What are the management options for umbilical hernias?

Management Options for Umbilical Hernias

Prosthetic mesh repair is strongly recommended for umbilical hernias, as it significantly reduces recurrence rates compared to tissue repair alone, even in small hernias. 1

Classification and Initial Assessment

When evaluating umbilical hernias, consider:

• Size of fascial defect (small <1 cm, medium 1-3 cm, large >3 cm)
• Presence of complications (incarceration, strangulation, skin ulceration)
• Patient factors (age, comorbidities, presence of ascites)

Management Algorithm

Uncomplicated Umbilical Hernias

In Children:

• Most pediatric umbilical hernias close spontaneously by age 3-4 years 2
• Observation is appropriate for asymptomatic hernias in children under 4 years
• Surgical indications:
  • Defects greater than 1 cm persisting beyond age 3-4 years
  • Enlarging defects during observation period
  • Symptomatic hernias (pain, cosmetic concerns)
  • Complications (rare but significant)

In Adults:

• Surgical repair is indicated for symptomatic hernias
• Mesh repair is preferred over primary tissue repair, even for small defects, as it significantly reduces recurrence rates 1, 3
• Approach options:
  • Open repair: Traditional approach, suitable for most cases
  • Laparoscopic repair: Alternative for larger defects or recurrent hernias
  • Robotic repair: Emerging option with potential benefits in complex cases

Complicated Umbilical Hernias

For incarcerated/strangulated hernias:

• Emergency surgical intervention is required
• In clean surgical fields (no intestinal strangulation), prosthetic mesh repair is recommended 1
• In clean-contaminated fields (with bowel resection without gross spillage), synthetic mesh can still be safely used 1

Special Considerations: Umbilical Hernias with Ascites

Patients with cirrhosis and ascites have:

• Higher incidence of umbilical hernias (24%) 1
• Higher risk of complications including ulceration, incarceration, strangulation, and rupture
• Mortality rates of 60-88% with non-operative management of complicated hernias 1

Management approach:

• Optimize ascites control before elective repair
• Consider perioperative large volume paracentesis (LVP) or transjugular intrahepatic portosystemic shunt (TIPSS) to reduce risk of wound dehiscence and recurrence 1
• Surgical timing should be carefully considered:
  • Emergency surgery carries high mortality (OR=10.32) 1
  • Poor outcomes associated with Child-Pugh class C, ASA score ≥3, and MELD score ≥20 1

Surgical Techniques

• Primary fascial closure: May be appropriate for very small defects, but has higher recurrence rates
• Mesh repair techniques:
  • Onlay: Mesh placed anterior to fascial defect
  • Sublay: Mesh placed in retrorectus or preperitoneal space
  • Intraperitoneal: Mesh placed within peritoneal cavity (typically during laparoscopic approach)

Potential Complications

• Wound infection (more common in emergency repairs)
• Seroma formation
• Mesh-related complications (infection, erosion, migration)
• Recurrence (higher with tissue repair vs. mesh repair)
• In cirrhotic patients: wound dehiscence, ascites leak

Key Practice Points

• Mesh repair should be standard for adult umbilical hernias to minimize recurrence
• Elective repair is preferable to emergency repair when possible
• In children, observation until age 3-4 is appropriate for most cases
• For patients with cirrhosis and ascites, surgical repair timing and perioperative management should be discussed in a multidisciplinary setting involving surgeons, hepatologists, and anesthesiologists 1
• Incarceration of umbilical hernias in children is rare (approximately 1:1,500) but represents an important complication requiring prompt surgical intervention 4