Umbilical Hernia

An adult umbilical hernia protrudes through or immediately adjacent to the umbilical ring.

Adult disease is usually acquired and is associated with obesity, pregnancy, increased intra abdominal pressure, ascites and progressive weakening of the linea alba.

The sac commonly contains preperitoneal fat or omentum and may contain small bowel.

Small defects may have a relatively narrow neck compared with the volume of herniated contents and can therefore incarcerate.

Typical presentation is an umbilical swelling that enlarges with coughing or straining.

Symptoms range from no discomfort to local aching, pressure or pain during activity.

Examine:

• Defect size
• Reducibility
• Skin quality
• Tenderness
• Evidence of ascites
• Associated rectus diastasis

Acute persistent pain, irreducibility, vomiting or skin erythema raises concern for incarceration or strangulation.

Thin ulcerated skin over a large hernia, particularly with ascites, indicates impending skin failure and requires specialist surgical assessment.

Diagnosis is usually clinical.

Ultrasound: useful when the defect is small or obscured by obesity.

CT: useful for large, recurrent or complex defects and when planning reconstruction.

Repair symptomatic adult umbilical hernias.

Mesh repair reduces recurrence compared with suture repair and is preferred for most adult defects. Open repair using a flat mesh in the preperitoneal plane is appropriate for many primary umbilical hernias.

Very small defects may be suitable for primary suture repair in carefully selected patients, but recurrence rises as defect size increases and with obesity or rectus diastasis.

For larger defects or patients at increased risk of wound morbidity, minimally invasive repair may reduce wound complications.

Optimise obesity, diabetes and smoking where feasible before elective repair.

Patients with cirrhosis and ascites require careful optimisation. Poorly controlled ascites markedly increases wound complications, leakage and recurrence.

Acute incarceration without strangulation requires urgent assessment. Strangulation, bowel obstruction or compromised bowel requires emergency surgery.

If bowel is viable and the operative field remains clean, mesh repair is appropriate. Gross contamination changes mesh selection and may require staged reconstruction.