What are the management options for umbilical hernias?

Management of Umbilical Hernias

Mesh repair is strongly recommended for umbilical hernias in adults due to significantly lower recurrence rates compared to tissue repair, without increased risk of wound infection. 1

Diagnostic Approach

• Umbilical hernias present as protrusions at the umbilical ring due to incomplete closure or weakness
• Key assessment factors:
  • Size of fascial defect (measured in centimeters)
  • Presence of symptoms (pain, incarceration)
  • Patient age (pediatric vs adult)
  • Complicating factors (ascites, pregnancy)

Management Algorithm

Pediatric Umbilical Hernias

1. Observation for asymptomatic hernias

   • Most pediatric umbilical hernias close spontaneously by age 3-4 years 2
   • Regular follow-up to monitor for changes in size or symptoms
   • Strapping has not been shown to improve or accelerate closure 2

2. Surgical indications in children:

   • Defects greater than 1 cm persisting beyond age 3-4 years 2
   • Enlargement of fascial defect during observation period
   • Symptomatic hernias (pain, incarceration)
   • Complications (incarceration, strangulation)

3. Surgical approach for children:

   • Standard open umbilical hernia repair
   • Low complication rates (wound infections, stitch reactions) 3
   • Incarceration risk is rare but serious (approximately 1:1,500 umbilical hernias) 4

Adult Umbilical Hernias

1. Uncomplicated hernias:

   • Mesh repair is recommended regardless of hernia size 1, 5
   • Significantly lower recurrence rates with mesh (grade 1A recommendation) 1
   • Options include open, laparoscopic, or robotic approaches 5

2. Complicated hernias (incarceration without strangulation):

   • Emergent prosthetic repair with synthetic mesh is recommended
   • Low risk of infection in clean surgical fields (CDC wound class I) 1
   • Mesh repair shows lower recurrence rates without increased complications 1

3. Complicated hernias with intestinal strangulation:

   • Emergent repair with synthetic mesh can be performed even with bowel resection (without gross enteric spillage) 1
   • Associated with significantly lower risk of recurrence 1

Special Considerations: Umbilical Hernias with Ascites

1. Risk assessment:

   • Incidence reaches 24% in cirrhotic patients with ascites 1
   • High risk of complications including ulceration, incarceration, strangulation, and rupture 1
   • Non-operative management of complicated hernias can result in 60-88% mortality 1

2. Surgical risk factors:

   • Emergency surgery (OR=10.32)
   • Child-Pugh-Turcotte class C (OR=5.52)
   • ASA score ≥3 (OR=8.65)
   • MELD score ≥20 (OR=2.15) 1

3. Management approach:

   • Multidisciplinary discussion involving physicians, surgeons, and anesthesiologists 1
   • Optimize ascites management perioperatively (including large volume paracentesis)
   • Consider TIPSS (transjugular intrahepatic portosystemic shunt) in appropriate candidates to reduce ascites and risk of recurrence 1

Surgical Approaches

1. Open repair:

   • Traditional approach with direct visualization of the defect
   • Primary fascial closure with or without mesh reinforcement
   • Suitable for both small and large defects

2. Laparoscopic repair:

   • Comparable recurrence rates to open repair 1
   • Advantages include better visualization of the defect and reduced postoperative pain
   • Particularly useful for larger defects or recurrent hernias

3. Robotic repair:

   • Emerging option with potential advantages in complex cases 5
   • Allows for more precise suturing and mesh placement

Complications and Outcomes

• Recurrence rates:

  • Significantly higher with tissue repair compared to mesh repair 1
  • In one study, 19% recurrence with tissue repair vs. 0% with mesh repair 1

• Wound complications:

  • Low rates of wound infection with mesh repair even in clean-contaminated fields 1
  • Other complications include seroma, hematoma, and mesh-related issues

• Emergency complications:

  • Incarceration and strangulation require urgent surgical intervention
  • Morbidity and mortality rates of 37.2% and 3.9% respectively in emergency repairs 1

Pitfalls and Caveats

1. Avoid delaying repair of symptomatic hernias - incarceration risk may be small but consequences can be severe

2. Don't underestimate small hernias - even small defects benefit from mesh repair to reduce recurrence

3. Consider patient-specific factors - particularly in cirrhotic patients where timing and approach must be carefully planned

4. Recognize that pediatric and adult management differs significantly - most pediatric hernias resolve spontaneously while adult hernias typically require surgical repair

5. Beware of complications in special populations - patients with ascites require careful perioperative management to reduce morbidity and mortality