Introduction
Umbilical hernias, a common type of ventral abdominal hernia, occur at or near the umbilicus due to a defect in the ventral abdominal fascia. Frequently identified during routine physical examinations, these hernias are a significant concern for adults. While not all cases necessitate immediate surgery, a substantial majority, approximately 65%, of adults with umbilical hernias will eventually require surgical intervention. The optimal time for repair is before complications such as incarceration and strangulation of intraabdominal contents, like the omentum or bowel, arise. Umbilical herniorrhaphy offers several surgical approaches, including the option of synthetic or biologic mesh reinforcement.
This article provides a comprehensive overview for healthcare professionals on umbilical hernias in adults, focusing on 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:
Upon completion of this article, healthcare professionals should be able to:
- Recognize the clinical characteristics and physical manifestations of umbilical hernias in adult patients.
- Determine which adult patients are most likely to benefit from umbilical herniorrhaphy.
- Implement evidence-based practices in selecting surgical approaches and interventions for umbilical herniorrhaphy.
- Formulate interprofessional team strategies to enhance outcomes for adult patients diagnosed with an umbilical hernia.
Access free multiple choice questions on this topic.
Umbilical hernias are defined by the European Hernia Society as ventral abdominal hernias located within a 3 cm radius of the umbilicus. They represent a notable portion of adult abdominal wall hernias, accounting for 6% to 14% of all cases, second only to inguinal hernias in frequency.1, 2, 3 In contrast to adults, umbilical hernias are observed in 10% to 15% of infants, often resolving spontaneously by the age of two.4 Surgical intervention may be needed for pediatric umbilical hernias that persist beyond five years of age or exceed 1.5 cm in diameter. This discussion will concentrate on umbilical hernias in adults. For information regarding pediatric umbilical hernias, please refer to our StatPearls companion article, “Pediatric Umbilical Hernia.”5
Adult umbilical hernias are classified by size according to the European and American Hernia Societies. Hernias less than 4 cm are considered small.4 The hernia sac typically contains preperitoneal fat or omentum, but may also include a portion of the small intestine or, less frequently, the colon.6, 7
Many individuals receive an Umbilical Hernia Diagnosis during a routine physical examination. Asymptomatic hernias often lead to a preference for expectant management over immediate surgical repair. However, it’s important to note that approximately 65% of adults with umbilical hernias will eventually require surgical repair, with 3% to 5% of these cases being emergencies.6 Patients with asymptomatic umbilical hernias should receive comprehensive counseling about the signs and symptoms of incarceration and strangulation, as well as guidance on safe lifting techniques.
Surgical repair becomes necessary for umbilical hernias when patients experience pain, functional impairment, or hernia enlargement. The surgical approach is tailored to the hernia size and patient-specific factors, including comorbidities, body mass index, and the presence of other abdominal wall hernias. Elective umbilical hernia repair can be performed using local anesthesia with sedation or general anesthesia, while urgent surgeries typically require general anesthesia.
Etiology of Umbilical Hernias
Acquired umbilical hernias constitute approximately 90% of adult cases.1 Several factors increase the likelihood of developing an umbilical hernia. Obesity, metabolic syndrome, ascites, and a history of multiple pregnancies are significant predisposing conditions.3, 8 The configuration of the umbilical ring itself can also play a role in hernia formation.9 Any condition or activity that chronically or repeatedly elevates intraabdominal pressure can heighten the risk. There may also be a correlation between the use of umbilical site laparoscopic trocars and the development of umbilical hernias. Further risk factors include connective tissue disorders, ethnicity, Beckwith-Wiedemann syndrome, Trisomy 21, and poor nutritional status.8, 10, 11, 12, 13
Epidemiology of Umbilical Hernias
The incidence of umbilical hernias in adults ranges broadly, from 23% to 50%. The prevalence peaks in women between 31 and 40 years of age and in men between 61 and 70 years of age. Women are three times more likely to develop umbilical hernias, largely due to the physiological impacts of pregnancy and childbirth, along with a higher prevalence of obesity. Despite this higher incidence in women, about 70% of umbilical hernia surgical repairs are performed on men.14, 15, 3 Annually, approximately 175,000 umbilical hernia repairs are conducted in the United States, and 20 million are performed worldwide.16
Pathophysiology of Umbilical Hernias
The development of umbilical hernias is closely linked to the stretching of abdominal musculature and the accumulation of excess adipose tissue. These conditions can lead to the separation of muscles and the weakening of aponeuroses, creating an environment conducive to hernia formation.3, 8 Umbilical hernias typically arise in areas of inherent fascial weakness, such as the linea alba adjacent to the umbilicus or where umbilical vessels, particularly the umbilical vein, penetrate the abdominal wall.8, 6, 17 A notable anatomical finding in many patients with umbilical hernias is the absence of umbilical fascia, and the round hepatic ligament may be abnormally attached to the inferior margin of the umbilical ring.9 Conditions that chronically increase intraabdominal pressure, such as ascites, chronic constipation, and frequent heavy lifting, further contribute to the risk. Up to 20% of patients with cirrhotic ascites may develop umbilical hernias.
The neck of the hernia defect can be disproportionately narrow relative to the hernia sac size. This anatomical characteristic contributes to a lifetime incarceration and strangulation risk of 1% to 3%.6 The progression to strangulation involves disruption of venous drainage followed by arterial inflow, ultimately leading to infarction of the omentum and bowel.
History and Physical Examination for Umbilical Hernia Diagnosis
Umbilical hernias in adults are frequently asymptomatic, especially those measuring 1 cm or less. Often, these hernias are discovered incidentally during routine physical examinations or abdominal imaging conducted for unrelated reasons. Patients might report noticing or feeling a bulge in the umbilical area, particularly during activities that increase intraabdominal pressure, such as exercise or changes in body position. Men are more likely to present with painful umbilical hernias that limit their physical activity, while women tend to have larger, but asymptomatic hernias.1, 4 A significant proportion, up to 90%, of pregnant women may develop umbilical hernias, but treatment is usually only required if incarceration or symptoms occur.18 Pain is the most common complaint among patients with symptomatic umbilical hernias, reported by approximately 44% of patients. Discomfort-related activity limitations and episodes of nausea and vomiting associated with an intermittent bulge are also frequently reported.19
A thorough physical examination is crucial for umbilical hernia diagnosis. Ideally, patients should be examined in a supine position. In asymptomatic individuals, the hernia may become more apparent with Valsalva maneuver and is typically reducible. Palpation may allow for the assessment of fascial edges and estimation of the hernia defect size. It is important to also assess for other abdominal wall defects or findings indicative of systemic disease.18 Large umbilical hernias may be nonreducible due to loss of domain.20
Patients with symptomatic hernias commonly present with a noticeable protrusion at the umbilicus. In cases of incarcerated or strangulated hernias, patients will exhibit an irreducible and tender umbilical bulge, often with discoloration. Systemic symptoms like active emesis, tachycardia, and hypotension may be present in more severe cases. Many patients report a history of intermittent pain and hernia protrusion with spontaneous resolution prior to presentation with complications.21
A visual aid for umbilical hernia diagnosis, showing a clear protrusion at the umbilicus during physical examination.
Evaluation and Diagnostic Modalities
The diagnostic process for a suspected umbilical hernia primarily relies on clinical evaluation. The physical examination should commence with a careful visual inspection of the anterior abdominal wall. Skin changes such as discoloration, ulceration, or thickening can be indicative of strangulation.22
For patients presenting with an incarcerated hernia, an attempt at manual reduction should be performed using gentle, steady pressure. If reduction is successful and the patient is stable, discharge with a referral for elective surgery may be appropriate. However, if the hernia is nonreducible or there is concern about compromised intraabdominal contents, immediate surgical consultation is necessary.
Imaging modalities play a role in umbilical hernia diagnosis, particularly when the physical examination is inconclusive. Ultrasonography is an efficient and cost-effective option; studies have shown it can detect umbilical hernias in approximately 25% of the adult population.14 However, the effectiveness of ultrasound is operator-dependent and may be limited in patients with large hernias or significant obesity. Computed tomography (CT) scans can confirm the presence of hernias, delineate borders and contents, and identify any additional intraabdominal pathology.23
Magnetic resonance imaging (MRI) offers high sensitivity (92%) and specificity (95%) in diagnosing abdominal wall hernias, proving useful when ultrasound and CT findings are inconclusive.24 However, MRI scans are more time-consuming, may not be readily available in emergency settings or smaller facilities, and are less cost-effective than other imaging methods.
Routine laboratory studies are not necessary for patients with reducible umbilical hernias who appear well. However, for patients who appear ill or require surgical intervention for incarcerated or strangulated hernias, a complete blood count with leukocyte assessment is recommended as a minimum.
Treatment and Management Strategies
Nonoperative management can be considered for asymptomatic patients with umbilical hernias, as the yearly risk of strangulation is less than 1% in these cases.25 When considering this approach, it’s crucial to carefully evaluate comorbidities such as obesity or ascites, which could complicate emergent repair should it become necessary. Surgical repair is recommended for hernias that are symptomatic or increasing in size.4, 22, 26
Relative contraindications to umbilical hernia repair include Child-Pugh class B and C cirrhosis with uncontrolled ascites, active infection, anticoagulation, and coagulopathy. Despite these contraindications, studies suggest that elective umbilical hernia repair can be safely performed in most cirrhotic patients, even those with ascites, utilizing minimally invasive techniques and thorough preoperative planning. Mortality rates associated with umbilical hernia repair in patients with uncontrolled ascites are reported around 2%, with higher hernia recurrence rates.27, 28, 29, 30
Meticulous preoperative planning is essential to minimize hernia recurrence and overall morbidity and mortality. While specific research on umbilical hernia repair is limited, studies on various surgical procedures have established the benefits of smoking cessation for 4 weeks prior to surgery and optimizing body mass index to improve outcomes.4
Surgical Repair Techniques
For umbilical hernias smaller than or equal to 2 cm in diameter, primary suture repair is generally acceptable. The Mayo repair, which involves overlapping fascial layers, is a classic technique for smaller defects.31 However, for hernias larger than 2 cm, mesh herniorrhaphy is the preferred method. Primary suture repair for hernias of this size is associated with a significant recurrence rate of 10% to 14%.4, 32, 33, 34, 35
Mesh can be positioned either underneath (underlay) or over (onlay) the fascia and should be securely sutured in place. An overlap of 3 cm is recommended, though a 5 cm overlap is more commonly practiced for enhanced reinforcement.36 Onlay mesh placement is technically simpler but carries a higher risk of seromas, hematomas, and surgical site infections. Preperitoneal or underlay mesh placement typically results in fewer recurrences and wound complications.6 Fascial closure is recommended both before onlay mesh placement and after preperitoneal mesh placement.33 With mesh repair, recurrence rates for umbilical hernias are significantly reduced, ranging from 0% to 3%.34, 35, 37 Polypropylene mesh, known to create intraperitoneal adhesions, should be placed in a preperitoneal position.4, 38 Coated or biodegradable mesh options are available for cases involving exposed intraabdominal contents or contaminated surgical fields.6, 39
Laparoscopic umbilical hernia repair offers advantages in patients with morbid obesity, multiple abdominal wall defects, concurrent intraabdominal pathology, and recurrent hernias. However, it does not facilitate a multilayered subcutaneous repair. Laparoscopy may pose unacceptable physiological risks for certain patients. Trocar site hernias are a potential, though theoretical, risk, particularly in individuals with attenuated tissues.40 During laparoscopic repair, port placement must be lateral to the defect, and one port must be large enough for mesh insertion.41 The hernia sac is dissected free from the surrounding tissue using cautery and gentle traction. Contents are inspected post-reduction. The defect size is measured laparoscopically using umbilical tape, and the mesh is secured to the abdominal wall with tacks or sutures, ensuring several centimeters of overlap beyond the fascial edge. Mesh placement is verified upon deflation. Robotic hernia repair is emerging as a surgical option in some centers. While robotic approaches may simplify mesh attachment, they might involve longer operative times and higher costs.42
Emergent herniorrhaphy is mandatory for incarcerated or strangulated hernias. These procedures can be more technically challenging and may necessitate resection of nonviable intraabdominal contents, such as bowel or omentum. Mesh closure is recommended for emergent repairs whenever feasible.43
Surgical intervention for umbilical hernia diagnosis, illustrating mesh placement during open repair to reinforce the abdominal wall.
Differential Diagnosis
Various conditions can manifest as a periumbilical mass, necessitating a thorough differential diagnosis to ensure accurate umbilical hernia diagnosis and rule out other pathologies. Subcutaneous masses are typically mobile within the subcutaneous space, and no fascial defect is palpable. Conditions such as urachal remnants or abscesses may present with drainage. Lymphoma or neoplastic metastases tend to be irregular, may contain necrotic tissue, and are often fixed to surrounding tissues.
Alternative diagnoses to consider in the differential diagnosis of umbilical hernia include:
- Abscess
- Desmoid tumor 44
- Granuloma
- Hemangioma
- Hematoma
- Keloid
- Lipoma
- Lymphoma
- Primary hydatid cyst of the umbilicus 45
- Urachal anomaly or tumor
- Umbilical endometriosis 46
- Umbilical sebaceous cyst 47
- Metastatic disease
Prognosis
The prognosis following umbilical hernia repair is influenced by several factors, including the size of the hernia defect, patient’s smoking status, and existing comorbidities. An American Society of Anesthesiologists (ASA) score of ≥ 3, failure to use mesh for hernias larger than 2 cm, history of tobacco use, liver failure, and diabetes are factors that can negatively impact the success of the repair.48 The risk of surgical complications increases by approximately 1% for each 1 mm increase in fascial defect size.49 The Model for End-Stage Liver Disease (MELD) score is utilized to assess increased risk in patients with liver failure. Postoperative complication rates increase by 13.8% for every 1-point increase in the MELD score above the standard mean of 8.5.50, 49
Complications of Umbilical Hernia Repair
Complications are more commonly observed following open repairs without mesh reinforcement and include surgical site infections, hematomas, and early recurrence.51, 52, 53, 54 Independent risk factors for hernia recurrence include wound infection, diabetes, tobacco use, morbid obesity, and uncontrolled ascites.2, 55, 56
Mesh-specific complications include seromas, adhesions, bowel injury, foreign body reactions, and mesh infections or migration. Mesh removal may be necessary in managing these complications. Antibioma formation, a rare complication, is an undrained abscess encapsulated by a fibrous shell, resulting from antimicrobial treatment instead of surgical drainage.57
Postoperative and Rehabilitation Care
Uncomplicated, elective umbilical hernia repair is typically performed as a same-day procedure. Postoperative care focuses on pain management, early mobilization, wound protection, and pulmonary hygiene. Heavy lifting is restricted for several weeks, but light activity is encouraged. Stool softeners may be prescribed to prevent constipation, especially while taking pain medication. Patients are advised to avoid swimming or submerging the surgical site for 2 weeks. Specific wound care instructions are provided based on the type of dressing used.
Deterrence and Patient Education
Umbilical hernias are frequently encountered in clinical practice. Primary care providers and emergency department clinicians are often the first healthcare professionals to assess patients with both symptomatic and asymptomatic umbilical hernias. The interprofessional team plays a vital role in providing appropriate patient education and ensuring timely referral to surgical specialists when needed. Educating patients about risk factors, symptoms to watch for (like pain or a non-reducible bulge), and the importance of seeking prompt medical attention can improve outcomes and reduce complications.
Pearls and Other Key Considerations
Synthetic nonabsorbable mesh, including polypropylene, polyethylene terephthalate polyester, or expanded polytetrafluoroethylene, is commonly used for umbilical hernia repair.58 However, mesh selection depends on the anatomical location and the presence of contamination or infection. Synthetic, slowly absorbable mesh is utilized to minimize postoperative adhesions and in infected fields where nonabsorbable materials are contraindicated. Examples include polyglycolic acid with trimethylene carbonate, polyglactin, and poly-4-hydroxybutyrate.59 These materials degrade within 1 to 3 months and are associated with higher recurrence rates.30 Biologic mesh is reserved for repair in contaminated surgical fields (classes III and IV). Derived from human cadaveric or animal tissues, biologic mesh undergoes processing to remove cellular components, leaving only the collagen matrix. This type of mesh promotes tissue regeneration and fibrous tissue production while reducing scarring and infection risks.60, 59
Enhancing Healthcare Team Outcomes for Umbilical Hernia Management
An effective interprofessional team, encompassing emergency department staff, primary care physicians, surgeons, and nurses, is essential for minimizing complications and morbidity associated with untreated umbilical hernias. Identifying patients with elevated surgical risk factors and optimizing their condition preoperatively is critical. Surgical risk assessment requires coordinated effort and communication among all team members, including specialists in primary care, internal medicine, gastroenterology, general surgery, and anesthesiology.
Postoperative patient education regarding diet, glucose control, and smoking cessation is crucial in mitigating hernia recurrence. While most patients undergoing umbilical hernia repair experience positive outcomes, recurrence can occur in 1% to 3% of cases, even with mesh reinforcement.61, 62 Continuous quality improvement initiatives and standardized protocols can further enhance patient care and outcomes.
Review Questions
References
1.Shankar DA, Itani KMF, O’Brien WJ, Sanchez VM. Factors Associated With Long-term Outcomes of Umbilical Hernia Repair. JAMA Surg. 2017 May 01;152(5):461-466. [PMC free article: PMC5831449] [PubMed: 28122076]
2.Venclauskas L, Jokubauskas M, Zilinskas J, Zviniene K, Kiudelis M. Long-term follow-up results of umbilical hernia repair. Wideochir Inne Tech Maloinwazyjne. 2017 Dec;12(4):350-356. [PMC free article: PMC5776484] [PubMed: 29362649]
3.Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011 Jan 19;2(1):5. [PMC free article: PMC3031184] [PubMed: 21286228]
4.Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Simons MP., European and Americas Hernia Societies (EHS and AHS). Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg. 2020 Feb;107(3):171-190. [PubMed: 31916607]
5.Troullioud Lucas AG, Bamarni S, Panda SK, Mendez MD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 18, 2023. Pediatric Umbilical Hernia. [PubMed: 29083740]
6.Kulaçoğlu H. Current options in umbilical hernia repair in adult patients. Ulus Cerrahi Derg. 2015;31(3):157-61. [PMC free article: PMC4605112] [PubMed: 26504420]
7.Forrest JV, Stanley RJ. Transverse colon in adult umbilical hernia. AJR Am J Roentgenol. 1978 Jan;130(1):57-9. [PubMed: 413418]
8.Celdrán A, Bazire P, Garcia-Ureña MA, Marijuán JL. H-hernioplasty: a tension-free repair for umbilical hernia. Br J Surg. 1995 Mar;82(3):371-2. [PubMed: 7796013]
9.Fathi AH, Soltanian H, Saber AA. Surgical anatomy and morphologic variations of umbilical structures. Am Surg. 2012 May;78(5):540-4. [PubMed: 22546125]
10.Henriksen NA. Systemic and local collagen turnover in hernia patients. Dan Med J. 2016 Jul;63(7) [PubMed: 27399987]
11.Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surg Clin North Am. 2013 Oct;93(5):1255-67. [PubMed: 24035087]
12.Oma E, Jorgensen LN, Meisner S, Henriksen NA. Colonic diverticulosis is associated with abdominal wall hernia. Hernia. 2017 Aug;21(4):525-529. [PubMed: 28349226]
13.Belghiti J, Durand F. Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis. 1997;17(3):219-26. [PubMed: 9308126]
14.Bedewi MA, El-Sharkawy MS, Al Boukai AA, Al-Nakshabandi N. Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study. Hernia. 2012 Feb;16(1):59-62. [PubMed: 21796449]
15.Wang R, Qi X, Peng Y, Deng H, Li J, Ning Z, Dai J, Hou F, Zhao J, Guo X. Association of umbilical hernia with volume of ascites in liver cirrhosis: a retrospective observational study. J Evid Based Med. 2016 Nov;9(4):170-180. [PubMed: 27792277]
16.Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am. 1998 Dec;78(6):941-51, v-vi. [PubMed: 9927978]
17.Moschcowitz AV. THE PATHOGENESIS OF UMBILICAL HERNIA. Ann Surg. 1915 May;61(5):570-81. [PMC free article: PMC1406653] [PubMed: 17863359]
18.Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RK, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A. Classification of primary and incisional abdominal wall hernias. Hernia. 2009 Aug;13(4):407-14. [PMC free article: PMC2719726] [PubMed: 19495920]
19.Jackson OJ, Moglen LH. Umbilical hernia. A retrospective study. Calif Med. 1970 Oct;113(4):8-11. [PMC free article: PMC1501617] [PubMed: 5479354]
20.Chevrel JP. [Inguinal, crural, umbilical hernias. Physiopathology, diagnosis, complications, treatment]. Rev Prat. 1996 Apr 15;46(8):1015-23. [PubMed: 8762240]
21.Yang XF, Liu JL. Acute incarcerated external abdominal hernia. Ann Transl Med. 2014 Nov;2(11):110. [PMC free article: PMC4245506] [PubMed: 25489584]
22.Kokotovic D, Sjølander H, Gögenur I, Helgstrand F. Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safe. Hernia. 2016 Apr;20(2):281-7. [PubMed: 26838293]
23.Lassandro F, Iasiello F, Pizza NL, Valente T, Stefano ML, Grassi R, Muto R. Abdominal hernias: Radiological features. World J Gastrointest Endosc. 2011 Jun 16;3(6):110-7. [PMC free article: PMC3158902] [PubMed: 21860678]
24.Miller J, Cho J, Michael MJ, Saouaf R, Towfigh S. Role of imaging in the diagnosis of occult hernias. JAMA Surg. 2014 Oct;149(10):1077-80. [PubMed: 25141884]
25.Leubner KD, Chop WM, Ewigman B, Loven B, Park MK. Clinical inquiries. What is the risk of bowel strangulation in an adult with an untreated inguinal hernia? J Fam Pract. 2007 Dec;56(12):1039-41. [PubMed: 18053445]
26.DeAsis F, Gitelis M, Chao S, Lapin B, Linn J, Denham W, Haggerty S, Carbray J, Ujiki M, Olory-Togbe JL, Gbessi DG, Dossou FM, Lawani I, Souaibou YI, Gnangnon I, Denakpo M, Soton RR, Djrouo G, Gogan P, Trukhalev W, Kukosh M, Panyushkin A, Safronova E, Jairam A, Kaufmann R, Jeekel J, Lange JF, Volmer U, Kersten CC, Arlt G, Skach J, Harcubova R, Petrakova V, Mandoboy JD, Ngom G, Faye AL, Ndour O, Sankale AA, Ndoye M, Daneiii P, Leone N, Ballerini A, Bondurri A, Cavallaro G, Silecchia G, Raparelli L, Greco F, Iorio O, Iossa A, De Angelis F, Rizzello M, Olmi S, Cesana G, Baldazzi G, Manoocheri F, Campanile FC, Munipalle P, Khan S, Gwiti P, Kanakala V, Viswanath Y, Kokotovic D, Sjølander H, Gögenur I, Helgstrand F, Devadhar S, Hounnou G, Elegbede OT, Hadonou AA, Mensah ED, Agossou-Voyeme AK, Konate I, Toure AO, Cisse M, Zaki M, Diao ML, Tendeng JN, Toure FB, Toure CT, Subramanian V, Froghi F, de Carvalho FC, Salimin L, Drabble E. Humbilical & Epigastric Hernia. Hernia. 2015 Apr;19 Suppl 1:S35-42. [PubMed: 26518843]
27.Guo C, Liu Q, Wang Y, Li J. Umbilical Hernia Repair in Cirrhotic Patients With Ascites: A Systemic Review of Literature. Surg Laparosc Endosc Percutan Tech. 2020 Dec 16;31(3):356-362. [PubMed: 33347087]
28.McKay A, Dixon E, Bathe O, Sutherland F. Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia. 2009 Oct;13(5):461-8. [PubMed: 19652907]
29.Yu BC, Chung M, Lee G. The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute. Ann Surg Treat Res. 2015 Aug;89(2):87-91. [PMC free article: PMC4518035] [PubMed: 26236698]
30.D’Orazio B, Almasio PL, Corbo G, Patti R, Di Vita G, Geraci G. Umbilical hernioplasty in cirrhotic patients with ascites A case control study. Ann Ital Chir. 2020;91:697-704. [PubMed: 33554937]
31.Mayo WJ. VI. An Operation for the Radical Cure of Umbilical Hernia. Ann Surg. 1901 Aug;34(2):276-80. [PMC free article: PMC1425538] [PubMed: 17861015]
32.Shrestha D, Shrestha A, Shrestha B. Open mesh versus suture repair of umbilical hernia: Meta-analysis of randomized controlled trials. Int J Surg. 2019 Feb;62:62-66. [PubMed: 30682412]
33.Melkemichel M, Stjärne L, Bringman S, Widhe B. Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation. Hernia. 2022 Dec;26(6):1483-1489. [PMC free article: PMC9684217] [PubMed: 34591212]
34.Halm JA, Heisterkamp J, Veen HF, Weidema WF. Long-term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and mesh repair. Hernia. 2005 Dec;9(4):334-7. [PubMed: 16044203]
35.Venclauskas L, Silanskaite J, Kiudelis M. Umbilical hernia: factors indicative of recurrence. Medicina (Kaunas). 2008;44(11):855-9. [PubMed: 19124962]
36.Talwar AA, Perry NJ, McAuliffe PB, Desai AA, Thrippleton S, Broach RB, Fischer JP. Shifting the Goalpost in Ventral Hernia Care: 5-year Outcomes after Ventral Hernia Repair with Poly-4-hydroxybutyrate Mesh. Hernia. 2022 Dec;26(6):1635-1643. [PubMed: 36114396]
37.Aslani N, Brown CJ. Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis. Hernia. 2010 Oct;14(5):455-62. [PubMed: 20635190]
38.Emans PJ, Schreinemacher MH, Gijbels MJ, Beets GL, Greve JW, Koole LH, Bouvy ND. Polypropylene meshes to prevent abdominal herniation. Can stable coatings prevent adhesions in the long term? Ann Biomed Eng. 2009 Feb;37(2):410-8. [PubMed: 19034665]
39.Elango S, Perumalsamy S, Ramachandran K, Vadodaria K. Mesh materials and hernia repair. Biomedicine (Taipei). 2017 Sep;7(3):16. [PMC free article: PMC5571666] [PubMed: 28840830]
40.Lau H, Patil NG. Umbilical hernia in adults. Surg Endosc. 2003 Dec;17(12):2016-20. [PubMed: 14574545]
41.Earle D, Roth JS, Saber A, Haggerty S, Bradley JF, Fanelli R, Price R, Richardson WS, Stefanidis D., SAGES Guidelines Committee. SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc. 2016 Aug;30(8):3163-83. [PubMed: 27405477]
42.Chen YJ, Huynh D, Nguyen S, Chin E, Divino C, Zhang L. Outcomes of robot-assisted versus laparoscopic repair of small-sized ventral hernias. Surg Endosc. 2017 Mar;31(3):1275-1279. [PubMed: 27450207]
43.Birindelli A, Sartelli M, Di Saverio S, Coccolini F, Ansaloni L, van Ramshorst GH, Campanelli G, Khokha V, Moore EE, Peitzman A, Velmahos G, Moore FA, Leppaniemi A, Burlew CC, Biffl WL, Koike K, Kluger Y, Fraga GP, Ordonez CA, Novello M, Agresta F, Sakakushev B, Gerych I, Wani I, Kelly MD, Gomes CA, Faro MP, Tarasconi A, Demetrashvili Z, Lee JG, Vettoretto N, Guercioni G, Persiani R, Tranà C, Cui Y, Kok KYY, Ghnnam WM, Abbas AE, Sato N, Marwah S, Rangarajan M, Ben-Ishay O, Adesunkanmi ARK, Lohse HAS, Kenig J, Mandalà S, Coimbra R, Bhangu A, Suggett N, Biondi A, Portolani N, Baiocchi G, Kirkpatrick AW, Scibé R, Sugrue M, Chiara O, Catena F. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017;12:37. [PMC free article: PMC5545868] [PubMed: 28804507]
44.Master SR, Mangla A, Shah C. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Mar 1, 2024. Desmoid Tumor. [PubMed: 29083753]
45.Tarahomi M, Alizadeh Otaghvar H, Ghavifekr NH, Shojaei D, Goravanchi F, Molaei A. Primary Hydatid Cyst of Umbilicus, Mimicking an Umbilical Hernia. Case Rep Surg. 2016;2016:9682178. [PMC free article: PMC4844872] [PubMed: 27190669]
46.Hansadah S, Begum J, Kumar P, Singh S, Balakrishnan D, Kundu A. Umbilical Hernia as Forerunner of Primary Umbilical Endometriosis: A Case Report. Medeni Med J. 2021 Dec 19;36(4):348-351. [PMC free article: PMC8694163] [PubMed: 34939402]
47.Monib S, Xanthis AG. Umbilical Sebaceous Cyst Mimicking Infected Urachal Sinus. Eur J Case Rep Intern Med. 2019;6(5):001098. [PMC free article: PMC6542488] [PubMed: 31157184]
48.Sardzinski EE, Roberts AP, Malat JP, King NE, Oulton ZW, Janta-Lipinska J, Kalathia CA, Hamilton JS, Brown ZG, Dornas HB, Toomey PG. Smoking History and the Development of Incisional Umbilical Hernia After Laparoscopic and Laparoendoscopic Single-Site Cholecystectomy. Am Surg. 2023 Aug;89(8):3501-3502. [PubMed: 36880854]
49.Lindmark M, Strigård K, Löwenmark T, Dahlstrand U, Gunnarsson U. Risk Factors for Surgical Complications in Ventral Hernia Repair. World J Surg. 2018 Nov;42(11):3528-3536. [PMC free article: PMC6182761] [PubMed: 29700567]
50.Zielsdorf SM, Kubasiak JC, Janssen I, Myers JA, Luu MB. A NSQIP Analysis of MELD and Perioperative Outcomes in General Surgery. Am Surg. 2015 Aug;81(8):755-9. [PubMed: 26215235]
51.Westen M, Christoffersen MW, Jorgensen LN, Stigaard T, Bisgaard T. Chronic complaints after simple sutured repair for umbilical or epigastric hernias may be related to recurrence. Langenbecks Arch Surg. 2014 Jan;399(1):65-9. [PubMed: 24037253]
52.Kaufmann R, Halm JA, Eker HH, Klitsie PJ, Nieuwenhuizen J, van Geldere D, Simons MP, van der Harst E, van ‘t Riet M, van der Holt B, Kleinrensink GJ, Jeekel J, Lange JF. Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Lancet. 2018 Mar 03;391(10123):860-869. [PubMed: 29459021]
53.Rogmark P, Petersson U, Bringman S, Eklund A, Ezra E, Sevonius D, Smedberg S, Osterberg J, Montgomery A. Short-term outcomes for open and laparoscopic midline incisional hernia repair: a randomized multicenter controlled trial: the ProLOVE (prospective randomized trial on open versus laparoscopic operation of ventral eventrations) trial. Ann Surg. 2013 Jul;258(1):37-45. [PubMed: 23629524]
54.Helgstrand F, Jørgensen LN, Rosenberg J, Kehlet H, Bisgaard T. Nationwide prospective study on readmission after umbilical or epigastric hernia repair. Hernia. 2013 Aug;17(4):487-92. [PubMed: 23793858]
55.Bencini L, Sanchez LJ, Bernini M, Miranda E, Farsi M, Boffi B, Moretti R. Predictors of recurrence after laparoscopic ventral hernia repair. Surg Laparosc Endosc Percutan Tech. 2009 Apr;19(2):128-32. [PubMed: 19390279]
56.Leonetti JP, Aranha GV, Wilkinson WA, Stanley M, Greenlee HB. Umbilical herniorrhaphy in cirrhotic patients. Arch Surg. 1984 Apr;119(4):442-5. [PubMed: 6703901]
57.Jain A, Mahakalkar C, Jajoo S, Aravind Kumar C. Mesh Antibioma: A New Entity in the Presentation of Late-Onset Mesh Infection. Cureus. 2023 Mar;15(3):e36144. [PMC free article: PMC10101185] [PubMed: 37065419]
58.Rastegarpour A, Cheung M, Vardhan M, Ibrahim MM, Butler CE, Levinson H. Surgical mesh for ventral incisional hernia repairs: Understanding mesh design. Plast Surg (Oakv). 2016 Spring;24(1):41-50. [PMC free article: PMC4806756] [PubMed: 27054138]
59.FitzGerald JF, Kumar AS. Biologic versus Synthetic Mesh Reinforcement: What are the Pros and Cons? Clin Colon Rectal Surg. 2014 Dec;27(4):140-8. [PMC free article: PMC4477030] [PubMed: 26106284]
60.Bellows CF, Alder A, Helton WS. Abdominal wall reconstruction using biological tissue grafts: present status and future opportunities. Expert Rev Med Devices. 2006 Sep;3(5):657-75. [PubMed: 17064250]
61.Appleby PW, Martin TA, Hope WW. Umbilical Hernia Repair: Overview of Approaches and Review of Literature. Surg Clin North Am. 2018 Jun;98(3):561-576. [PubMed: 29754622]
62.Hew S, Yu W, Robson S, Starkey G, Testro A, Fink M, Angus P, Gow P. Safety and effectiveness of umbilical hernia repair in patients with cirrhosis. Hernia. 2018 Oct;22(5):759-765. [PubMed: 29589135]
Disclosures: Anouchka Coste declares no relevant financial relationships with ineligible companies.
Disclosures: Sahand Bamarni declares no relevant financial relationships with ineligible companies.
Disclosures: Stephen Leslie declares no relevant financial relationships with ineligible companies.
