What are the management options for umbilical hernia?

Management of Umbilical Hernia

Surgical Repair is Recommended for Most Umbilical Hernias

All symptomatic umbilical hernias should undergo surgical repair with mesh placement, as mesh repair significantly reduces recurrence rates compared to tissue repair (19% vs 0% in comparative studies), even for small defects. 1

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Initial Assessment and Decision-Making

When to Operate vs Observe

Adults:

• Repair all symptomatic umbilical hernias regardless of size to prevent complications 1
• Repair asymptomatic hernias with defects >1 cm due to risk of incarceration and strangulation 1, 2
• Defects <1 cm may be considered for suture repair, though mesh is still preferred 2

Pediatric Population:

• Observe asymptomatic umbilical hernias until age 3-4 years, as most close spontaneously 3
• Operate on defects >1 cm by age 3-4 years if no spontaneous closure occurs 3
• Operate earlier if the defect enlarges during observation or becomes symptomatic 3
• Incarceration and strangulation are uncommon in children 3

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Surgical Technique Selection

Mesh Placement is Superior to Tissue Repair

Use mesh for all repairs except the smallest defects (<1 cm), as mesh reduces recurrence rates without increasing wound infection rates in clean surgical fields. 4, 1

Approach Options:

Open Repair:

• Appropriate for small hernias and can be performed under local anesthesia for defects <2 cm 5
• Place mesh in preperitoneal space with 3 cm overlap of the hernia defect 2

Laparoscopic Repair:

• Shows lower wound infection rates and shorter hospital stays 1
• Allows evaluation of hernia content viability and detection of occult contralateral hernias 1
• Particularly advantageous in cirrhotic patients to avoid skin incisions and ascitic fluid leaks 5
• Techniques include TAPP, TEP, IPOM, and eTEP approaches 1, 6

eTEP (Enhanced-view Totally Extraperitoneal):

• Safe and reproducible technique for defects >1 cm 6
• Places mesh outside abdominal cavity while maintaining minimally invasive approach 6
• Mean operative time 101.8 minutes with low complication rates 6

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Mesh Selection Based on Surgical Field Contamination

Clean Fields (CDC Class I - No Bowel Compromise):

• Use synthetic mesh for all clean cases, as it provides lowest recurrence rates without increasing infection risk 4, 1

Clean-Contaminated Fields (CDC Class II - Strangulation Without Gross Spillage):

• Synthetic mesh can be safely used even with intestinal strangulation and/or bowel resection without gross enteric spillage 4, 1
• No significant increase in 30-day wound-related morbidity 4, 1

Contaminated Fields (CDC Class III - Bowel Necrosis/Gross Spillage):

• Primary tissue repair for defects <3 cm 4, 1
• Biological mesh when direct suture not feasible for larger defects 4, 1
• Cross-linked biological mesh for larger defects and higher mechanical stress 1
• Non-cross-linked biological mesh for complete tissue remodeling 1
• Polyglactin mesh as alternative if biological mesh unavailable 4, 1

Dirty Fields (CDC Class IV - Peritonitis):

• Primary repair for small defects (<3 cm) 4, 1
• Biological mesh for larger defects 4, 1
• Open wound management with delayed repair if needed 4, 1

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Special Population: Cirrhotic Patients with Ascites

Elective Repair Strategy:

Optimize ascites control before elective repair to reduce wound dehiscence and recurrence. 1

• Umbilical hernias occur in up to 24% of cirrhotic patients with ascites 1
• Emergency surgery carries 10-fold higher mortality risk (OR=10.32) 1
• Control ascites with sodium restriction (2 g/day), diuretics, and paracentesis 1, 5
• Consider perioperative TIPS if ascites cannot be controlled medically 1, 5
• Defer repair until liver transplantation if transplant is imminent 1

Emergency Repair Indications:

Operate emergently for strangulated, incarcerated (irreducible), or ruptured umbilical hernias despite refractory ascites. 1

• Mandatory hepatology consultation for postoperative ascites management 1
• Surgery should be performed by surgeon experienced with cirrhotic patients 1
• Postoperative TIPS placement if ascites cannot be controlled medically 1, 5
• Excise necrotic skin tissue during repair 5
• Laparoscopic approach preferred to avoid skin incisions and ascitic fluid leaks 5

Critical Pitfall:

Avoid rapid ascites removal or large volume paracentesis immediately before/after surgery, as this can paradoxically cause hernia incarceration. 1

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Emergency Repair for Complicated Hernias

Red Flags Requiring Immediate Surgery:

Operate immediately for signs of intestinal strangulation, as delayed diagnosis increases septic complications and mortality. 1

• Irreducible hernia with severe pain 1
• Skin changes (redness, discoloration, necrosis) over hernia 1
• Signs of bowel obstruction (vomiting, inability to pass gas/stool) 1
• Systemic inflammatory response syndrome (SIRS) 1
• Elevated lactate, CPK, or D-dimer levels 1
• CT findings of compromised bowel blood flow 1
• Symptoms persisting >8 hours (associated with higher morbidity) 1

Surgical Approach for Incarcerated/Strangulated Hernias:

Laparoscopic approach may be used for incarcerated hernias without strangulation or suspected bowel necrosis; use open preperitoneal approach if bowel resection anticipated. 4

• Manual reduction can be attempted if onset <24 hours, no strangulation signs, and minimal pain 1
• Hernioscopy (mixed laparoscopic-open technique) useful for evaluating viability of herniated bowel 1
• Time from symptom onset to surgery is the most important prognostic factor (P<0.005) 1
• Delayed treatment >24 hours associated with higher mortality 1

Unstable Patients (Severe Sepsis/Septic Shock):

• Open management recommended to prevent abdominal compartment syndrome 4
• Monitor intra-abdominal pressure intraoperatively 4
• Attempt early definitive closure after stabilization 4
• Skin-only closure acceptable if fascial closure not possible, with delayed repair later 4

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Postoperative Management

Expected Outcomes:

• Low recurrence rates with mesh repair (0-4.3%) 1
• Postoperative complications occur in approximately 2% of cases 2
• Complication-related reoperations in 0.7% of cases 2

Antimicrobial Prophylaxis:

• Short-term prophylaxis for incarcerated hernias without ischemia (CDC Class I) 4
• 48-hour prophylaxis for strangulation and/or bowel resection (CDC Classes II-III) 4
• Full antimicrobial therapy for peritonitis (CDC Class IV) 4

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Key Pitfalls to Avoid

• Never use absorbable prosthetic materials, as they lead to inevitable hernia recurrence 1
• Avoid tissue repair even for small defects, as mesh significantly reduces recurrence 1, 2
• Do not use synthetic mesh in contaminated fields (CDC Class III), as infection rates can reach 21% 1
• In cirrhotic patients, coordinate ascites management carefully with hepatology to prevent wound dehiscence 1, 5
• Do not delay surgery for signs of strangulation, as elapsed time is the most important prognostic factor 1