Recommended Treatment for Umbilical Hernia
All umbilical hernias should be surgically repaired with mesh reinforcement, except for the smallest defects (<1 cm), as mesh significantly reduces recurrence rates compared to tissue repair alone. 1
Surgical Approach Based on Hernia Characteristics
Elective Repair (Uncomplicated Hernias)
Mesh repair is mandatory for all defects ≥1 cm to prevent the high recurrence rates (up to 19%) seen with tissue repair alone. 1, 2
- Synthetic mesh is the standard choice for clean surgical fields (no contamination or strangulation). 1
- Laparoscopic techniques (TAPP, TEP, IPOM, or eTEP) offer lower wound infection rates and shorter hospital stays compared to open repair. 1, 3
- Open mesh repair remains appropriate when laparoscopic expertise is unavailable or patient factors preclude minimally invasive surgery. 2
The eTEP (enhanced-view totally extraperitoneal) approach is emerging as a safe and reproducible technique that places mesh outside the abdominal cavity while maintaining minimally invasive benefits, though it requires higher surgical expertise. 3
Emergency Repair (Complicated Hernias)
Immediate surgical intervention is required for any signs of strangulation, including: 1
- Irreducible hernia with increasing pain
- Systemic Inflammatory Response Syndrome (SIRS)
- Elevated lactate, CPK, or D-dimer levels
- Skin changes (redness, discoloration, necrosis) over the hernia
- Symptoms persisting >8 hours
Mesh selection in emergency settings depends on surgical field contamination: 1
- Clean-contaminated fields (CDC Class II - strangulation with bowel resection but no gross spillage): Synthetic mesh can be safely used without increased wound morbidity
- Contaminated/dirty fields (CDC Class III-IV - bowel necrosis or gross spillage):
- Primary repair for small defects (<3 cm)
- Biological mesh for larger defects when direct suture is not feasible
- Polyglactin mesh as alternative when biological mesh unavailable
Critical timing consideration: Elapsed time from symptom onset to surgery is the most important prognostic factor (P<0.005), with delayed treatment >24 hours associated with significantly higher mortality. 1
Special Population Considerations
Cirrhotic Patients with Ascites
This population faces unique challenges, as umbilical hernias occur in up to 24% of cirrhotic patients with ascites, and emergency surgery carries 10-fold higher mortality risk (OR=10.32). 1
Elective repair strategy: 1
- Optimize ascites control before surgery with sodium restriction (2 g/day) and diuretics
- Consider perioperative TIPSS to reduce wound dehiscence and recurrence
- Defer repair until liver transplantation if transplant is imminent
- Involve multidisciplinary discussion with hepatology
Emergency repair (strangulated/ruptured hernias): 1
- Surgery is mandatory despite refractory ascites
- Must be performed by surgeon experienced with cirrhotic patients
- Mandatory hepatology consultation for postoperative ascites management
- Consider TIPS placement postoperatively if ascites cannot be controlled medically
- Avoid large volume paracentesis immediately before/after surgery (can paradoxically cause incarceration)
Pregnant Women
Timing algorithm: 4
- Incarcerated/strangulated hernia: Emergency repair regardless of trimester
- Symptomatic uncomplicated hernia: Elective repair in second trimester (safest timing)
- Small asymptomatic hernia: Postpone until after delivery
- Postpartum repair: Can be performed as early as 8 weeks postpartum, though waiting 1 year allows hormonal stabilization and return to normal body weight
Mesh is essential even during pregnancy, as suture-only repairs have unacceptably high recurrence rates with the increased intra-abdominal pressure of pregnancy. 4
Pediatric Patients
Observation is appropriate for most pediatric umbilical hernias, as the majority close spontaneously. 5
Surgical repair indicated when: 5
- Defect >1 cm persisting beyond age 3-4 years
- Progressive enlargement during observation period
- Symptomatic (pain, incarceration)
Critical Pitfalls to Avoid
- Never perform tissue repair alone for defects ≥1 cm, even if they appear small—recurrence rates are unacceptably high (up to 19% vs 0-4.3% with mesh). 1
- Do not use absorbable prosthetic materials, as they lead to inevitable hernia recurrence due to complete dissolution. 1
- 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 incarceration—coordinate carefully with hepatology. 1
- Do not delay emergency repair when strangulation is suspected—every hour increases morbidity and mortality. 1