What is the initial management for a new umbilical hernia presenting to the emergency department (ED)?

Emergency Department Management of New Umbilical Hernia

The initial management for a new umbilical hernia in the emergency department should include assessment for complications (incarceration or strangulation), with surgical consultation for complicated hernias requiring urgent repair, while uncomplicated hernias can be discharged with outpatient surgical follow-up. 1

Initial Assessment

• Evaluate for signs of incarceration (irreducible hernia with pain) or strangulation (irreducible with signs of bowel ischemia including severe pain, erythema, fever) 1, 2
• Assess for risk factors including cirrhosis with ascites, which occurs in up to 24% of cirrhotic patients and increases complication risk 1
• Check for bowel obstruction symptoms (nausea, vomiting, abdominal distention) which may indicate incarcerated contents 3, 2

Management Algorithm

For Complicated Hernias (Incarcerated/Strangulated):

1. Immediate surgical consultation 1
2. NPO status, IV fluids, pain management 2
3. Consider manual reduction only if:
   • Recent onset (<24 hours)
   • No signs of strangulation
   • Minimal pain 2
4. Surgical approach considerations:
   • For strangulated hernias requiring bowel resection without gross spillage, synthetic mesh can still be used safely 1
   • In contaminated/dirty surgical fields with bowel necrosis and gross enteric spillage, primary repair is recommended for small defects (<3 cm) 1
   • Biological mesh is recommended when direct suture is not feasible in contaminated fields 1

For Uncomplicated Hernias:

1. Discharge with outpatient surgical referral 2
2. Patient education on warning signs requiring return to ED:
   • Increasing pain
   • Irreducibility
   • Vomiting
   • Skin changes over hernia 2

Special Considerations

Cirrhotic Patients with Ascites:

• Emergency surgery carries significantly higher mortality risk (OR=10.32) 1
• If emergent repair is needed, consult hepatology for postoperative ascites management 4
• TIPS placement may be considered after emergent operation if ascites cannot be controlled medically 4
• Surgery should be performed by a surgeon experienced in caring for cirrhotic patients 4

Pediatric Patients:

• Incarceration is rare in children (approximately 1:1,500 umbilical hernias) 5
• Undigested vegetable matter in small bowel may precipitate obstruction in pediatric cases 5
• There may be an increasing trend of incarceration in pediatric umbilical hernias 6

Clinical Pitfalls and Caveats

• Don't miss strangulated hernias - they require immediate surgical intervention to prevent bowel necrosis and sepsis 1, 2
• Avoid rapid ascites removal in cirrhotic patients as it can paradoxically cause hernia incarceration 1
• Recognize that unusual contents like the appendix can herniate, potentially leading to appendicitis within the hernia 3
• Mesh repair significantly reduces recurrence rates compared to tissue repair and should be recommended for definitive management, even for small defects 1