Umbilical Hernia Surgical Management
All umbilical hernias should be repaired using mesh reinforcement regardless of defect size, as mesh repair significantly reduces recurrence rates compared to tissue repair (19% vs 0-4.3%) and should be performed electively to prevent life-threatening complications. 1, 2
Indications for Surgical Repair
Adult Patients
- Repair all symptomatic umbilical hernias electively after diagnosis to prevent incarceration, strangulation, and rupture 1, 3
- Elective repair is strongly preferred over emergency repair, as emergency surgery carries significantly higher mortality risk (OR=10.32) 1
- Even asymptomatic hernias warrant repair given the risk of acute complications 1
Pediatric Patients
- Observe hernias until age 3-4 years, as most close spontaneously 4
- Operate on defects >1 cm by age 3-4 years 4
- Repair immediately if the defect persists, enlarges during observation, or becomes symptomatic regardless of age 4
- Strapping does not accelerate closure and is not recommended 4
Mesh Selection Based on Surgical Field Contamination
Clean Fields (No Bowel Compromise)
- Use synthetic mesh (standard polypropylene) as the primary choice 1, 3
- Synthetic mesh provides optimal outcomes with lowest recurrence rates 1, 2
Clean-Contaminated Fields (CDC Class II)
- Synthetic mesh can be safely used even with intestinal strangulation and/or bowel resection without gross enteric spillage 1
- No significant increase in 30-day wound-related morbidity compared to non-mesh repair 1
Contaminated/Dirty Fields (CDC Classes III-IV)
- Primary suture repair for small defects (<3 cm) with bowel necrosis and/or gross enteric spillage 1
- Biological mesh when direct suture is not feasible for larger defects 1
- Cross-linked biological mesh is more resistant to mechanical stress for larger defects 1
- Non-cross-linked biological mesh completely remodels into autologous tissue 1
- Polyglactin mesh is an alternative when biological mesh is unavailable 1
- Avoid absorbable prosthetic materials as they lead to inevitable hernia recurrence 1
- Beware: synthetic mesh infection rates can reach 21% in contaminated fields 1
Surgical Approach Selection
Open Mesh Repair
- Onlay technique with standard polypropylene mesh for straightforward cases 3
- Suitable for most adult umbilical hernias 3
Laparoscopic Approaches
- Intraperitoneal Onlay Mesh (IPOM): mesh placed inside peritoneal cavity and fixed to abdominal wall 1
- Transabdominal Preperitoneal (TAPP) and Total Extraperitoneal (TEP): mesh placed in preperitoneal space 1
- Enhanced-view Totally Extraperitoneal (eTEP): newer technique placing mesh outside abdominal cavity with minimally invasive approach 5
- Requires composite mesh (not standard polypropylene) to prevent adhesions 3
- Advantages: lower wound infection rates, shorter hospital stays, ability to evaluate hernia content viability and repair occult contralateral hernias 1
- Disadvantages: longer operative times (mean 101.8 minutes for eTEP), requires higher surgical expertise 5
Hernioscopy
- Mixed laparoscopic-open technique effective for evaluating viability of herniated loops 1
- Particularly useful after spontaneous reduction of strangulated hernias 1
Emergency Repair Indications
Red Flags Requiring Immediate Surgery
- Intestinal strangulation requires emergency surgical repair immediately 1
- Systemic Inflammatory Response Syndrome (SIRS) predicts bowel strangulation 1
- Elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels indicate possible strangulation 1
- Contrast-enhanced CT showing compromised blood flow to herniated bowel 1
- Symptoms persisting >8 hours associated with significantly higher morbidity 1
- Skin changes over hernia (redness, discoloration, necrosis) indicate advanced strangulation 1
- Delayed treatment >24 hours after symptom onset increases mortality rates 1
Manual Reduction Criteria
- Consider only if onset <24 hours, no signs of strangulation, and minimal pain present 1
- Educate patients on warning signs: increasing pain, irreducibility, vomiting 1
Special Population: Cirrhotic Patients with Ascites
Risk Stratification
- Umbilical hernias occur in up to 24% of cirrhotic patients with ascites 1
- High risk of incarceration, strangulation, and rupture 1
- Emergency surgery mortality risk significantly elevated (OR=10.32) 1
Elective Repair Strategy
- Optimize ascites control before elective repair 1
- Consider perioperative large volume paracentesis (LVP) or TIPSS to reduce wound dehiscence and recurrence 1
- Defer repair until liver transplantation if transplant is imminent 1
- Multidisciplinary discussion with hepatology required 1
Emergency Repair in Cirrhotic Patients
- Emergency surgery mandatory for strangulated, incarcerated (irreducible), or ruptured hernias despite refractory ascites 1
- Surgery must be performed by surgeon experienced in caring for cirrhotic patients 1
- Mandatory hepatology consultation for postoperative ascites control 1
- Postoperative management: sodium restriction to 2 g/day, minimize IV maintenance fluids 1
- Consider TIPS placement if ascites cannot be controlled medically postoperatively 1
- Operative mortality can be reduced to as low as 5% with proper perioperative management 1
Critical Pitfalls to Avoid
- Never perform tissue repair alone—always use mesh, even for small hernias, as suture repair has 19-54% recurrence rates 1, 6
- In cirrhotic patients, avoid rapid ascites removal and large volume paracentesis immediately before/after surgery, as this can paradoxically cause incarceration 1
- Do not use absorbable prosthetic materials—they dissolve completely and cause inevitable recurrence 1
- Recognize that obesity (BMI >30), hernia size >2 cm, and smoking are risk factors for recurrence 3, 6
- Common complications include large seromas and surgical site infections, which may result in recurrence 3