What is the best course of treatment for an adult patient with a suspected infected umbilical hernia, possibly with a history of previous abdominal surgeries or conditions increasing intra-abdominal pressure?

Management of Infected Umbilical Hernia in Adults

For an adult with a suspected infected umbilical hernia, immediate surgical intervention with source control is the priority, combined with broad-spectrum antibiotics and aggressive fluid resuscitation, particularly if there are signs of peritonitis or systemic sepsis. 1

Immediate Assessment and Stabilization

Clinical Evaluation

• Assess for signs of complicated intra-abdominal infection: Look for diffuse peritonitis (abdominal rigidity, rebound tenderness), signs of sepsis (hypotension, tachycardia, altered mental status), or local complications (skin necrosis, perforation, strangulation, evisceration). 1, 2
• Risk stratification is critical: Use APACHE II score within 24 hours of admission to predict mortality and guide intensity of management in patients with complicated intra-abdominal infection. 1
• Special consideration for cirrhotic patients: Umbilical hernias occur in approximately 20% of patients with cirrhosis due to ascites, weakened fascia, and malnutrition—these patients face significantly higher morbidity and mortality. 1, 3

Resuscitation

• Begin rapid fluid resuscitation immediately upon suspicion of infection to restore intravascular volume and enhance visceral perfusion—volume depletion is common from fever, poor oral intake, and systemic inflammation. 1, 4
• For septic shock, resuscitation must begin immediately when hypotension is identified, and should continue concurrently with surgical preparation. 1, 5

Antibiotic Therapy

Timing and Selection

• Initiate broad-spectrum antibiotics as soon as the diagnosis is suspected, ideally within 1 hour for patients with septic shock. 1, 4
• Empiric coverage must target mixed aerobic/anaerobic flora typical of complicated intra-abdominal infections, including gram-negative organisms, gram-positive cocci, and anaerobes. 1, 4

Specific Regimens

• For mild-to-moderate community-acquired infection: Ertapenem, moxifloxacin, or piperacillin-tazobactam as single agents; alternatively, ceftriaxone or ciprofloxacin combined with metronidazole. 1
• For high-risk or severe infection (septic shock, advanced age, immunocompromised): Imipenem-cilastatin, meropenem, doripenem, or piperacillin-tazobactam. 1, 4
• Ensure adequate drug levels are maintained intraoperatively, which may require additional dosing just before the procedure. 1

Surgical Management

Timing of Intervention

• Emergency surgery should not be delayed for complete physiologic stabilization if diffuse peritonitis is present—resuscitative measures should continue during the procedure, as delayed source control increases mortality. 1, 5
• For hemodynamically stable patients without acute organ failure, intervention may be delayed up to 24 hours if appropriate antibiotics are given and close monitoring is provided. 1

Surgical Approach

• The primary goals are: drain infected foci, control ongoing contamination, debride necrotic tissue (including compromised skin), and restore anatomic function. 1, 5
• For stable patients with localized infection: Primary repair with mesh reinforcement is preferred, as mesh reduces recurrence rates even in small hernias. 6
• For unstable patients with severe sepsis or diffuse peritonitis: Open management is recommended to prevent abdominal compartment syndrome—measure intra-abdominal pressure intraoperatively if feasible. 1
• Avoid primary fascial closure under excessive tension or when risk of recurrent intra-abdominal hypertension exists, as this can lead to abdominal compartment syndrome. 1

Special Techniques

• Incisional negative pressure wound therapy (iNPWT) combined with hernioplasty has shown promising results in high-risk patients, including those with cirrhosis and complicated hernias, with local complication rates around 10.7% and 90-day mortality of 7.1%. 3
• For patients with ascites and cirrhosis: Control ascites preoperatively with sodium restriction, diuretics, and large-volume paracentesis if needed—optimal fluid control minimizes hernia progression and surgical complications. 1

Mesh Considerations

• Prosthetic mesh reduces recurrence but increases infection risk in contaminated fields—use cross-linked biological meshes as a delayed option for abdominal wall reconstruction when primary closure is not possible. 1
• In the presence of gross contamination or peritonitis, consider staged repair with temporary abdominal closure and delayed definitive reconstruction. 1

Postoperative Management

Antibiotic Duration

• For patients with adequate source control and resolving signs of infection, discontinue antibiotics when clinical improvement is evident—typically 3-5 days for non-critically ill patients, up to 7 days for critically ill or immunocompromised patients. 1, 4
• Oral step-down therapy with ciprofloxacin plus metronidazole, levofloxacin plus metronidazole, or moxifloxacin can be used once clinical improvement occurs. 1

Ascites Control (for cirrhotic patients)

• Postoperative sodium restriction and diuretic optimization are key determinants of successful outcome in patients with cirrhosis—uncontrolled ascites increases wound complications and hernia recurrence. 1
• Consider TIPS or liver transplantation for patients with refractory ascites and recurrent hernia complications. 1

Monitoring

• Watch for abdominal compartment syndrome in the immediate postoperative period, particularly in patients who underwent emergency repair with fascial closure—signs include oliguria, increased ventilatory pressures, and hemodynamic instability. 1
• Scheduled relaparotomy is not recommended unless there is intestinal discontinuity, inability to close the abdominal fascia, or intra-abdominal hypertension. 1, 5

Critical Pitfalls to Avoid

• Never delay surgery for complete stabilization in diffuse peritonitis—this significantly increases mortality. 5
• Do not rely on antibiotics alone without drainage for infected hernias with abscess or peritonitis—source control is essential. 1
• Avoid primary closure under tension in emergency settings with contamination—this leads to compartment syndrome and wound dehiscence. 1
• Do not use chest tubes or simple drains for ascites management in cirrhotic patients—these lead to protein depletion and infection risk. 1
• Avoid elective hernia repair in cirrhotic patients with uncontrolled ascites—optimize fluid status first or defer until liver transplantation. 1