Introduction
Umbilical hernias, defined by the European Hernia Society as ventral abdominal hernias located within 3 cm above or below the umbilicus, are a common condition encountered in adults. Representing a significant portion of abdominal wall hernias, they are second only to inguinal hernias in frequency, accounting for 6% to 14% of all cases. While often resolving spontaneously in infants, adult umbilical hernias frequently necessitate surgical intervention, with approximately 65% eventually requiring repair. The optimal timing for repair is before complications like incarceration or strangulation arise. Various surgical approaches exist for umbilical herniorrhaphy, including the use of synthetic or biologic mesh.
This article provides a comprehensive review of umbilical hernias in adults, covering etiology, epidemiology, evaluation, management, and potential complications. It emphasizes the crucial role of an interprofessional healthcare team in optimizing patient outcomes for this prevalent abdominal wall defect.
Objectives:
- Recognize the clinical characteristics and physical presentations of umbilical hernias in adult patients.
- Determine suitable adult candidates for umbilical herniorrhaphy.
- Utilize evidence-based strategies when selecting surgical approaches and interventions for umbilical herniorrhaphy.
- Formulate interprofessional team approaches to enhance outcomes for adult patients with umbilical hernias.
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Historically, umbilical hernias in adults have been classified by size by both European and American Hernia Societies. A hernia less than 4 cm is generally considered small. The hernia sac typically contains preperitoneal fat or omentum, but may also include portions of the small intestine or, less frequently, the colon.
Diagnosis often occurs during routine physical exams. Asymptomatic hernias may be managed expectantly, but patient counseling on incarceration and strangulation risks, along with safe lifting practices, is essential. Surgical repair becomes necessary when pain, dysfunction, or hernia enlargement is present. Surgical approach is dictated by hernia size, patient comorbidities, BMI, and the presence of other abdominal wall hernias. While elective repairs can be done under local or general anesthesia, urgent cases often require general anesthesia.
Etiology
Acquired umbilical hernias constitute approximately 90% of adult cases. Predisposing factors include obesity, metabolic syndrome, ascites, and a history of multiple pregnancies. Umbilical ring configurations can also contribute to hernia formation. Any condition causing chronic or repeated increases in intraabdominal pressure elevates risk. There may be a link between umbilical site laparoscopic trocar use and umbilical hernias. Further risk factors encompass connective tissue disorders, ethnicity, Beckwith-Wiedemann syndrome, Trisomy 21, and poor nutritional status.
Epidemiology
Adult umbilical hernia incidence ranges from 23% to 50%. Prevalence peaks in women aged 31 to 40 and men aged 61 to 70. Women are three times more likely to develop umbilical hernias, attributed to pregnancy, childbirth, and higher obesity rates. Despite higher incidence in women, 70% of surgical repairs are performed on men. Annually, approximately 175,000 umbilical hernia repairs occur in the US, and 20 million globally.
Pathophysiology
Abdominal muscle stretching and excess adiposity contribute to muscle separation and aponeurosis weakening, facilitating umbilical hernia development. Hernias typically arise in areas of fascial weakness, such as the linea alba near the umbilicus or where umbilical vessels, especially the umbilical vein, penetrate the abdominal wall. Many patients lack an umbilical fascia, and the round hepatic ligament may abnormally attach to the umbilical ring’s inferior margin. Conditions chronically increasing intraabdominal pressure, like ascites, chronic constipation, and heavy lifting, further contribute. Up to 20% of patients with cirrhotic ascites develop umbilical hernias.
The hernia defect neck can be narrower than the sac, with a 1% to 3% lifetime risk of incarceration and strangulation. Strangulation progresses from venous drainage disruption to arterial inflow compromise, leading to omental and bowel infarction.
History and Physical Examination
Adult umbilical hernias are often asymptomatic, particularly those ≤ 1 cm. Many are incidentally discovered during routine exams or abdominal imaging for other reasons. Patients might report a bulge with increased intraabdominal pressure, such as during exercise or positional changes. Men more frequently present with painful, activity-limiting hernias, while women often have larger, asymptomatic hernias. Up to 90% of pregnant women may develop umbilical hernias, usually requiring no treatment unless incarcerated or symptomatic. Pain is the most common complaint in symptomatic cases, reported by 44% of patients. Activity limitation due to discomfort and nausea/vomiting episodes associated with intermittent bulges may also be reported.
Examination should ideally be supine. Asymptomatic hernias are often reducible and reproducible with Valsalva maneuver. Fascial edges can be palpated to estimate defect size. Other abdominal wall defects or systemic disease signs should be noted. Large hernias may be nonreducible due to loss of domain. Symptomatic hernias typically present with a visible umbilical protrusion. Incarcerated or strangulated hernias manifest as irreducible, tender, and often discolored umbilical bulges. Patients may appear unwell, with emesis, tachycardia, and hypotension. Many have prior episodes of pain and protrusion with spontaneous resolution.
Evaluation
Umbilical hernia evaluation is primarily clinical, beginning with anterior abdominal wall inspection. Skin changes like discoloration, ulceration, or thickening may indicate strangulation.
Incarcerated hernias warrant manual reduction attempts using gentle, steady pressure. Successful reduction in a stable patient allows discharge with elective surgery referral. Nonreducible hernias or concerns about compromised contents necessitate urgent surgical consultation.
Imaging is indicated for suspected hernias with equivocal physical exams. Ultrasonography is efficient and cost-effective, detecting hernias in about 25% of adults in one study. However, it’s operator-dependent and less effective in obese patients or with large hernias. CT scans confirm hernia presence, define borders and contents, and identify other intraabdominal pathology. MRI boasts 92% sensitivity and 95% specificity for abdominal wall hernias, useful when ultrasound and CT are inconclusive. However, MRI is lengthier, less available in emergency settings, and less cost-effective.
Stable patients with reducible hernias don’t require lab studies. Ill-appearing patients or those needing surgery for incarceration/strangulation should have at least a complete blood count to evaluate for leukocytosis.
Treatment and Management
Nonoperative management can be considered for asymptomatic umbilical hernias, with a yearly strangulation risk under 1%. However, comorbidities like obesity or ascites, which can complicate emergent repair, must be carefully considered. Symptomatic or enlarging hernias should be repaired. Relative contraindications to repair include Child-Pugh class B and C cirrhosis with uncontrolled ascites, active infection, anticoagulation, and coagulopathy. Minimally invasive techniques and preoperative planning have shown manageable risk in elective repairs for most cirrhotic patients, even with ascites. Mortality in umbilical hernia repair with uncontrolled ascites is reported at 2%, with high recurrence rates.
Preoperative planning is crucial for reducing recurrence and morbidity/mortality. While umbilical hernia-specific research is limited, studies across surgical procedures demonstrate the benefits of smoking cessation for 4 weeks preoperatively and BMI reduction to <40 kg/m². Optimizing nutritional status, managing diabetes, and addressing other comorbidities are also important.
Surgical Repair
For umbilical hernias ≤ 2 cm, primary suture repair, such as the Mayo repair, is acceptable. However, recurrence rates range from 11% to 52%. For hernias > 2 cm, mesh herniorrhaphy is preferred. Primary suture repair for larger hernias has a 10% to 14% recurrence rate. Mesh can be placed as an underlay (beneath fascia) or onlay (over fascia) and should be sutured in place with a recommended 3-cm overlap, often extended to 5 cm. Onlay mesh is technically simpler but carries higher risks of seromas, hematomas, and surgical site infections. Preperitoneal or underlay mesh placement results in fewer recurrences and wound complications. Fascial closure is recommended before onlay mesh or after preperitoneal mesh placement. Mesh repair recurrence rates range from 0% to 3%. Polypropylene mesh, which can cause intraperitoneal adhesions, should be preperitoneal. Coated or biodegradable mesh alternatives are available for exposed intraabdominal contents or contaminated fields.
Laparoscopic umbilical hernia repair is advantageous in morbid obesity, multiple abdominal wall defects, concurrent intraabdominal pathology, and recurrent hernias. However, it doesn’t allow multilayered subcutaneous repair, and laparoscopy carries risks for some patients. Trocar site hernias are a potential risk in those with attenuated tissue. Laparoscopic repair requires port placement lateral to the defect, with one port large enough for mesh insertion. The hernia sac is dissected free using cautery and traction. Contents are inspected post-reduction. Defect size is measured laparoscopically, and mesh is tacked or sutured with several centimeters of fascial overlap. Mesh placement is verified upon desufflation. Robotic hernia repair is an option in some centers, potentially simplifying mesh attachment but possibly increasing operative time and cost.
Emergent herniorrhaphy is necessary for incarceration or strangulation. These procedures are more complex and may involve resecting nonviable bowel or omentum. Mesh closure is recommended in emergent repairs whenever feasible.
Differential Diagnosis
Several conditions can mimic a periumbilical mass. Subcutaneous masses are usually mobile, with no palpable defect. Urachal remnants or abscesses may drain. Lymphoma or neoplastic metastases can be irregular, necrotic, and fixed.
Differential diagnoses for umbilical hernia include:
- Abscess
- Desmoid tumor
- Granuloma
- Hemangioma
- Hematoma
- Keloid
- Lipoma
- Lymphoma
- Primary hydatid cyst of the umbilicus
- Urachal anomaly or tumor
- Umbilical endometriosis
- Umbilical sebaceous cyst
- Metastatic disease
Prognosis
Umbilical hernia repair outcomes are influenced by defect size, tobacco use, and comorbidities. ASA score ≥ 3, failure to use mesh for hernias > 2 cm, tobacco history, liver failure, and diabetes negatively impact repair success. Surgical complication rates increase by 1% per 1 mm increase in fascial defect size. MELD score is used to assess risk in liver failure patients, with postoperative complication rates increasing 13.8% per 1-point MELD score increase above 8.5.
Complications
Complications are more common after open repairs without mesh, including surgical site infections, hematomas, and early recurrence. Wound infection, diabetes, tobacco use, morbid obesity, and uncontrolled ascites are independent recurrence risk factors. Mesh-specific complications include seromas, adhesions, bowel injury, foreign body reaction, and mesh infections/migration, potentially requiring mesh removal. Antibioma formation, a rare undrained abscess due to antimicrobial treatment instead of surgical drainage, is another complication.
Postoperative and Rehabilitation Care
Uncomplicated umbilical hernia repair is typically an outpatient procedure. Postoperative care focuses on pain management, early ambulation, wound protection, and pulmonary hygiene. Lifting restrictions are advised for several weeks, while light activity is encouraged. Stool softeners may be prescribed to prevent constipation, particularly with pain medication use. Swimming and submersion are restricted for 2 weeks, and specific wound care instructions are provided based on the dressing used.
Deterrence and Patient Education
Umbilical hernias are frequently seen in clinical practice. Primary care providers and emergency department clinicians are often the first point of contact for patients with both symptomatic and asymptomatic hernias. The interprofessional team should provide appropriate patient education and referral.
Pearls and Other Issues
Synthetic nonabsorbable mesh, including polypropylene, polyethylene terephthalate polyester, or expanded polytetrafluoroethylene, is commonly used for umbilical hernia repair. Mesh choice depends on anatomical placement and contamination/infection risk. Synthetic, slowly absorbable mesh reduces postoperative adhesions and is used in infected fields where nonabsorbable materials are contraindicated. Examples include polyglycolic acid with trimethylene carbonate, polyglactin, and poly-4-hydroxybutyrate. These degrade within 1 to 3 months and have higher recurrence rates. Biologic mesh, derived from human cadaveric or animal tissue, is used in contaminated surgical fields (classes III and IV). It promotes collagen and fibrous tissue production while minimizing scarring and infection.
Enhancing Healthcare Team Outcomes
An interprofessional team, including emergency department staff, primary care clinicians, surgeons, and nurses, is crucial for preventing complications and morbidity from untreated umbilical hernias. Identifying and optimizing patients with elevated surgical risk factors preoperatively is vital. Surgical risk assessment requires coordinated effort and communication among primary care, internal medicine, gastroenterology, general surgery, and anesthesiology.
Ongoing postoperative education on diet, glucose control, and smoking cessation is important for mitigating hernia recurrence. While most patients have good outcomes post-umbilical hernia repair, recurrence can occur in 1% to 3% of cases, even with mesh use.
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References
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