How to manage a small umbilical fat-containing hernia?

Management of Small Umbilical Fat-Containing Hernia

Small umbilical hernias containing only fat should be surgically repaired using mesh technique when symptomatic, while asymptomatic hernias <1 cm may be observed with periodic follow-up. 1, 2, 3

Diagnosis and Assessment

• Definition: Umbilical hernia occurs due to incomplete closure or weakness at the umbilical ring, allowing protrusion of intraabdominal contents (in this case, fat) 4
• Incidence: Common condition with prevalence of 1.9-18.5% in the general population 4
• Evaluation:
  • Measure defect size (small defined as <2 cm) 3
  • Assess for symptoms (pain, discomfort, cosmetic concerns)
  • Determine reducibility
  • Evaluate for complications (incarceration, strangulation)

Management Algorithm

1. Asymptomatic Small Umbilical Hernias

• For defects <1 cm:

  • Observation with periodic follow-up is appropriate 4, 3
  • Monitor for:
    • Enlargement of defect
    • Development of symptoms
    • Signs of complications

• For defects 1-2 cm:

  • Consider elective repair, especially if:
    • Defect persists beyond age 3-4 (in children) 4
    • Defect enlarges during observation
    • Patient has risk factors for enlargement (obesity, chronic cough, constipation) 5

2. Symptomatic Small Umbilical Hernias

• Surgical repair is indicated for:
  • Pain or discomfort at hernia site
  • Cosmetic concerns causing psychological distress
  • Risk of incarceration/strangulation
  • Defects >1 cm 3

3. Surgical Approach

• Preferred technique: Mesh repair with preperitoneal placement and 3 cm overlap of the defect 2, 3

  • Reduces recurrence rates compared to suture repair, even in small hernias
  • Use non-absorbable (permanent) flat mesh 3

• Suture repair: May be considered only for very small defects (<1 cm) 3

  • Higher recurrence risk (1.3-1.8%) compared to mesh repair 3
  • Not recommended for patients with risk factors for recurrence

• Surgical timing considerations:

  • For pregnant women or those planning pregnancy:
    • Defer repair until after childbirth if asymptomatic 6
    • If repair is performed, mesh technique is preferred to reduce recurrence risk during future pregnancies 6
    • Repair can be performed as early as 8 weeks postpartum 6

Special Considerations

Pregnancy

• Pregnancy may cause herniation or make existing hernias apparent due to increased intra-abdominal pressure 6
• For pregnant women with umbilical hernias:
  • Emergency repair if incarcerated/strangulated
  • Elective repair if symptomatic (preferably in second trimester)
  • Postpone repair for asymptomatic hernias until after childbirth 6

Children

• Most umbilical hernias in children close spontaneously by age 4 7, 4
• Higher complication rates (12.3%) in children <4 years compared to older children (3.1%) 7
• Consider watchful waiting until age 4 unless:
  • Defect is >1 cm
  • Hernia is symptomatic or shows signs of complications
  • Defect persists or enlarges during observation 4

Patients with Ascites

• Increased risk of complications including pressure necrosis, rupture, and evisceration 1
• Control ascites before elective herniorrhaphy 1
• Consider laparoscopic approach when feasible 1
• Prosthetic mesh may reduce recurrence but increases infection risk 1

Postoperative Care

• Pain management and early mobilization
• Monitor for complications:
  • Hematoma (1.6-1.86%)
  • Seroma (0.4%)
  • Wound infection (0.4-1.6%)
  • Chronic pain (1.7%)
  • Recurrence 5

Common Pitfalls to Avoid

• Underestimating small hernias: Even small umbilical hernias should be repaired with mesh when symptomatic to reduce recurrence risk 2, 3
• Ignoring patient risk factors: Consider factors like obesity, chronic cough, and pregnancy when planning management 5, 6
• Premature repair in children: Unnecessary early repair increases complication risk; consider watchful waiting until age 4 for asymptomatic hernias 7, 4
• Inadequate mesh overlap: Ensure at least 3 cm overlap of the defect when using mesh repair 3
• Failure to control ascites: In patients with ascites, control fluid accumulation before elective repair 1

Despite current guidelines recommending mesh repair for umbilical hernias, registry data shows that suture repair is still used in approximately 75% of small umbilical hernias, which may contribute to higher recurrence rates 3.