From the Guidelines
The recommended approach for an obstructed umbilical hernia repair where toxic fluid is encountered during dissection is repair with a biological mesh (option C). When toxic or contaminated fluid is found during hernia repair, this indicates potential bowel compromise and contamination of the surgical field. In such contaminated cases, the use of a biological mesh is recommended as it becomes vascularized and remodelled into autologous tissue after implantation, offering a low-morbidity alternative to prosthetic mesh products in these complex settings, with good results also in immune-compromised patients 1. 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. Some key points to consider in this scenario include:
- The high infection rates associated with the use of polypropylene mesh in contaminated fields 1
- The potential for biological meshes to provide a collagen-based extracellular matrix scaffold for host fibroblasts to induce angiogenesis and deposit new collagen 1
- The importance of considering the species of origin, type of collagen matrix utilized, decellularization process, presence or absence of cross-linkage, and other factors when selecting a biological mesh 1
- The need for careful patient selection and consideration of factors such as BMI, defect size, and number of biological meshes used to minimize the risk of bulge and recurrence 1
- The potential benefits of using biological meshes in contaminated fields, including reduced risk of infection and improved outcomes in immune-compromised patients 1.
From the Research
Umbilical Hernia Repair Techniques
When toxic fluid is encountered during dissection in an obstructed umbilical hernia repair, the choice of repair technique is crucial. The following options are considered:
- Mayo repair
- Anatomical repair
- Repair with mesh
- Tension suture
Evidence-Based Recommendations
Based on the available studies 2, 3, 4, 5, 6, the use of mesh in umbilical hernia repair is associated with a lower risk of recurrence compared to suture closure. The studies suggest that:
- Mesh repair reduces the risk of recurrence, even in small hernias 4, 6
- Primary repair may be suitable for small defects, but mesh repair is recommended for larger defects or when toxic fluid is encountered 3, 5
- The use of mesh does not significantly increase the risk of chronic pain, but may be associated with a higher risk of seroma 4, 6
Considerations for Repair Technique
When toxic fluid is present, the risk of infection and recurrence may be higher. In this scenario, the use of mesh may be beneficial in reducing the risk of recurrence. However, the choice of repair technique ultimately depends on the individual patient's condition and the surgeon's expertise.
Key Findings
- Mesh repair is associated with a lower risk of recurrence compared to suture closure 4, 6
- Primary repair may be suitable for small defects, but mesh repair is recommended for larger defects or when toxic fluid is encountered 3, 5
- The use of mesh does not significantly increase the risk of chronic pain, but may be associated with a higher risk of seroma 4, 6