What is the recommended treatment for an umbilical hernia?

Umbilical Hernia Treatment Recommendations

Mesh repair is strongly recommended for umbilical hernias, regardless of size, as it significantly reduces recurrence rates compared to tissue repair. 1, 2

General Treatment Approach

• Surgical repair is indicated for all symptomatic umbilical hernias to prevent complications 2
• Mesh repair should be used even for small defects, as it has been shown to decrease recurrence rates compared to tissue repair (19% recurrence with tissue repair vs 0% with mesh repair) 1
• For asymptomatic hernias, repair should still be considered if the Hernia-Neck Ratio (HNR) is >2.5, as this predicts higher risk of complications with 91% sensitivity and 84% specificity 3

Mesh Selection Based on Surgical Field

• In clean surgical fields (CDC wound class I - no intestinal strangulation):

  • Synthetic mesh is recommended and has low infection risk 4
  • This applies to cases with intestinal incarceration without signs of strangulation 1

• In clean-contaminated fields (CDC class II - with bowel resection but without gross spillage):

  • Synthetic mesh can still be safely used without significant increase in 30-day wound-related morbidity 1

• In contaminated/dirty fields (CDC classes III and IV - with bowel necrosis or gross enteric spillage):

  • Primary repair is recommended for small defects (<3 cm) 1
  • Biological mesh should be used when direct suture is not feasible 1
  • Avoid absorbable prosthetic materials as they lead to inevitable hernia recurrence 1

Surgical Approaches

• Open mesh repair:

  • Standard approach with onlay mesh placement 1, 5
  • Lower recurrence rates compared to tissue repair 1

• Laparoscopic approaches:

  • Associated with lower wound infection rates and shorter hospital stays 4, 6
  • Options include Intraperitoneal Onlay Mesh (IPOM), Transabdominal Preperitoneal (TAPP), and Total Extraperitoneal (TEP) repairs 1
  • Enhanced-view totally extraperitoneal (eTEP) approach is a safe and effective minimally invasive option with the benefit of placing mesh outside the abdominal cavity 6

Special Considerations for Cirrhotic Patients with 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 1
• Management should include:
  • Optimizing ascites control before elective repair 1
  • Considering perioperative large volume paracentesis (LVP) or transjugular intrahepatic portosystemic shunt (TIPSS) to reduce wound dehiscence and recurrence 1
  • Multidisciplinary discussion involving physicians, surgeons, and anesthetists to determine timing of repair 4, 1
  • Deferring repair until liver transplantation if transplant is imminent 1

Pediatric Considerations

• Most pediatric umbilical hernias close spontaneously and observation with periodic follow-up is appropriate in most cases 7
• Surgical repair is recommended for:
  • Defects greater than 1 cm by age 3-4 years 7
  • Persistence or enlargement of fascial defect during observation 7
  • Symptomatic hernias 7

Potential Complications and Risk Factors

• Common complications include seroma formation and surgical site infection 5
• Risk factors for recurrence include:
  • Obesity 5
  • Ascites 1, 5
  • Excessive weight gain following repair 5
  • Smoking 5
• In cirrhotic patients, rapid ascites removal can paradoxically cause hernia incarceration 1

Expected Outcomes

• Low recurrence rates with mesh repair (0-4.3%) 1
• Generally favorable outcomes after umbilical hernia repairs 2
• Some patients may have chronic complaints, mostly related to recurrences 2