From the Guidelines
The best approach for an obstructed umbilical hernia repair where toxic fluid is encountered during dissection is to use a biological mesh for repair, as recommended by the most recent guidelines 1. When toxic or contaminated fluid is discovered during hernia repair, this indicates potential bowel compromise and contamination of the surgical field. In this situation, a synthetic mesh repair should be avoided due to the high risk of mesh infection in a contaminated field. The use of biological mesh is recommended for stable patients with strangulated hernia with bowel necrosis and/or gross enteric spillage during intestinal resection (contaminated, CDC wound class III) or peritonitis from bowel perforation (dirty surgical field, CDC wound class IV), when the size of the defect is small (< 3 cm) and direct suture is not feasible 1. Some key points to consider in this scenario include:
- Thorough irrigation of the contaminated area with warm saline
- Debridement of any necrotic tissue
- Assessment of bowel viability with resection if necessary
- The choice between a cross-linked and a non-cross-linked biological mesh should be evaluated depending on the defect size and degree of contamination 1
- If biological mesh is not available, either polyglactin mesh repair or open wound management with delayed repair may be a viable alternative 1
- Postoperatively, broad-spectrum antibiotics should be continued, and the patient should be monitored closely for signs of infection or recurrence. It's also important to note that the most recent study on this topic, published in 2023, highlights the importance of using biological meshes in contaminated fields, with lower rates of hernia recurrence, higher resistance to infections, and lower risk of displacement compared to synthetic meshes 1.
From the Research
Umbilical Hernia Repair Techniques
When toxic fluid comes out during dissection in an obstructed umbilical hernia repair, the choice of repair technique is crucial. The following techniques are considered:
- Mayo repair: This technique is one of the most common methods used to repair incisional, umbilical, and epigastric hernias 2. However, it has been associated with a high percentage of recurrences.
- Anatomical repair: There is limited information available on the use of anatomical repair for umbilical hernias in the context of toxic fluid discharge.
- Repair with mesh: Studies have shown that mesh repair is associated with a lower risk of recurrence compared to suture closure 3, 4, 5. Mesh repair has been recommended for umbilical hernias, especially for larger defects.
- Tension suture: There is no specific information available on the use of tension suture for umbilical hernia repair in the context of toxic fluid discharge.
Recommendations Based on Evidence
Based on the available evidence, repair with mesh is the recommended technique for umbilical hernia repair, especially when toxic fluid is present during dissection 3, 4, 5. This is because mesh repair has been shown to reduce the risk of recurrence and is suitable for larger defects. The use of mesh in elective repair of umbilical hernia has been associated with a lower risk of recurrence compared to suture closure 4.
Considerations for Hernia Size and Mesh Placement
The size of the hernia is an important consideration for mesh placement. While some studies suggest that mesh placement is most commonly recommended for hernias larger than 2.0 cm 6, others have found that hernia size is not an independent predictor of recurrence 6. However, in the context of toxic fluid discharge, the use of mesh is likely to be beneficial in reducing the risk of recurrence and promoting healing.