What is the recommended treatment for an umbilical hernia?

Umbilical Hernia Treatment Guidelines

Surgical repair is indicated for all symptomatic umbilical hernias and should include mesh reinforcement for defects larger than 1 cm to reduce recurrence rates. 1

Indications for Repair

• Symptomatic hernias - Require surgical intervention
• Complicated hernias - Emergency repair needed for:
  • Incarceration (if manual reduction unsuccessful)
  • Strangulation (requires immediate intervention)
  • Intestinal obstruction
  • Skin ulceration or necrosis
  • Rupture of hernia sac 1

Surgical Approach Based on Defect Size

Small Defects (<1 cm)

• Suture repair acceptable 1, 2
• Simple fascial closure in a tension-free procedure 3

Medium to Large Defects (≥1 cm)

• Mesh repair strongly recommended 1, 4
• Preperitoneal mesh placement with 3 cm overlap of defect 1
• Non-absorbable (permanent) flat mesh preferred 2

Special Considerations

Cirrhotic Patients with Ascites

• Umbilical hernias occur in 24% of cirrhotic patients with ascites 5
• High-risk factors for mortality:
  • 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) 5
• Non-operative management of complicated hernias in cirrhotic patients results in 60-88% mortality 5
• Multidisciplinary approach involving physicians, surgeons, and anesthetists is essential 5
• Optimization of ascites control before repair is recommended 1

Pregnant Women

• Emergency repair if incarcerated/strangulated
• Elective repair if symptomatic
• Postpone repair for asymptomatic hernias until after childbirth 1

Surgical Technique Options

• Open repair - Recommended for unstable patients or suspected bowel compromise
• Laparoscopic approach - Consider for stable patients without strangulation signs 1
• Mesh options:
  • Clean cases: Polypropylene mesh (gold standard)
  • Clean-contaminated/contaminated: Biologic or biosynthetic meshes 1

Postoperative Management

• Multimodal analgesic regimen to minimize opioid use
• Non-opioid medications as first-line (acetaminophen, NSAIDs)
• Early mobilization
• Progressive core strengthening after 3-6 months 1

Outcomes and Complications

• Recurrence rates:
  • Higher with suture repair (8.4%) compared to mesh repair for defects >1 cm 2, 6
  • Increased risk in patients with coexisting hernias (OR 2.84) 6
• Complications:
  • Wound infection
  • Seroma formation
  • Cellulitis 3
  • Higher surgical complication rates with mesh repair (OR 6.63) 6

Pediatric Considerations

• Most pediatric umbilical hernias close spontaneously
• Observation with periodic follow-up appropriate in most cases
• Surgery recommended for:
  • Defects >1 cm by age 3-4 years
  • Persistence or enlargement of defect during observation 7

Pitfalls and Caveats

• Despite guideline recommendations for mesh use in defects >1 cm, approximately 75% of small (<2 cm) umbilical hernias are still treated with suture repair 2
• Preperitoneal mesh placement as recommended in guidelines is used in only 1.8% of cases 2
• Recent data shows increasing rates of pain at rest (2.6% vs 3.3%), pain on exertion (5.7% vs 6.6%), and recurrences (1.3% vs 1.8%) between 2013 and 2018 2
• Balance between recurrence risk (higher with suture) and complication risk (higher with mesh) must be considered 6