What is the recommended treatment for a patient with a large umbilical hernia?

Large Umbilical Hernia: Patient Education and Treatment Recommendations

Primary Treatment Recommendation

All large umbilical hernias should be repaired with mesh reinforcement, as this approach significantly reduces recurrence rates compared to suture repair alone, regardless of hernia size. 1, 2

Why Mesh Repair is Essential

• Mesh repair dramatically reduces recurrence rates from 19% with suture-only repair to 0-4.3% with mesh, without increasing wound infection rates in clean surgical fields 1
• Even for hernias as small as 1 cm, mesh should be used because tissue repair alone has unacceptably high recurrence rates 1, 2
• Synthetic mesh (such as polypropylene) is the standard choice for uncomplicated hernias in clean surgical fields 3, 1

Surgical Approach Options

For uncomplicated large umbilical hernias, both open and laparoscopic approaches are effective:

• Laparoscopic repair offers shorter hospital stays, lower wound infection rates, and the ability to identify hidden hernias 1
• Common laparoscopic techniques include IPOM (Intraperitoneal Onlay Mesh), TAPP (Transabdominal Preperitoneal), and the newer eTEP (enhanced-view Totally Extraperitoneal) approach 1, 4
• Open mesh repair remains highly effective with excellent outcomes and may be preferred based on surgeon expertise 1, 5

Timing of Repair

Elective repair should be performed soon after diagnosis to prevent complications:

• Delaying repair increases risk of incarceration, strangulation, and emergency surgery 1
• Emergency surgery carries dramatically higher mortality risk (10-fold increase) compared to elective repair 1
• Do not wait for symptoms to worsen - repair should be performed regardless of current symptom severity 1

Warning Signs Requiring Immediate Emergency Care

Patients must seek immediate medical attention if they develop:

• Sudden severe pain at the hernia site that persists 1
• Inability to push the hernia back in (irreducibility) 1
• Nausea and vomiting, which may indicate bowel obstruction 3, 1
• Fever ≥38°C combined with rapid heart rate (≥110 beats/minute) 1
• Skin changes over the hernia including redness, darkening, or breakdown 1
• Signs of infection such as severe sepsis symptoms (confusion, decreased urination, rapid breathing) 1

Special Considerations for High-Risk Patients

Patients with Liver Cirrhosis and Ascites

If you have liver disease with fluid accumulation (ascites), special preparation is critical:

• Ascites must be medically controlled before elective surgery through strict sodium restriction (2000 mg/day) and diuretic medications (spironolactone up to 400 mg/day plus furosemide up to 160 mg/day) 1
• Emergency surgery in cirrhotic patients carries 10-fold higher mortality risk, making preoperative optimization essential 1
• TIPS procedure (transjugular intrahepatic portosystemic shunt) may be needed to control ascites before or after hernia repair 1
• After surgery, aggressive ascites management is mandatory to prevent wound breakdown and hernia recurrence 1
• Critical pitfall to avoid: Rapid removal of large volumes of ascitic fluid can paradoxically cause the hernia to become trapped 1

Patients with Anemia

If you are anemic, this should be corrected before elective surgery:

• Preoperative anemia increases risk of complications, blood transfusions, and mortality 1
• Iron supplementation (oral or intravenous) should be given 2-4 weeks before surgery when possible 1
• Intravenous iron is more effective than oral iron at restoring hemoglobin levels 1

Expected Recovery and Outcomes

With proper mesh repair, patients can expect:

• Hospital stay of 1-3 days for uncomplicated repairs 4, 6
• Very low recurrence rates (0-4.3%) with mesh repair 1
• Return to normal activities within 2-4 weeks (specific timing depends on surgical approach and individual healing)
• Minimal long-term complications when mesh is properly placed 1

Key Takeaway Messages

The most important points to remember:

• Mesh repair is mandatory - suture-only repair has unacceptably high failure rates 1, 2
• Elective repair is safer than emergency repair - don't delay until complications develop 1
• Watch for warning signs and seek immediate care if they occur 1
• Medical optimization before surgery (controlling ascites, correcting anemia) significantly improves outcomes 1