What is the recommended treatment for an umbilical hernia?

Treatment of Umbilical Hernias

All umbilical hernias should be repaired surgically using mesh reinforcement, as mesh repair significantly reduces recurrence rates compared to tissue repair alone, regardless of hernia size. 1

Surgical Approach Selection

Mesh Repair is Mandatory

• Mesh should be used for all umbilical hernia repairs, even for small defects (<1 cm), as it reduces recurrence rates from 19% to 0-4.3% compared to tissue repair. 1, 2
• Tissue repair alone should be avoided even for small defects due to unacceptably high recurrence rates. 1

Technique Options Based on Clinical Scenario

For Clean, Uncomplicated Hernias:

• Synthetic mesh is recommended for all clean surgical fields (no intestinal strangulation). 1
• Multiple approaches are available: open onlay, laparoscopic IPOM (Intraperitoneal Onlay Mesh), TAPP (Transabdominal Preperitoneal), TEP (Total Extraperitoneal), or eTEP (enhanced-view totally extraperitoneal). 1, 3
• Laparoscopic approaches show lower wound infection rates and shorter hospital stays compared to open repair. 1

For Incarcerated Hernias Without Strangulation:

• Mesh repair remains safe and recommended. 1
• Manual reduction can be attempted if onset is recent (<24 hours), no signs of strangulation exist, and minimal pain is present. 1

For Strangulated Hernias (Clean-Contaminated Field, CDC Class II):

• Emergency surgical repair is mandatory immediately upon diagnosis. 1
• Synthetic mesh can still be safely used even with intestinal strangulation and bowel resection, provided there is no gross enteric spillage. 1
• No significant increase in 30-day wound-related morbidity occurs with mesh in this setting. 1

For Contaminated/Dirty Fields (CDC Classes III and IV):

• Primary repair without mesh for small defects (<3 cm) with bowel necrosis and/or gross enteric spillage. 1
• Biological mesh (preferably cross-linked for larger defects) when direct suture is not feasible for defects >3 cm. 1
• Avoid absorbable prosthetic materials as they lead to inevitable recurrence. 1

Timing of Repair

Elective Repair:

• Repair should be performed regardless of size to prevent complications. 1
• Do not delay repair waiting for spontaneous closure in adults. 1

Emergency Repair Indications:

• Signs of intestinal strangulation (irreducibility, severe pain, vomiting, skin changes including redness/discoloration/necrosis). 1
• SIRS (Systemic Inflammatory Response Syndrome) is predictive of bowel strangulation. 1
• Elevated lactate, CPK, or D-dimer levels suggest bowel strangulation. 1
• Symptoms persisting longer than 8 hours are associated with significantly higher morbidity. 1
• Delayed treatment beyond 24 hours after onset of acute complications increases mortality. 1

Special Population: Cirrhotic Patients with Ascites

Risk Stratification:

• Umbilical hernias occur in up to 24% of cirrhotic patients with ascites. 1
• Emergency surgery carries significantly higher mortality risk (OR=10.32). 1

Elective Repair Strategy:

• Optimize ascites control before elective repair with sodium restriction to 2 g/day and diuretics. 1
• Consider perioperative large volume paracentesis (LVP) or TIPS to reduce wound dehiscence and recurrence. 1
• Defer repair until liver transplantation if transplant is imminent. 1
• Surgery should be performed by a surgeon experienced in caring for cirrhotic patients. 1

Emergency Repair in Cirrhotic Patients:

• Emergency surgery is mandatory for strangulated, incarcerated (irreducible), or ruptured hernias despite refractory ascites. 1
• Mandatory hepatology consultation for postoperative ascites management. 1
• Postoperative management includes sodium restriction to 2 g/day, minimizing IV maintenance fluids, and considering TIPS if ascites cannot be controlled medically. 1

Critical Pitfalls to Avoid

• Never perform tissue repair alone—always use mesh. 1, 2
• Avoid synthetic mesh in contaminated fields (CDC class III) where infection rates can reach 21%. 1
• In cirrhotic patients, rapid ascites removal can paradoxically cause hernia incarceration—coordinate carefully with hepatology. 1
• Do not use absorbable prosthetic materials as they completely dissolve and cause inevitable recurrence. 1
• Elapsed time from symptom onset to surgery is the most important prognostic factor for complicated hernias (P<0.005). 1