What is the treatment for a patient with a ruptured umbilical hernia?

Treatment of Ruptured Umbilical Hernia

A ruptured umbilical hernia requires immediate emergency surgical repair with primary closure or mesh depending on contamination level, combined with aggressive perioperative management of ascites if cirrhosis is present. 1

Immediate Emergency Management

Proceed directly to emergency surgery without delay when umbilical hernia rupture is confirmed, as this represents a surgical emergency with high mortality risk if treatment is delayed. 1

Key Assessment Points

• Evaluate for intestinal strangulation using systemic inflammatory response syndrome (SIRS) criteria, lactate levels, CPK, and D-dimer—all are predictive of bowel strangulation and guide urgency. 1
• Obtain contrast-enhanced CT to assess bowel viability and extent of contamination if patient stability permits. 1
• Assess patient stability immediately—presence of severe sepsis or septic shock dramatically changes surgical approach. 1

Surgical Approach Based on Contamination Level

The surgical strategy depends entirely on CDC wound classification at the time of repair:

Clean-Contaminated Field (CDC Class II)

• Use synthetic mesh if intestinal strangulation and/or bowel resection occurred without gross enteric spillage—this carries no increase in 30-day wound-related morbidity and significantly reduces recurrence. 1
• This represents the highest quality evidence (Grade 1A) and should be your default approach when contamination is limited. 1

Contaminated/Dirty Field (CDC Class III-IV)

• Perform primary suture repair when the defect is small (<3 cm) in the presence of bowel necrosis, gross enteric spillage, or peritonitis from perforation. 1
• Use biological mesh when direct suture is not feasible due to defect size >3 cm—cross-linked biological mesh is preferred for larger defects and higher mechanical stress. 1, 2
• Consider polyglactin mesh or open wound management with delayed repair if biological mesh is unavailable. 1

Unstable Patients (Severe Sepsis/Septic Shock)

• Perform open management without immediate definitive closure to prevent abdominal compartment syndrome—measure intra-abdominal pressure intraoperatively. 1
• Attempt early definitive closure following patient stabilization, but only when risk of excessive tension or recurrent intra-abdominal hypertension is minimal. 1
• Accept skin-only closure if definitive fascial closure cannot be achieved—manage subsequent eventration with delayed abdominal closure and synthetic mesh repair at a later stage. 1

Special Considerations for Cirrhotic Patients

Ruptured umbilical hernia in cirrhotic patients (also called "Flood syndrome") carries exceptionally high mortality and requires specialized management. 3, 4

Perioperative Management

• Ensure surgery is performed by a surgeon experienced in managing cirrhotic patients and obtain mandatory hepatology consultation for postoperative ascites control. 2, 5
• Implement aggressive postoperative ascites management including sodium restriction to 2 g/day, minimizing IV maintenance fluids, and maximizing diuretic therapy (spironolactone up to 400 mg/day plus furosemide up to 160 mg/day in 100:40 mg ratio). 2, 5
• Consider TIPS placement postoperatively if ascites cannot be controlled medically to prevent wound dehiscence and recurrence. 2, 5

Novel Adjunctive Technique

• Apply incisional negative pressure wound therapy (iNPWT) in cirrhotic patients with ruptured hernias—recent evidence shows this reduces local wound complications to 10.7% with 90-day mortality of only 7.1%, comparable to elective repairs. 6
• Consider placement of large-bore Robinson drainage tubes (two tubes) for 10-14 days postoperatively until wound healing is complete, which has reduced morbidity from 25% to 10% and decreased recurrence rates. 7

Antimicrobial Management

• Administer 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC wound classes II-III). 1
• Provide full antimicrobial therapy (not just prophylaxis) for patients with peritonitis from bowel perforation (CDC wound class IV). 1
• Use gyrase inhibitors in cirrhotic patients to prevent spontaneous bacterial peritonitis during the perioperative period. 7

Critical Pitfalls to Avoid

• Never delay surgery in ruptured umbilical hernia—elapsed time from symptom onset to surgery is the most important prognostic factor (P<0.005), and delays beyond 24 hours significantly increase mortality. 2
• Avoid rapid or large volume paracentesis immediately before or after surgery in cirrhotic patients, as this can paradoxically cause incarceration or wound complications. 2, 5
• Do not use absorbable prosthetic materials as they lead to inevitable hernia recurrence due to complete dissolution. 2
• Avoid synthetic mesh in heavily contaminated fields (CDC class III with gross spillage or class IV) as infection rates can reach 21%, requiring mesh explantation in 72.7% of infected cases. 2

Expected Outcomes

• Operative mortality in experienced hands can be as low as 5% for incarcerated or ruptured hernias in cirrhotic patients when proper perioperative management is employed. 2, 5
• Non-operative management of ruptured hernias in cirrhosis results in mortality rates of 60-88%, making surgery mandatory despite risks. 5
• Emergency surgery in cirrhotic patients carries dramatically increased mortality (OR=10.32) compared to elective repair, but remains life-saving when rupture occurs. 2, 5