What is the management for an umbilical hernia?

Management of Umbilical Hernia

Surgical repair of umbilical hernia should be determined through a multidisciplinary discussion involving physicians, surgeons, and anesthetists, with the timing and approach tailored to patient-specific factors. 1

Adult Umbilical Hernia Management

Surgical Indications

• Symptomatic umbilical hernias require surgical intervention
• For medium to large defects, mesh repair is strongly recommended with 1.5-2.5 cm overlap for defects >8 cm 1
• In cirrhotic patients with ascites, special considerations apply due to high mortality risk with non-operative management (60-88%) 1

Surgical Approach Selection

1. Clean surgical field (CDC class I):

   • Prosthetic repair with synthetic mesh is recommended
   • Associated with lower recurrence rates without increased infection risk
   • Short-term antimicrobial prophylaxis 1

2. Clean-contaminated field (CDC class II):

   • Emergent prosthetic repair with synthetic mesh can be performed
   • No increase in 30-day wound-related morbidity
   • 48-hour antimicrobial prophylaxis 1

3. Contaminated/dirty field (CDC class III/IV):

   • Small defects (<3 cm): primary repair
   • Larger defects: biological mesh or alternative strategies
   • Full antimicrobial therapy for dirty fields 1

Surgical Techniques

• Open, laparoscopic, and robotic options are available 2
• Enhanced-view totally extraperitoneal (eTEP) approach is a safe, effective minimally invasive technique for defects >1 cm 3
• Mesh repair is generally recommended even for small hernias to decrease recurrence rates 2

Special Considerations for Cirrhotic Patients

• Risk factors for mortality 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

• Perioperative management should include:

  • Optimizing ascites control using large volume paracentesis (LVP)
  • Considering TIPSS (transjugular intrahepatic portosystemic shunt) to reduce wound dehiscence and hernia recurrence 1
  • Suitability and timing of repair should be determined through multidisciplinary discussion 4

Pediatric Umbilical Hernia Management

Watchful Waiting

• Recommended for uncomplicated pediatric umbilical hernias until 4 years of age 5
• Most umbilical hernias spontaneously close by 3-5 years of age 6
• Complications of untreated umbilical hernias are rare (incarceration rate: 1:1500) 5

Surgical Intervention

• Indicated when spontaneous closure fails to occur by age 4 5
• Early intervention (under 4 years) associated with:
  • 12.3% postoperative complication rate
  • Higher costs
  • Higher rates of postoperative hospitalization and emergency room visits 5

Alternative Non-Surgical Treatment

• Adhesive strapping can be considered as an alternative to surgery and observation
• Promotes early spontaneous closure compared to observation alone (closure speed: 2.59 vs 0.37 mm/week)
• Achieves closure in 91% of infants after 2-13 weeks of treatment
• Note: 5.6% discontinuation rate due to skin complications 6

Surgical Techniques for Pediatric Umbilical Hernias

• Transumbilical repair with longitudinal umbilical incision and fascial defect closure is a safe option with satisfactory cosmetic results 7

Pitfalls and Caveats

• Avoid premature surgical intervention in children under 4 years unless complications arise
• In cirrhotic patients, careful perioperative management is essential to reduce mortality risk
• Consider mesh repair even for small hernias to reduce recurrence rates
• Monitor for complications after repair, including infection, recurrence, and chronic pain

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with umbilical hernias while minimizing morbidity and mortality.