a longitudinal incision in the umbilicus and closure of the fascial defect 3
Surgical Techniques
- Laparoscopic-assisted, open umbilical hernia repair is a technique that combines the benefits of open and laparoscopic approaches 4
- This technique involves a standard periumbilical incision, open dissection of the hernia, and closure of the fascial defect with laparoscopic intraperitoneal onlay mesh fixation 4
- A study found that this technique resulted in no recurrences and favorable outcomes, including in patients with recurrent hernias 4
Comparison of Surgical Approaches
- A study compared two surgical approaches for incarcerated and strangulated inguinal hernia: preperitoneal hernioplasty through the lower abdominal median incision and laparoscope (TAPP) 5
- The study found that TAPP had better comfort and faster recovery, with reduced acute pain, shorter hospital stay, and earlier return to normal activities 5
- Another study compared emergent laparoscopic and open repair of acutely incarcerated and strangulated hernias, finding that laparoscopic repair had better short- and long-term results 6