Paraumbilical Hernia

A paraumbilical hernia is an acquired defect of the linea alba immediately adjacent to the umbilical ring rather than directly through its centre.

It is most common in adults and is associated with obesity, multiparity and chronically increased intra abdominal pressure.

The sac may contain preperitoneal fat, omentum or bowel. Progressive enlargement can produce a large sac through a relatively smaller fascial neck, increasing the risk of incarceration.

Presentation is a swelling immediately above or below the umbilicus, commonly with discomfort during coughing, lifting or prolonged standing.

Large hernias may become partially or completely irreducible because omentum becomes chronically adherent within the sac.

Tender irreducibility, vomiting, abdominal distension or overlying inflammatory skin change suggests an acute complication.

Diagnosis is usually clinical.

Ultrasound: useful for small or uncertain defects.

CT: useful for large, recurrent or complex hernias and when the relationship between several midline defects must be defined.

Management follows the same principles as adult umbilical hernia.

Symptomatic defects should undergo repair.

Mesh reinforcement is preferred for most adult paraumbilical hernias because primary suture repair carries a higher recurrence risk. A preperitoneal flat mesh is an effective approach for many uncomplicated defects.

Close the fascial defect where technically feasible rather than simply bridging the opening with mesh.

A minimally invasive approach is useful for larger defects, obesity, multiple defects or increased wound complication risk.

Emergency repair is required for strangulation, bowel obstruction or compromised contents.

At emergency surgery, assess bowel viability before reducing the significance of the operation to "hernia repair". Any necrotic bowel must be resected and contamination determines whether permanent mesh is appropriate.