Risk of Strangulation in Small Umbilical Hernias
The risk of strangulation in small umbilical hernias is low, estimated at 10-25%, but requires immediate surgical intervention when suspected due to potentially life-threatening complications. 1, 2
Strangulation Risk Factors
- Size and closure pattern: Strangulation may occur as the fascial defect decreases in size, particularly in infants 3
- Defect size: Smaller defects (<2 cm) that remain open may have higher risk of incarceration compared to larger defects
- Duration: Persistent umbilical hernias that don't close spontaneously have increased risk
- Symptoms: Presence of pain or discomfort may indicate potential complications
Clinical Presentation of Strangulation
When strangulation occurs, patients typically present with:
- Severe pain and tenderness at the hernia site
- Erythema and hardness of the umbilical area
- Irreducibility of the hernia (inability to reduce)
- Signs of systemic inflammatory response syndrome (SIRS)
- Mechanical ileus on abdominal radiography 3
- In severe cases: peritonitis, bowel perforation 4
Management Approach
For Uncomplicated Small Umbilical Hernias:
Pediatric patients: Most umbilical hernias in children close spontaneously, and observation with periodic follow-up is appropriate in most cases 5
- Surgical repair recommended for defects >1 cm that persist beyond age 3-4 years
- Persistence or enlargement of fascial defect during observation period warrants consideration of repair regardless of age
Adult patients:
For Suspected Strangulation:
- Immediate surgical intervention is required when strangulation is suspected 1
- Delayed treatment beyond 24 hours significantly increases mortality 1
- Surgical approach includes:
- Identification and isolation of the hernia sac
- Assessment of bowel viability
- Resection of non-viable bowel if necessary
- Fascial closure with non-absorbable sutures
Special Considerations
Pregnant women: Emergency repair if incarcerated/strangulated, elective repair if symptomatic, and postponement of repair for asymptomatic hernias until after childbirth 1
Cirrhotic patients: Higher risk population with umbilical hernias occurring in up to 20% of patients with long-standing cirrhosis and ascites 4
- Risk factors for mortality include emergency surgery, Child-Pugh-Turcotte class C, ASA score ≥3, and MELD score ≥20 1
Complications of Untreated Strangulation
- Bowel necrosis and perforation
- Peritonitis
- Sepsis
- Death 4
Pitfalls to Avoid
- Delayed diagnosis: Strangulation can progress rapidly to life-threatening complications
- Misdiagnosis: Symptoms may be attributed to other causes of abdominal pain
- Inappropriate strapping: No evidence suggests that strapping improves or accelerates closure of umbilical hernias 5
- Neglecting small defects: Even small umbilical hernias carry a risk of strangulation and should be monitored
The evidence clearly indicates that while the risk of strangulation in small umbilical hernias is relatively low, the consequences can be severe. Surgical intervention should not be delayed when strangulation is suspected, as mortality increases significantly with treatment delays beyond 24 hours.