Umbilical hernias are defined as hernia defects occurring 3 cm superior or inferior to the umbilicus. In 1882, T. F. Chevasse reported success using the transperitoneal approach in the case of a strangulated umbilical hernia.
Indications
- Umbilical hernia in adults (due to increased risk of strangulation)
- Incarceration/strangulation
Contraindications
- Children < 5 years old
Preoperative Considerations
- Mesh repair considerations
- Size of defect (evidence suggests use if defect ≥1 cm)
- Patients with increased risk of recurrence: obesity, diabetes, COPD, collagen synthesis disorders
- Suture-based repair considerations
- Defect <1-2 cm
- BMI <30 kg/m2
Relevant Information
- Defects >1 cm (though routinely not carried out until defect >2 cm) → mesh (per European and American Hernia Societies)
- Pregnant women may experience umbilical hernias. The majority of them will be small and rarely need surgery while pregnant. Surgery will be heavily considered if the hernias become large and significantly symptomatic (e.g., pain, intermittent obstructive symptoms). If this is the case, surgery can be offered during the 2nd trimester.
- Umbilical hernias in children usually resolve by 2 years
- Usually resolve by 2 years old
- Repair is delayed until 5 years old
- Primary repair is carried out for children. Laparoscopic repair isn’t utilized.
Surgical Technique
- Approach varies – can be cosmetic supraumbilical, infraumbilical, or umbilical incision
- Patient is placed in the supine position and the skin is prepped and draped in the usual sterile fashion, with extra care given to make sure the umbilicus is clean.
- A curved incision is made superiorly or inferior around the umbilicus. The umbilicus proper should be retained in the skin flap. The incision is made to the hernia sac and the sac is mobilized except for its attachment to the back of the umbilical skin. This is dissected carefully to avoid creating a buttonhole. The neck of the hernia sac is dissected from adjacent tissues and carried down to the level of the linea alba and anterior sheaths of the rectus muscle.
- In adults, the hernia contents are usually omentum which can be sharply dissected and returned to the abdominal cavity. If there is a strong suspicion for gangrenous intestines, the abdominal cavity should be entered through an extended midline incision to allow for complete mobilization of the incarcerated bowel.
- Once the contents of the sac is reduced and the neck is defined, the decision on how to repair the fascial defect can be made.
- Defects <2 cm (and definitely <1 cm)→ peritoneum is closed in primary; excess sac excised
- Figure-of-eight
- Simple interrupted fashion in transverse direction
- Defect closed with 2-0 slowly absorbable monofilament suture or nonabsorbable suture
- Defects 2-4 cm → two-layer “vest-over-trousers” (Mayo technique)
- Upper fascia imbricated over lower fascia with row of interrupted 2-0 sutures that begin and end high on the “vest”
- “Trousers” are secured with horizontal mattress sutures at the “belt line.” When the sutures are secured, the free superior edge (“vest”) overhangs the inferior fascia (“trousers”) and a second layer of interrupted 2-0 sutures are used to secure the free edge.
- Defects >4 cm → mesh
- Open preperitoneal repair (with flat mesh)
- Dissection carried through dermis until hernia sac is identified. Hernia sac should be preserved to facilitate entry into preperitoneal plane
- Dissection in the preperitoneal plane is carried out circumferentially under the fascia until a pocket that can accommodate a mesh that overlaps defect by 3-5 cm is made and mesh is placed in preperitoneal space with care to make sure mesh lays flat
- Defect is closed over mesh using permanent or slowly absorbable suture and skin is closed
- Con: creation of large subcutaneous flap can increase risk of SSO and SSI
- Open intraperitoneal repair
- Patch can be placed in preperitoneal or intraperitoneal position
- Using a barrier-coated hernia patch allows the mesh to be placed intraperionteally. If so, the hernia sac should be transected at level of fascia and contents should be returned to abdominal cavity.
- Abdominal wall and peritoneal are cleared to ensure there are no adhesions and mesh is introduced and fixed to abdominal wall with sutures (usually at 12 and 6 o’clock through linea alba and 3 and 9 o’clock through rectus sheath muscles). Fascia is reapproximated over top and skin is closed using slowly absorbable suture.
- Open preperitoneal repair (with flat mesh)
- Defects <2 cm (and definitely <1 cm)→ peritoneum is closed in primary; excess sac excised
- Apex of subcutaneous tissue below the umbilicus is sutured to the linea alba with 2-0 absorbable sutures to produce an ingoing bellybutton. Absorbable sutures are used to obliterate the subcutaneous dead space.
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