From the Guidelines
The recommended approach for an obstructed umbilical hernia repair where toxic fluid is encountered during dissection is option C, Repair with mesh. When toxic or contaminated fluid is discovered during hernia repair, this indicates potential bowel compromise, however, the absence of intestinal wall ischaemia makes patients less prone to bacterial translocation, as stated in the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. According to the study by Abd Ellatif et al., mentioned in the guidelines, mesh hernioplasty is crucial to prevent recurrence and that it is safe for repairing acutely incarcerated hernias, with low rates of wound infection (4.3%) and recurrence (4.3%) 1. Some key points to consider in this scenario include:
- The use of mesh in hernia repair has been shown to have advantages, including low rate of long-term complications and reduction of recurrence 1.
- A prospective randomized trial by Abdel-Baki et al. compared the use of mesh repair and tissue repair in 42 cases with acute para-umbilical hernia, and found no statistically significant difference in wound infection rate between the two groups, and a significant reduction in recurrence rate in the mesh repair group 1.
- Anatomical repair (option B) may not provide the same level of reinforcement as mesh repair, and Mayo repair (option A) and tension sutures (option D) may cause excessive tension or tissue ischemia, leading to poor wound healing. Therefore, based on the most recent and highest quality evidence, repair with mesh (option C) is the recommended approach for an obstructed umbilical hernia repair where toxic fluid is encountered during dissection.
From the Research
Umbilical Hernia Repair
During obstructed umbilical hernia repair, the presence of toxic fluid indicates a potentially contaminated field, which increases the risk of infection and recurrence.
- The use of mesh in umbilical hernia repair has been shown to decrease recurrence rates, even in small hernias 2.
- Mesh reinforcement is recommended for umbilical hernia repair, as suture repairs have high recurrence rates 3.
- The use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm is superior, even in certain emergency situations 4.
- In the presence of toxic fluid, a mesh repair may be preferred to reduce the risk of recurrence and infection.
Repair Options
Considering the options provided:
- A. Mayo repair: This is a type of suture repair, which may not be the best option in the presence of toxic fluid due to the high risk of recurrence.
- B. Anatomical repair: This type of repair may not provide adequate reinforcement in the presence of toxic fluid.
- C. Repair with mesh: This is the recommended option, as it provides reinforcement and reduces the risk of recurrence and infection.
- D. Tension suture: This type of repair may not be suitable in the presence of toxic fluid, as it can lead to high recurrence rates.
Recommendation
Based on the available evidence, the recommended type of repair in the presence of toxic fluid during obstructed umbilical hernia repair is: