What is the best course of treatment for a patient with a worsening reducible umbilical hernia?

From the Guidelines

The best course of treatment for a patient with a worsening reducible umbilical hernia is surgical repair. This recommendation is based on the most recent and highest quality evidence, which suggests that surgical repair is the most effective way to prevent complications and improve quality of life for patients with umbilical hernias 1. The patient's hernia has been worsening over the last 8 months, and surgical repair is recommended to prevent further complications.

Key Considerations

• The patient's hernia is reducible, but it has been worsening over time, which increases the risk of complications such as incarceration or strangulation.
• The patient is in stable condition, but surgical repair is still recommended to prevent further complications and improve quality of life.
• The standard surgical approach involves either open or laparoscopic herniorrhaphy, with mesh reinforcement typically used for hernias larger than 1-2 cm to reduce recurrence rates.
• Prior to surgery, patients should avoid heavy lifting and strenuous activities that increase intra-abdominal pressure.
• While awaiting surgery, patients can manually reduce the hernia when it protrudes and may use an abdominal binder for temporary symptom relief, though this is not a substitute for definitive repair.

Recommendations

• Surgical repair is generally performed as an outpatient procedure under general anesthesia, with recovery taking 2-6 weeks depending on the technique used and size of the hernia.
• Patients should seek immediate medical attention if the hernia becomes painful, tender, or irreducible, as this may indicate incarceration or strangulation requiring emergency intervention.
• The use of prosthetic mesh may reduce the recurrence rate, but it may also increase the risk of infections and other complications 1.
• The suitability and timing of surgical repair of umbilical hernia should be considered in discussion with the patient and multidisciplinary team involving physicians, surgeons, and anaesthetists 1.

From the Research

Patient Condition and Treatment Options

• The patient is a 38-year-old male with a reducible umbilical hernia that has worsened over the last 8 months.
• The hernia is small, measuring 0.95 cm, and is reducible, with the patient able to push it back in.
• The patient is in stable condition and has been referred for general surgery to repair the hernia.

Treatment Considerations

• According to 2, elective repair after diagnosis is advised, and mesh reinforcement is recommended to reduce recurrence rates.
• 3 suggests that treatment options should be tailored to the clinical situation, and mesh should be used for repair, even in small hernias, to decrease recurrence rates.
• 4 found that mesh repair halved the long-term risk of recurrence compared with sutured repair, and did not increase the risk of chronic pain or rate of reoperation for complications.

Timing of Surgery

• 5 discusses the timing of surgery for umbilical hernia in pregnant women, but does not provide direct guidance for non-pregnant patients.
• However, 5 suggests that elective repair can be proposed for symptomatic hernias, and that asymptomatic hernias can be repaired after childbirth or at a later time.
• 6 emphasizes the importance of preventing complications and performing surgical repair in elective conditions, particularly in patients with underlying health conditions.

Recommended Course of Treatment

• Based on the patient's condition and the available evidence, elective repair with mesh reinforcement is likely the best course of treatment to reduce the risk of recurrence and minimize complications.
• The patient's stable condition and lack of distress suggest that emergency repair is not necessary, and that elective repair can be scheduled at a convenient time.
• The use of mesh reinforcement, as recommended by 2 and 3, can help to reduce the risk of recurrence and improve long-term outcomes.