What is the recommended management for umbilical hernia?

Management of Umbilical Hernia

The suitability and timing of surgical repair for umbilical hernia should be determined through a multidisciplinary discussion involving physicians, surgeons, and anesthetists, with particular caution in patients with cirrhosis and ascites. 1

General Approach to Umbilical Hernias

Indications for Surgical Repair

• Symptomatic umbilical hernias require surgical intervention 2
• Asymptomatic umbilical hernias with high risk of complications should be repaired, particularly:
  • Hernias with Hernia-Neck-Ratio (HNR) > 2.5 (91% sensitivity, 84% specificity for predicting complications) 3
  • Defects > 1 cm in children by age 3-4 years 4
  • Persistent or enlarging fascial defects during observation period 4

Surgical Approach Options

• Mesh repair is preferred even for small hernias as it significantly decreases recurrence rates 2, 5
• Surgical options include:
  • Open repair (traditional approach)
  • Laparoscopic repair (for stable patients with reducible hernias)
  • Robotic repair (emerging option)

Management Algorithm Based on Clinical Scenario

1. Uncomplicated Umbilical Hernias

• Small defects (<2 cm):

  • Mesh repair is generally recommended 2
  • Consider primary suture repair using short-stitch technique for very small defects without risk factors for recurrence 5
  • Note: Primary suture repair showed comparable recurrence rates (5.2%) to patch repair (5.8%) in small hernias 5

• Medium to large defects:

  • Mesh repair is strongly recommended 2
  • For defects >8 cm, mesh should overlap the defect edge by 1.5-2.5 cm 6

2. Complicated Umbilical Hernias (Incarceration/Strangulation)

• Clean surgical field (CDC class I - incarceration without strangulation):

  • Prosthetic repair with synthetic mesh is recommended 1
  • Associated with lower recurrence rate without increased infection risk 1

• Clean-contaminated field (CDC class II - strangulation without gross spillage):

  • Emergent prosthetic repair with synthetic mesh can be performed 1
  • No increase in 30-day wound-related morbidity and lower recurrence risk 1

• Contaminated/dirty field (CDC class III/IV - bowel necrosis/perforation):

  • Small defects (<3 cm): Primary repair recommended 1
  • Larger defects: Consider biological mesh 1
  • If biological mesh unavailable: Polyglactin mesh or open wound management with delayed repair 1

3. Special Considerations for Patients with Cirrhosis and Ascites

• Umbilical hernias occur in 24% of cirrhotic patients with ascites 1
• Non-operative management of complicated hernias in cirrhotic patients carries mortality rates of 60-88% 1
• Risk factors for mortality in cirrhotic patients:
  • 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
• Perioperative management:
  • Optimize ascites control using large volume paracentesis (LVP)
  • Consider TIPSS (transjugular intrahepatic portosystemic shunt) perioperatively to reduce wound dehiscence and hernia recurrence 1

Antimicrobial Prophylaxis Guidelines

• Clean surgical field (CDC class I): Short-term prophylaxis 1
• Clean-contaminated/contaminated field (CDC classes II/III): 48-hour antimicrobial prophylaxis 1
• Dirty field (CDC class IV - peritonitis): Full antimicrobial therapy 1

Potential Complications and Outcomes

• Surgical complications:

  • Wound infection
  • Recurrence (higher in patients with diastasis recti) 5
  • Chronic pain (higher with mesh patch repair - 17.3% vs 12.3% with suture repair) 5

• Complications of untreated hernias:

  • Incarceration
  • Strangulation
  • Rupture with evisceration (extremely rare) 4

Early detection and prompt surgical intervention are crucial for reducing complications and mortality, particularly in high-risk patients with cirrhosis and ascites.