What is the treatment for an umbilical hernia?

Treatment of Umbilical Hernia

Surgical repair is the definitive treatment for umbilical hernias, with mesh repair recommended for defects larger than 1 cm to reduce recurrence rates. 1, 2

Assessment and Classification

• Size-based approach:

  • Small defects (<1 cm): Suture repair may be considered
  • Medium defects (1-3 cm): Mesh repair recommended
  • Large defects (>3 cm): Mesh repair with adequate overlap essential
  • Very large defects (>8 cm): Mesh with 1.5-2.5 cm overlap required 1

• Patient factors affecting treatment decisions:

  • Presence of symptoms (pain, incarceration)
  • Comorbidities (cirrhosis with ascites, obesity)
  • Emergency vs. elective presentation

Treatment Algorithm

1. Asymptomatic Umbilical Hernias

• In children: Observation with periodic follow-up as most close spontaneously by age 3-4 3
• In adults: Elective repair recommended due to risk of complications 4

2. Elective Repair (Standard Approach)

• Technique selection:

  • For defects <1 cm: Primary suture repair with non-absorbable sutures 2
  • For defects ≥1 cm: Mesh repair with preperitoneal placement and 3 cm overlap 1, 2

• Approach options:

  • Open repair: Most common, allows direct visualization
  • Laparoscopic approach: For reducible hernias, offers shorter hospital stay 1
  • Robotic options: Available in specialized centers 4

3. Emergency Repair (Complicated Hernias)

• Immediate surgical intervention required for:

  • Incarceration with signs of strangulation
  • Intestinal obstruction
  • Perforation 5, 1

• Technique for emergency cases:

  • Primary repair with non-absorbable sutures if contaminated field
  • Synthetic mesh can be used in clean-contaminated fields with low infection risk 1
  • Local anesthesia can be used in absence of bowel gangrene 1

Special Considerations

Cirrhotic Patients with Ascites

• Higher risk of complications (37.2% morbidity, 3.9% mortality) 5
• Optimize ascites management perioperatively:
  • Sodium restriction (2g/day)
  • Consider TIPS (Transjugular Intrahepatic Portosystemic Shunt) evaluation 5, 1
• Multidisciplinary approach involving physicians, surgeons, and anesthesiologists 5

Mesh Selection and Placement

• Standard cases: Non-absorbable (permanent) flat mesh in preperitoneal space 1, 2
• Contaminated fields: Biologic or biosynthetic meshes can be considered 5
• Placement technique: Preperitoneal with adequate overlap (3 cm) recommended 1

Outcomes and Complications

• Recurrence rates:

  • Overall: 8.4% (no significant difference between mesh and suture repair in some studies) 6
  • Higher risk in patients with coexisting hernias (OR 2.84) 6
  • European registry data shows higher recurrence with suture repair (1.8%) vs. mesh 2

• Complications:

  • Surgical site infections
  • Seroma formation
  • Chronic pain (5-12% experience moderate to severe pain one year postoperatively) 1
  • Mesh-related complications (higher complication rate with mesh, OR 6.63) 6

Follow-up Care

• Schedule appointments at 1-2 weeks, 4-6 weeks, and 1 year 1
• Monitor for recurrence and chronic pain
• Patient education on modifiable risk factors (smoking, diabetes control, weight management) 1

Despite the higher complication rate associated with mesh repair, current guidelines still recommend mesh for defects >1 cm due to lower long-term recurrence rates. The surgical approach should be selected based on defect size, patient characteristics, and whether the presentation is emergent or elective.