Management of Umbilical Hernia
Infants and Children: Observation is Standard
The vast majority of umbilical hernias in infants close spontaneously by age 3-4 years and should be observed without intervention. 1, 2
Observation Criteria in Pediatric Patients
- Defects <1 cm: Observe until age 3-4 years, as spontaneous closure occurs in most cases 2
- Defects 1-2 cm: Continue observation but monitor closely for signs of enlargement 2
- Asymptomatic hernias: The great majority are asymptomatic and require only periodic follow-up 2
Indications for Surgical Repair in Children
Surgical repair is indicated when:
- Defect >1 cm persisting beyond age 3-4 years 2
- Progressive enlargement of the fascial defect during observation period, regardless of age 2
- Incarceration or strangulation (rare but requires immediate emergency repair) 3
- Symptomatic hernias causing intermittent umbilical or abdominal pain 2
Critical Pitfall in Pediatric Management
Strapping or taping has no proven benefit and does not improve or accelerate closure—avoid this outdated practice 2
Adults: Surgery is Indicated for All Symptomatic Hernias
All symptomatic umbilical hernias in adults should be repaired surgically using mesh, as mesh significantly reduces recurrence rates compared to suture repair (0-4.3% vs 19-54%). 3, 4, 5
Surgical Approach Based on Defect Size
Small Defects (<1 cm)
- Suture repair may be considered for defects <1 cm, though mesh is increasingly preferred even for these small hernias 6
- Current practice shows 75% of small (<2 cm) hernias are still treated with suture repair, though this contradicts guideline recommendations 6
Medium Defects (1-2 cm)
- Mesh repair is recommended to minimize recurrence risk 4, 6
- Suture repair for defects >1 cm carries recurrence rates of 19-54% 5
Large Defects (>2 cm)
- Mesh repair is mandatory—primary suture repair is associated with ~42% recurrence rate and should be avoided 3
- Defect size >2 cm is an independent risk factor for recurrence 5
Mesh Selection Algorithm
For clean surgical fields (elective, uncomplicated hernias):
- Synthetic mesh is recommended with preperitoneal placement and 3 cm overlap beyond defect margins 3, 6
- Mesh does not increase wound infection rates in clean fields 3
For emergency/complicated hernias:
| Contamination Level | Mesh Type | Defect Consideration |
|---|---|---|
| Clean-contaminated (CDC Class II) – strangulation without gross spillage | Synthetic mesh safe | Any size [3] |
| Contaminated (CDC Class III) – bowel necrosis without perforation | Biological mesh if >3 cm; primary repair if <3 cm | [3] |
| Dirty (CDC Class IV) – perforation with spillage | Biological mesh if >3 cm; consider open management with delayed repair | [3] |
Emergency Red Flags Requiring Immediate Surgery
Patients with suspected intestinal strangulation require emergency surgical repair immediately, as delayed treatment beyond 24 hours significantly increases mortality. 3
Critical Warning Signs
- Irreducibility of previously reducible hernia 3
- Severe, persistent pain lasting >8 hours (associated with significantly higher morbidity) 3
- Tachycardia ≥110 bpm (earliest physiologic warning sign, even if only abnormal vital sign) 3
- Fever ≥38°C combined with tachycardia (indicates possible strangulation) 3
- Skin changes over hernia: redness, discoloration, or necrosis 3
- Persistent vomiting suggesting bowel obstruction 3
- Signs of sepsis: hypotension, altered mental status, decreased urine output 3
Laboratory Indicators of Strangulation
- Elevated lactate ≥2.0 mmol/L predicts non-viable bowel 1
- Elevated CPK and D-dimer levels 3
- Elevated white blood cell count 3
- Systemic Inflammatory Response Syndrome (SIRS) criteria 3
Common Pitfall
Never dismiss isolated tachycardia as insignificant—it may be the sole early sign of deep infection or intra-abdominal complication 3
Special Population: Cirrhotic Patients with Ascites
Cirrhotic patients with umbilical hernias face dramatically higher surgical mortality (OR=10.32 for emergency vs elective repair) and require aggressive preoperative ascites optimization. 3
Preoperative Optimization Strategy
- Sodium restriction to 2000 mg/day 3
- Aggressive diuretic therapy: spironolactone up to 400 mg/day plus furosemide up to 160 mg/day in 100:40 mg ratio 3
- Large volume paracentesis as needed for symptomatic relief (with albumin 8 g/L if >5L removed) 3
- Consider TIPS placement to facilitate better ascites control before elective repair 3
Emergency Indications in Cirrhotic Patients
Despite refractory ascites, emergency surgery is mandatory for:
- Strangulated or incarcerated hernias that cannot be reduced 3
- Ruptured umbilical hernias with or without evisceration 3
- Signs of peritonitis from hernia complications 3
Critical Postoperative Management
- Mandatory hepatology consultation for postoperative ascites control 3
- Minimize IV maintenance fluids 3
- Consider TIPS placement if ascites cannot be controlled medically postoperatively 3
- Avoid large volume paracentesis immediately before or after surgery—rapid ascites removal can paradoxically cause incarceration 3
Risk Stratification
High-risk features include:
Postoperative Complications and Management
Early Warning Signs
- Tachycardia ≥110 bpm: Earliest sign of deep infection or abscess, even without other abnormal vitals 3
- Fever ≥38°C with tachycardia: Warrants urgent surgical evaluation for deep infection 3
- Persistent wound drainage beyond 2 weeks: Consider seroma vs infection 3
Mesh-Related Complications
- Mesh infection occurs in 1.9-5% of cases, with 72.7% requiring complete mesh explantation 3
- Risk factors: emergency operations, smoking, ASA score ≥3, longer operative duration 3
- Superficial infections: ~72% can be treated with antibiotics alone without mesh removal 3
When to Remove Mesh
Complete mesh removal is indicated only when mesh is grossly infected—avoid routine removal for superficial wound infections 3