What type of repair is recommended during an obstructed umbilical hernia repair when toxic fluid is encountered?

Management of Obstructed Umbilical Hernia with Toxic Fluid

For obstructed umbilical hernia repair where toxic fluid is encountered during dissection, anatomical repair without mesh is recommended to prevent infection and complications.

Surgical Field Classification and Repair Options

When toxic fluid is encountered during umbilical hernia repair, the surgical field becomes contaminated (CDC wound class III or IV), which significantly impacts the choice of repair technique:

• In contaminated/dirty surgical fields (CDC Classes III and IV), primary anatomical repair is recommended for small defects (<3 cm) with contamination from toxic fluid 1, 2
• Mesh placement in contaminated fields carries a high risk of surgical site infection, with infection rates potentially as high as 21% 2
• The presence of toxic fluid indicates potential bacterial contamination, making primary suture repair the safer option to avoid mesh-related complications 1

Evidence Supporting Anatomical Repair in Contaminated Fields

• The World Journal of Emergency Surgery guidelines specifically recommend primary repair for hernias with contamination 1
• In clean surgical fields, mesh is preferred due to lower recurrence rates, but this advantage is outweighed by infection risk in contaminated cases 2
• When toxic fluid is present, the risk of mesh infection significantly increases, potentially requiring subsequent mesh removal and additional procedures 1

Alternative Options When Primary Closure Is Not Feasible

If the defect is too large for primary closure:

• Biological mesh may be considered as an alternative when direct suture is not feasible in contaminated fields 2
• Cross-linked biological mesh offers more resistance to mechanical stress and is better for larger defects 2
• Non-cross-linked biological mesh completely remodels into autologous tissue but provides less structural support 2
• Polyglactin mesh is an alternative when biological mesh is unavailable 2
• Open wound management with delayed repair is another option in highly contaminated cases 2

Why Mayo Repair and Tension Suture Are Not Recommended

• Mayo repair (vest-over-pants technique) creates tension on the repair and has higher recurrence rates compared to simple anatomical repair 3, 4
• Tension sutures can lead to tissue ischemia and increased pain, without providing significant benefits over standard anatomical repair 5, 4

Why Mesh Repair Is Contraindicated in This Scenario

• Despite mesh repair showing lower recurrence rates in clean fields (19% vs 0% in one study), the presence of toxic fluid creates a contaminated field where mesh is contraindicated 2, 6
• Mesh placement in contaminated fields significantly increases the risk of mesh infection, which may necessitate mesh removal and lead to hernia recurrence 1
• The 2017 World Society of Emergency Surgery guidelines specifically caution against synthetic mesh use in contaminated fields 1

Postoperative Considerations

• Antimicrobial therapy is recommended for patients with contamination or peritonitis 7
• Close monitoring for signs of infection is essential in the postoperative period 1
• Patient education regarding warning signs requiring return to the emergency department is important, including increasing pain, drainage, or fever 2

Clinical Pitfalls and Caveats

• Avoid mesh placement in contaminated fields despite the temptation to reduce recurrence rates 1, 2
• Consider the size of the defect when choosing the repair technique; larger defects may require component separation or staged repair 2
• Be prepared for potentially higher recurrence rates with primary repair, and discuss this with the patient 6, 4
• In cases of significant contamination, consider leaving the wound open or placing drains to prevent abscess formation 1, 7