In a 64‑year‑old adult with a reducible, asymptomatic umbilical hernia, should elective mesh repair be performed?

Management of Asymptomatic Umbilical Hernia in a 64-Year-Old Adult

Elective mesh repair should be performed for this 64-year-old patient with a reducible, asymptomatic umbilical hernia to prevent future complications and significantly reduce recurrence risk. 1, 2

Rationale for Elective Repair

Mesh repair is strongly recommended regardless of hernia size or symptoms because it dramatically reduces recurrence rates compared to observation or suture repair alone. 1, 3 The evidence demonstrates:

• Mesh repair reduces recurrence to 0-4.3% compared to 11-19% with suture repair and even higher rates with observation 1, 2
• A landmark randomized trial showed mesh repair had only 1% recurrence versus 11% with suture repair over 64 months of follow-up 2
• Repair should be performed regardless of size to prevent complications, as emergency surgery carries dramatically higher mortality risk 1

Why Not Wait?

Delaying repair until symptoms develop or complications occur significantly increases surgical risk and mortality. 1 Key considerations include:

• Emergency surgery for complicated hernias carries an odds ratio of 10.32 for mortality compared to elective repair 1
• Elapsed time from symptom onset to surgery is the most important prognostic factor (P<0.005) for poor outcomes 1
• Symptoms persisting longer than 8 hours are associated with significantly higher morbidity rates 1
• At age 64, the patient is a reasonable surgical candidate now, but may develop comorbidities that increase operative risk if repair is delayed 2

Surgical Approach and Technique

Mesh repair should be performed using synthetic mesh in this clean surgical field, with mesh extending at least 3 cm beyond the defect margins. 1, 4 The approach should include:

• Open or laparoscopic technique based on surgeon expertise and defect characteristics 3
• Synthetic polypropylene mesh is appropriate for clean fields (no contamination) 1, 4
• Mesh fixation using tackers or transfascial sutures, avoiding vital structures 1
• Local anesthetic with sedation is the preferred anesthetic technique (used in 98% of cases in one large series) 2

Expected Outcomes

Mesh repair provides excellent long-term results with minimal complications in elective settings. 2, 5 Evidence shows:

• Mean operative time approximately 45 minutes for mesh repair 2
• No significant increase in surgical site infection compared to suture repair 5
• Seroma formation occurs more frequently with mesh (number needed to harm = 30) but does not affect long-term outcomes 5
• No significant difference in chronic pain rates between mesh and suture repair 5
• Recurrence rate of only 1% with mesh versus 11% with suture repair 2

Critical Pitfalls to Avoid

Do not perform suture repair even for small defects, as mesh significantly reduces recurrence regardless of hernia size. 1, 3 Additional cautions include:

• Avoid delaying repair in hopes the hernia will remain asymptomatic—complications can develop suddenly 1
• Do not dismiss this as "just a small hernia"—even hernias <1 cm benefit from mesh repair 1, 3
• Ensure adequate mesh overlap (minimum 3 cm) to prevent recurrence 1
• Recognize that obesity, smoking, and excessive weight gain post-repair are risk factors for recurrence and should be addressed preoperatively 6

Preoperative Optimization

Address modifiable risk factors before elective surgery to optimize outcomes. 1 This includes:

• Smoking cessation, as smoking increases recurrence risk 6
• Weight optimization if obese, as higher BMI increases recurrence rates 7
• Correction of anemia if present using oral or IV iron supplementation 1
• Delay surgery 2-4 weeks if needed to allow hemoglobin improvement 1