What is the recommended treatment for an umbilical hernia?

Recommended Treatment for Umbilical Hernia

All umbilical hernias should be repaired surgically using mesh reinforcement, regardless of size, as mesh repair significantly reduces recurrence rates compared to tissue repair (19% vs 0%) and prevents potentially life-threatening complications. 1

Surgical Approach Selection

Standard Elective Repair

• Mesh repair is mandatory for all umbilical hernias, even small defects, as tissue repair alone has unacceptably high recurrence rates 1, 2
• Laparoscopic techniques (TAPP, TEP, or IPOM) offer lower wound infection rates and shorter hospital stays compared to open repair 1
• The enhanced-view totally extraperitoneal (eTEP) approach is a safe and reproducible alternative that places mesh outside the abdominal cavity while maintaining minimally invasive benefits 3
• Open onlay mesh repair remains appropriate when laparoscopic expertise is unavailable 4

Mesh Selection Based on Contamination

• Clean surgical fields: Use synthetic mesh (standard polypropylene for open, composite mesh for laparoscopic) 1, 4
• Clean-contaminated fields (intestinal strangulation without gross spillage): Synthetic mesh can still be used safely with no significant increase in 30-day wound-related morbidity 1
• Contaminated/dirty fields (bowel necrosis with gross spillage): Use biological mesh for defects >3 cm; primary repair only for small defects <3 cm 1
• Avoid absorbable prosthetic materials as they lead to inevitable recurrence due to complete dissolution 1

Emergency Indications Requiring Immediate Surgery

Red Flags for Strangulation

• Irreducible hernia with signs of strangulation requires emergency surgical repair immediately to prevent septic complications and death 1
• Systemic Inflammatory Response Syndrome (SIRS) predicts bowel strangulation 1
• Elevated lactate, CPK, and D-dimer levels indicate possible bowel strangulation 1
• Skin changes (redness, discoloration, necrosis) over the hernia indicate advanced strangulation 1
• Symptoms persisting >8 hours are associated with significantly higher morbidity 1
• Elapsed time from symptom onset to surgery is the most important prognostic factor (P<0.005) 1

Manual Reduction Criteria

• Manual reduction can be attempted only if onset <24 hours, no signs of strangulation, and minimal pain present 1
• If reduction fails or any concerning signs exist, proceed immediately to surgery 1

Special Population: Cirrhotic Patients with Ascites

Timing of Elective Repair

• Perform elective repair even for minimally symptomatic hernias to avoid emergency surgery, which carries 10-fold higher mortality risk (OR=10.32) 1, 5
• Optimize ascites control before elective repair using sodium restriction (2 g/day) and diuretics 1, 5
• Consider perioperative large volume paracentesis or TIPS to reduce wound dehiscence and recurrence 1
• Defer repair until liver transplantation only if transplant is imminent 1

Emergency Repair in Cirrhotic Patients

• Emergency surgery is mandatory for strangulated or ruptured hernias despite refractory ascites 1, 5
• Surgery must be performed by a surgeon experienced in cirrhotic patients 1
• Mandatory hepatology consultation for postoperative ascites management 1
• Consider TIPS placement postoperatively if ascites cannot be controlled medically 1, 5
• Excise necrotic skin tissue during repair 5

Critical Pitfalls to Avoid

• Never perform tissue repair without mesh, even for small defects, as recurrence rates are unacceptably high 1, 2
• Avoid synthetic mesh in contaminated fields (CDC class III) where infection rates reach 21% 1
• In cirrhotic patients, avoid rapid ascites removal as it can paradoxically cause hernia incarceration 1
• Do not perform large volume paracentesis immediately before or after surgery without careful hepatology coordination 1
• Never use absorbable prosthetic materials 1
• Minimize IV maintenance fluids postoperatively in cirrhotic patients to prevent ascites accumulation 1

Pediatric Exception

• In children, observation with periodic follow-up is appropriate as the majority close spontaneously 6
• Recommend surgery for defects >1 cm by age 3-4 years, or earlier if the defect persists, enlarges, or becomes symptomatic 6