What is the appropriate management for an adult or child with an infected umbilical hernia?

Management of Infected Umbilical Hernia

An infected umbilical hernia requires emergency surgical repair with careful mesh selection based on the degree of contamination: synthetic mesh can be safely used in clean-contaminated fields (intestinal strangulation without gross spillage), while biological mesh or primary repair is recommended for contaminated/dirty fields with bowel necrosis or perforation. 1

Immediate Assessment and Red Flags

Emergency surgery is mandatory when any of the following are present:

• Signs of strangulation: tachycardia ≥110 bpm, fever ≥38°C, persistent vomiting, or systemic inflammatory response syndrome (SIRS) 1
• Skin changes over the hernia: redness, discoloration, necrosis, or signs of impending rupture 1
• Peritonitis: indicating hernia rupture or bowel perforation 1
• Elevated laboratory markers: lactate, CPK, D-dimer, or white blood cell count suggesting bowel ischemia 1
• Symptoms >8 hours duration: associated with significantly higher morbidity and mortality 1

Critical pitfall: Do not dismiss tachycardia as the only abnormal vital sign—it may be the earliest and only indicator of serious complications. 1

Surgical Approach Based on Contamination Level

Clean-Contaminated Fields (CDC Class II)

For intestinal strangulation with bowel resection but without gross enteric spillage:

• Use synthetic mesh safely—no significant increase in 30-day wound-related morbidity compared to non-mesh repair 1
• Laparoscopic approach preferred when feasible, showing lower wound infection rates and shorter hospital stays 1
• Hernioscopy (mixed laparoscopic-open technique) effective for evaluating viability of herniated loops 1

Contaminated/Dirty Fields (CDC Classes III-IV)

For bowel necrosis with gross enteric spillage or established peritonitis:

• Primary repair for small defects (<3 cm) 1
• Biological mesh for larger defects (>3 cm) when direct suture not feasible 1
• Cross-linked biological mesh is more resistant to mechanical stress and better for larger defects 1
• Polyglactin mesh is an alternative when biological mesh unavailable 1
• For unstable patients with severe sepsis/septic shock: open management without immediate mesh placement to prevent abdominal compartment syndrome, with delayed definitive closure after stabilization 1

Important caveat: Synthetic mesh in contaminated fields (CDC class III) carries infection rates as high as 21%, making biological mesh the safer choice. 1

Special Considerations for Cirrhotic Patients

Cirrhotic patients with infected umbilical hernias face dramatically elevated risks and require specialized management:

Emergency Surgery Protocol

• Emergency repair is mandatory for strangulated, incarcerated (irreducible), or ruptured hernias despite refractory ascites 2, 1
• Surgery must be performed by a surgeon experienced in managing cirrhotic patients 1
• Mandatory hepatology consultation for postoperative ascites control 1
• Emergency surgery carries 10-fold higher mortality (OR=10.32) compared to elective repair 1
• With optimal perioperative management, operative mortality can be reduced to as low as 5% 1

Critical Perioperative Ascites Management

Postoperative ascites control is the key determinant of successful outcome:

• Sodium restriction to 2 g/day (88 mmol) 2, 1
• Minimize or eliminate IV maintenance fluids 1
• Aggressive diuretic therapy: spironolactone up to 400 mg/day plus furosemide up to 160 mg/day in 100:40 mg ratio 1
• Consider TIPS placement if ascites cannot be controlled medically to prevent wound dehiscence and recurrence 2, 1

Critical pitfall: Avoid large volume paracentesis immediately before or after surgery—rapid ascites removal can paradoxically cause incarceration. 2, 1

Emerging Evidence for Wound Management

Recent data from 2025 suggests that incisional negative pressure wound therapy (iNPWT) combined with surgical repair in cirrhotic patients with complicated umbilical hernias yields favorable outcomes: 10.7% local wound complications, 35.7% systemic complications, and 7.1% 90-day mortality. 3 This represents a significant improvement over historical outcomes and may be considered as an adjunct to standard surgical management.

Antimicrobial Therapy

• Short-term prophylaxis for incarcerated hernias without ischemia (CDC Class I) 1
• 48-hour prophylaxis for strangulation and/or bowel resection (CDC Classes II-III) 1
• Full antimicrobial therapy for established peritonitis (CDC Class IV) 1

Mesh Fixation and Technique

When mesh is used:

• Mesh should extend beyond defect boundaries by at least 3 cm for umbilical hernias 1
• Secure using tackers or transfascial sutures, avoiding tackers near vital structures 1
• Ensure tension-free placement 1

Postoperative Monitoring

• Monitor for wound dehiscence, particularly in cirrhotic patients with inadequate ascites control 1
• Watch for mesh infection (occurs in 1.9-5% of cases), which may require complete explantation in 72.7% of cases 1
• Risk factors for mesh infection include emergency operations, smoking, ASA score ≥3, and longer operative duration 1