What is the recommended management for paraumbilical (near the belly button) vs umbilical (at the belly button) hernias?

Management of Paraumbilical vs Umbilical Hernias

Both paraumbilical and umbilical hernias should be repaired using mesh techniques, as this significantly reduces recurrence rates compared to tissue repair, regardless of whether the hernia is at or near the umbilicus. 1

Definitions and Differences

• Umbilical hernia: Occurs directly at the umbilicus (belly button), often through the umbilical ring 2
• Paraumbilical hernia: Occurs adjacent to the umbilicus, through the linea alba 3, 4

Surgical Management Recommendations

Elective Repair Indications

• Symptomatic hernias (pain, cosmetic concerns, incarceration risk) 2
• Repair should be performed regardless of size to prevent complications 1

Surgical Approach Options

1. Open Mesh Repair

   • Traditional approach with lower recurrence rates than tissue repair 1
   • Shorter operative time compared to laparoscopic approach (mean 42.2 vs 58.1 minutes) 3
   • Higher risk of wound complications compared to laparoscopic approach 5

2. Laparoscopic Repair

   • Associated with:
     • Lower wound infection rates (OR 2.35 in favor of laparoscopic) 5
     • Lower recurrence rates (OR 4.06 in favor of laparoscopic) 5
     • Shorter hospital stay (mean difference 26.85 hours shorter) 5
     • Less postoperative pain (pain score 2.95 vs 6.10 in open repair) 3
     • Longer operative time than open repair 3, 5

3. Open Intraperitoneal Onlay Mesh (IPOM) Technique

   • Particularly beneficial for small defect hernias 4
   • Shorter hospital stay compared to other techniques 4
   • Shorter operative time than laparoscopic approach 4

Mesh Selection

• Synthetic mesh is recommended for clean surgical fields (no intestinal strangulation) 1
• Mesh repair significantly reduces recurrence rates compared to tissue repair (19% vs 0% in one study) 1

Special Considerations

Complicated/Emergency Hernias

• For incarcerated hernias without strangulation:

  • Mesh repair is still recommended and safe 1
  • Low rates of wound infection (4.3%) and recurrence (4.3%) reported 1

• For strangulated hernias requiring bowel resection without gross spillage:

  • Synthetic mesh can still be used safely 1
  • No significant increase in wound-related morbidity at 30 days 1

Patients with Cirrhosis and Ascites

• Umbilical hernias occur in up to 24% of cirrhotic patients with ascites 1
• High risk of complications including incarceration, strangulation, and rupture 1
• Emergency surgery carries significantly higher mortality risk (OR=10.32) 1
• Management recommendations:
  • Optimize ascites control before elective repair 1
  • Consider perioperative large volume paracentesis (LVP) or TIPSS to reduce wound dehiscence and recurrence 1
  • Surgical timing should involve multidisciplinary discussion 1
  • Defer repair until liver transplantation if transplant is imminent 1

Postoperative Care and Outcomes

• Expected outcomes:

  • Low recurrence rates with mesh repair (0-4.3%) 1, 3
  • Higher patient satisfaction with laparoscopic approach (7.85 vs 6.00 on satisfaction scale) 3

• Potential complications:

  • Seroma (10-15% in both open and laparoscopic approaches) 3
  • Surgical site infection (higher in open repair, 15% vs rare in laparoscopic) 3, 5
  • Wound dehiscence (higher risk with open repair) 5

Clinical Pitfalls and Caveats

• Don't underestimate large paraumbilical hernias - CT imaging may be necessary to determine true defect size and contents 6
• Avoid tissue repair even for small defects, as mesh significantly reduces recurrence 1
• In cirrhotic patients, rapid ascites removal can paradoxically cause hernia incarceration 1
• Consider patient factors (obesity, ascites, comorbidities) when selecting surgical approach 4, 6
• Laparoscopic approach may be technically challenging in very large hernias but offers better outcomes 5