What is the recommended management for umbilical hernias?

Management of Umbilical Hernias

Mesh repair is recommended for umbilical hernias larger than 1 cm, while suture repair should only be considered for defects smaller than 1 cm. 1, 2

General Approach to Umbilical Hernia Management

Adult Patients

1. Surgical Indications:

   • Symptomatic umbilical hernias
   • Defects larger than 1 cm
   • Complications (incarceration, strangulation, skin ulceration)
   • Persistent or enlarging hernias

2. Surgical Technique:

   • Defects <1 cm: Suture repair may be considered
   • Defects >1 cm: Mesh repair with 1.5-2.5 cm overlap of defect edges 2
   • Defects >3 cm or >20 cm²: Definite mesh repair with adequate overlap 2
   • Approach options: open, laparoscopic, or robotic repair 3

3. Postoperative Care:

   • Monitor for at least 24 hours for hemodynamic stability and surgical site complications
   • Pain management: Acetaminophen 500-1000 mg every 6 hours as first-line treatment
   • Avoid NSAIDs due to bleeding risk 2

Pediatric Patients

1. Conservative Management:

   • Observation is appropriate for most pediatric umbilical hernias
   • Most close spontaneously by age 4 years 4
   • Strapping does not improve or accelerate closure 4

2. Surgical Indications:

   • Defects larger than 1-2 cm that persist beyond age 3-4 years
   • Persistence or enlargement during observation
   • Symptomatic hernias
   • Complications (rare but include incarceration) 5, 4

Special Considerations

Patients with Cirrhosis and Ascites

• Higher incidence of umbilical hernias (24% in patients with ascites) 6
• Increased risk of complications including skin ulceration, incarceration, strangulation, and rupture
• Surgical repair should be considered in a multidisciplinary discussion involving physicians, surgeons, and anesthesiologists 6
• Perioperative optimization of ascites management (including large volume paracentesis and TIPSS) may reduce wound dehiscence and hernia recurrence 6

Risk Factors for Poor Outcomes

• 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) 6

Potential Complications

• Wound infection (4-12%)
• Incisional/port site hernia
• Respiratory complications
• Bleeding
• Ileus 2
• Chronic pain
• Recurrence (higher with suture repair than mesh repair) 3, 1

Follow-up Care

• Monitor for recurrence and complications
• CT scan of abdomen and pelvis if pain persists beyond 1 month 2
• Recurrence rates: approximately 10.6-12.3% with mesh repair compared to 17.1% without mesh 2, 1

Warning Signs Requiring Immediate Attention

• Severe constant pain
• Redness or skin changes over the hernia
• Nausea, vomiting, inability to pass gas or stool
• Fever or general malaise 2

Despite guideline recommendations for mesh repair in most umbilical hernias, recent registry data shows that suture repair is still used in approximately 75% of small (<2 cm) umbilical hernias, with higher rates of pain and recurrence compared to mesh repair 1. This highlights the gap between evidence-based recommendations and current practice patterns.