What imaging, assessment, and treatment are recommended for a symptomatic 38‑year‑old woman with a known umbilical hernia?

Management of Symptomatic Umbilical Hernia in a 38-Year-Old Woman

For a symptomatic 38-year-old woman with an umbilical hernia, clinical examination is typically sufficient for diagnosis, but ultrasound should be obtained if the diagnosis is uncertain or complications are suspected, followed by elective surgical repair with mesh to minimize recurrence risk. 1, 2

Initial Clinical Assessment

The primary goal is to determine whether complications requiring urgent intervention are present, as these directly impact morbidity and mortality 3:

• Assess reducibility: Attempt to manually reduce the hernia. Inability to reduce indicates incarceration requiring urgent evaluation 3
• Pain characteristics: Constant, severe, unrelenting pain suggests incarceration or strangulation requiring urgent intervention 3
• Skin changes: Examine for erythema, discoloration, or pressure necrosis over the hernia site, which indicate compromised blood supply 3
• Obstructive symptoms: Ask about nausea, vomiting, constipation, or inability to pass gas, which suggest bowel obstruction 4, 3
• Systemic signs: Fever or signs of infection are red flags requiring urgent intervention 3

Imaging Strategy

For Uncomplicated, Symptomatic Hernias

Clinical examination alone is typically sufficient for diagnosis of uncomplicated umbilical hernias 1. However, imaging should be obtained when:

• Ultrasound is first-line if the diagnosis is uncertain or you need to assess hernia contents and reducibility 1, 3
• No imaging is needed if the hernia is clearly reducible on examination and the patient desires elective repair 1

When Complications Are Suspected

If any red flag symptoms are present, proceed with:

• CT scan with IV contrast is recommended when complications such as incarceration, strangulation, or bowel obstruction are suspected 1, 5
• CT provides superior visualization of herniated contents, vascular status, and can identify bowel wall thickening, absent enhancement (indicating strangulation), or pneumatosis (indicating necrosis) 5

Laboratory Testing

• No routine labs needed for simple, reducible umbilical hernias 3
• If complications suspected: Obtain CBC (leukocytosis), lactate (ischemia), CRP/procalcitonin (infection severity), and basic metabolic panel (electrolytes, renal function) 3

Treatment Approach

Elective Surgical Repair (Uncomplicated Hernia)

Mesh repair is strongly recommended over suture repair alone, as mesh reduces recurrence rates even in small hernias 6, 2:

• Open approach with preperitoneal flat mesh is the recommended technique for most umbilical hernias 2
• Laparoscopic approach may be considered if the hernia defect is large or the patient has increased risk of wound morbidity 2
• Suture repair should not be performed for hernias >1 cm, as this results in 42% recurrence rates compared to mesh repair 1

Timing of Surgery

• Elective repair is appropriate for symptomatic but uncomplicated hernias, as emergency surgery carries dramatically increased mortality (OR=10.32) compared to elective repair 1
• Schedule surgery within a reasonable timeframe to prevent progression to complications, as non-operative management of complicated hernias carries 60-88% mortality 1

Common Pitfalls to Avoid

• Do not delay evaluation of irreducible hernias: Any hernia that cannot be reduced requires urgent surgical consultation 3
• Do not underestimate small hernias: Even hernias <1 cm benefit from mesh repair to reduce recurrence 2
• Do not rely solely on plain radiographs: If complications are suspected, proceed directly to CT with contrast rather than starting with plain films 5