Are umbilical hernias in adults managed conservatively?

Management of Umbilical Hernias in Adults

Umbilical hernias in adults should not be managed conservatively unless there are specific contraindications to surgery, as they have high recurrence rates and risk of complications when left untreated. 1

Indications for Surgical Repair

• Surgical repair is indicated for symptomatic umbilical hernias in adults 2
• Even asymptomatic umbilical hernias should generally be repaired due to:
  • Risk of incarceration, strangulation, and rupture 1
  • High recurrence rates (up to 54%) with conservative management 3
  • Poor outcomes with non-operative management of complicated hernias (mortality rates 60-88%) 1

Special Considerations for Cirrhotic Patients with Ascites

For patients with cirrhosis and ascites (who have a higher incidence of umbilical hernias at approximately 20%):

• Optimal fluid control, appropriate nutrition, and conservative management with binders may minimize hernia development and progression 1
• Patients who are candidates for liver transplantation in the near future should defer hernia repair until during or after transplantation 1
• For patients in whom transplantation is not imminent (low MELD score), elective herniorrhaphy may be offered after careful consideration of risks/benefits 1
• Risk factors for mortality in cirrhotic patients include:
  • 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

Surgical Approach

• Mesh repair is recommended over simple suture repair due to significantly lower recurrence rates 3, 2, 4
• No recurrences were noted in mesh repairs compared to 13% recurrence rate with suture repairs in long-term follow-up 3
• Laparoscopic repair offers advantages over open repair:
  • Lower postoperative pain scores
  • Shorter hospital stay
  • Lower wound morbidity rates 5
• Clinically apparent ascites should be controlled before elective herniorrhaphy, with laparoscopic approaches preferred 1

Complications to Monitor

• Complications of untreated umbilical hernias include:
  • Incarceration
  • Pressure necrosis
  • Rupture
  • Evisceration
  • Peritonitis 1
• A rapid decline in ascitic fluid volume (e.g., large volume paracentesis) can paradoxically cause incarceration 1
• Postoperative complications include:
  • Seroma formation
  • Surgical site infection
  • Recurrence 4

Risk Factors for Recurrence

• Obesity
• Ascites
• Excessive weight gain following repair
• Smoking 4

Conclusion

While conservative management with binders may have a role in temporarily managing umbilical hernias in cirrhotic patients with ascites or those awaiting liver transplantation, the majority of adult umbilical hernias should be surgically repaired due to high recurrence rates and risk of complications with conservative management alone. Mesh repair is superior to suture repair, and the timing and approach should be determined based on patient factors, particularly in those with cirrhosis and ascites.