What is the appropriate management approach for umbilical hernias in adults?

Management of Umbilical Hernias in Adults

Small, asymptomatic umbilical hernias (1 cm or less) can be clinically observed. This approach is supported by current evidence and guidelines regarding the management of small umbilical hernias in adults 1.

Evaluation of Answer Options

A. Repair is contraindicated in patients with cirrhosis

FALSE. While umbilical hernia repair in cirrhotic patients requires careful consideration, it is not contraindicated. According to guidelines, the "suitability and timing of surgical repair of umbilical hernia should be considered in discussion with the patient and multidisciplinary team involving physicians, surgeons and anaesthetists" 2. Repair may actually be necessary to prevent complications such as skin ulceration, incarceration, strangulation, and rupture, which can occur in cirrhotic patients with umbilical hernias 2.

B. Most umbilical hernias in adults are congenital

FALSE. While umbilical hernias can be congenital, most adult umbilical hernias are acquired. In cirrhotic patients, for example, the incidence of abdominal wall hernia is 16% and reaches 24% in the presence of ascites, with more than half being umbilical hernias 2. These hernias develop due to increased intra-abdominal pressure from ascites rather than from congenital defects.

C. Small, asymptomatic hernias (1 cm or less) can be clinically observed

TRUE. According to guidelines and registry data, suture repair should only be considered for small hernia defects of less than 1 cm 3. This implies that very small asymptomatic hernias can be observed clinically. The Praxis Medical Insights also supports conservative management for certain patient populations, such as those with cirrhosis, where "optimal fluid control, appropriate nutrition, and conservative management with binders may minimize hernia progression" 1.

D. Primary suture closure for umbilical hernias < 4 cm has a recurrence rate similar to repairs using supplemental mesh

FALSE. The evidence clearly shows higher recurrence rates with primary suture repair compared to mesh repair. According to research, "the primary suture for umbilical hernia is associated with a recurrence rate of 19-54%" 4. More recent data indicates that "mesh should be used for repair, because it has been shown to decrease recurrence rates, even in small hernias" 5. The 5-year recurrence rates are approximately 10.6-12.3% with mesh repair compared to 17.1% without mesh 1.

Management Algorithm for Adult Umbilical Hernias

1. Assessment of Hernia Size and Symptoms:

   • For hernias ≤1 cm and asymptomatic: Clinical observation is appropriate 3
   • For hernias >1 cm or symptomatic: Surgical repair is recommended 3, 5

2. Surgical Approach Based on Hernia Size:

   • For hernias 1-2 cm: Consider suture repair, though mesh repair shows lower recurrence rates 3, 5
   • For hernias >2 cm: Mesh repair is strongly recommended 4, 5
   • For defects larger than 8 cm or an area of more than 20 cm²: Tension-free repair with mesh that overlaps the defect edge by 1.5–2.5 cm 2

3. Special Considerations:

   • Cirrhotic patients: Multidisciplinary approach needed; optimize ascites management perioperatively; consider TIPSS (transjugular intrahepatic portosystemic shunt) 2
   • Complicated hernias: Immediate surgical intervention is mandatory for strangulated hernias 1
   • Hernia-Neck-Ratio (HNR): Umbilical hernias with HNR >2.5 should be operated on regardless of symptoms due to higher risk of complications 6

4. Surgical Technique Selection:

   • Laparoscopic approach: Consider for stable patients; associated with lower morbidity (5-6%) compared to open approach (17-18%) 2, 7
   • Open approach: May be necessary for unstable patients or when bowel resection is anticipated 2

Potential Complications and Follow-up

• Postoperative complications include wound infection (4-12%), incisional hernia, respiratory complications, bleeding, and ileus 1
• Recurrence rates vary by technique: 8.7% for suture repair vs. minimal recurrence for mesh techniques 7
• Follow-up should include monitoring for signs of recurrence and complications 1

By following this evidence-based approach to umbilical hernia management in adults, clinicians can optimize outcomes while minimizing morbidity and recurrence rates.