An umbilical hernia is a ventral hernia located at or near the umbilicus. The European Hernia Society classification for abdominal wall hernias defines the umbilical hernia as a hernia located from 3 cm above to 3 cm below the umbilicus. It is the second most common type of hernia in an adult following inguinal hernia. It accounts for 6%-14% of all abdominal wall hernias in adults.
Umbilical hernias in adults are acquired in 90% . Only 10% of adult umbilical hernia report having had hernia in childhood. It more common in women or individuals with increased intra-abdominal pressure as in pregnancy, obesity, ascites, or chronic abdominal distention. Stretching of the abdominal musculature and the presence of adipose tissue acts to separate muscle bundles and layers, weakens aponeuroses and favors the appearance of umbilical hernias .
The Incidence of Umbilical hernia in the general adult population is 2% while it is much more common in obese multiparous women and cirrhotic patients. Up to 20% of cirrhotic patients with ascites develop umbilical hernia. It is more common in females with a ratio of 3:1. In general, umbilical hernias in males most often present incarcerated, whereas females are more likely to have an asymptomatic reducible hernia. 70% of umbilical hernia repairs are carried out in male. Approximately 175,000 umbilical hernia repairs are annually performed in the United States .
Anatomically, the umbilical hernia could occur either through a potential weakness present at the exit site of involuted umbilical vessels, most importantly the umbilical vein or through weakened umbilical fascia (Richet's fascia). Therefore, umbilical hernia covering consist of skin, subcutaneous tissue, weakened superficial fascia, weakened umbilical fascia and peritoneum, practically all these layers are greatly attenuated and fused together. It has been noted that patients with Umbilical hernia often lack the umbilical fascia, and the round hepatic ligament is not attached to the inferior border of the umbilical ring.
Chronic abdominal wall distension with increased intra-abdominal pressure like in pregnancy, patient with ascites or peritoneal dialysis, stretching of the abdominal muscles fibers, and the weakness of connective tissue may be responsible for the occurrence of umbilical hernia. About 20% of cirrhotic patients will develop umbilical hernia due to increase in the abdominal pressure from ascites, dilation of umbilical veins, and muscular or connective tissue weakness due to poor nutritional status contribute to herniation.
Umbilical hernia may contain preperitoneal fat tissue, omentum, and small intestine or a combination of those can take part. The transverse colon is very rarely involved. The neck of the hernia sac is usually narrow compared with the size of the herniated sac, hence, incarceration and strangulation are common. Therefore, an elective repair after diagnosis is advised.
Adult with umbilical hernia typically presents with protrusion or bulging from the umbilicus. Pain and GI discomfort are other possible but infrequent presenting symptoms while tenderness and incarceration are common physical finding. Small-sized umbilical hernia often asymptomatic and only sometimes causes some degree of discomfort. Large umbilical hernia in older, multiparous or obese women, generally symptomatic and which usually presents with progressively enlarging hernia and in most cases becomes tender or irreducible with time . Strangulation of the umbilical hernia is a frequent complication; typically patients present with irreducible tender umbilical bulge with skin color changes and signs of intestinal obstruction if the sac contains a loop of small bowel.
An umbilical hernia is diagnosed during the physical exam. Careful examination of the entire abdominal wall, especially around the previous scar is warranted. The content of the hernia and the size of the defect could be estimated. Sometimes imaging studies such as abdominal ultrasound or CT scan are warranted to evaluate for complications or if the clinical diagnosis is difficult, especially in patients with obesity. It is also important to evaluate the BMI, smoking status and pre-existing Cirrhosis, given the high risk in those patient population.
All adult umbilical hernias need to be fixed because of the high risk of complications. surgery is indicated in symptomatic patients. Relative contraindications include uncontrolled ascites.
There are two main surgical repair options for umbilical hernias: suture repair and mesh. Primary suture repair is performed either by simple primary suture repair which can be used for small defects (<2 cm) or by using Mayo technique which is basically an overlapping abdominal wall fascia in a “vest-over-pants” manner which was described by William Mayo in 1901 . Unfortunately, primary suture repair associate with 10% recurrence rate. A recent randomized, double-blind, controlled multicentre trial in Europe on adults with a primary umbilical hernia of diameter 1–4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. There were fewer recurrences in the mesh group than in the suture group 4% vs 12%. Therefore, It is recommended for umbilical hernia of >1cm to repaired by mesh.
Mesh repair can be performed via both open or laparoscopic approaches. Open mesh repair can either be placed as onlay or sublay fashion; the onlay mesh placement is the technically easier but associated with higher wound complications e.g. seroma or hematoma and surgical site infection in some cases. Preperitoneal or sublay mesh placement requires more surgical skill and experience but less recurrence and wound complications. Some surgeons prefer leaving fascial margins without approximation; however, fascial closure before onlay mesh or after preperitoneal mesh is recommended .
Laparoscopic mesh repair can be performed either via transabdominal preperitoneal approach (TAPP) or intraperitoneal onlay mesh (IPOM) technique. Laparoscopic repair resulted in shorter hospital stay, shorter return to normal activities, lower wound complications and recurrence rates.
IPOM technique is based on the dissection of the sac, repair the defect with continuous suture followed by placement of mesh with a broad overlap of at least 5 cm. Abdominal wall structures like the falciform ligament must be dissected and the perivesical space must be opened to allow adequate incorporation and fixation of the mesh. 
TAPP approach involves reducing hernial sac contents, incising the peritoneum 5 cm away from the margin of the defect and creating a preperitoneal space. After obtaining adequate hemostasis, a mesh will be placed with at least 5-cm overlap on all sides. Finally, the mesh will be fixed with either a few absorbable tacks or suture and the same absorbable fixation system or suture will be used to close the peritoneal flap. It is suggested that TAPP decrease the risk of complication related to the intraperitoneal position of the mesh and has a lower complication rate than (IPOM) procedure.
After repair, the prognosis is good. However, recurrence is common in patients who continue to gain weight. In addition, there is a small risk of bowel obstruction.
Morbid obesity, high ASA-score (≥3), onlay repair, and concomitant bowel surgery are potential risk factors for surgical complication. Lindmark et al emphasize the size of the fascial defect as an important factor in the preoperative risk evaluation of patients with a ventral hernia. They conclude that surgical complication increases by 1% for each mm increase in fascial defect size.
1. Wound complications: including seroma, hematoma and surgical site infection. Open hernia repair techniques usually predispose to this kind of complication while the laparoscopic technique has resulted in a decrease in such complications.
2. Bowel injury and adhesion: laparoscopic technique predisposes to this type of complications. There is a low risk for enterotomy and dense adhesion related to direct contact of the mesh with the viscera.
3. Recurrence: There is a higher recurrence rate with primary repair even in defects of <4 cm. Morbid obesity > 30 kg/m, diabetes and wound infection are independent risk factors for recurrence. smoking also considered a risk for recurrence. Moreover, uncontrolled ascites is associated with a significant risk of recurrence.
Umbilical hernias are common in clinical practice. The majority of patients are first seen by the primary care provider or the emergency department physician. Because these hernias have a high risk of incarceration, surgery is recommended in all patients. an interprofessional team approach is necessary to avoid the morbidity of an umbilical hernia. In patients with associated comorbidity, a preoperative workup is necessary to reduce post-surgery complications. The nurse anesthetist must make sure that the patient is fit for surgery. Patients with cirrhosis and or ascites need to be thoroughly assessed prior to surgery, as complications are common
Once the surgery completed, the nurse should educate the patient on the importance of losing weight, quiet smoking and avoiding heavy lifting. Patient must be educated on healthy diet. Once the healing completed, the patient should be encouraged to increase physical activities and lose weight. This is vital in preventing a recurrence.
Nurse practitioners who see children should educate the parent that small hernias will spontaneously close but if they still remain open by age 5, surgery is required.
|||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 : the journal of hernias and abdominal wall surgery. 2009 Aug; [PubMed PMID: 19495920]|
|||Dabbas N,Adams K,Pearson K,Royle G, Frequency of abdominal wall hernias: is classical teaching out of date? JRSM short reports. 2011 Jan 19; [PubMed PMID: 21286228]|
|||Shankar DA,Itani KMF,O'Brien WJ,Sanchez VM, Factors Associated With Long-term Outcomes of Umbilical Hernia Repair. JAMA surgery. 2017 May 1; [PubMed PMID: 28122076]|
|||Venclauskas L,Jokubauskas M,Zilinskas J,Zviniene K,Kiudelis M, Long-term follow-up results of umbilical hernia repair. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2017 Dec; [PubMed PMID: 29362649]|
|||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. Journal of evidence-based medicine. 2016 Nov [PubMed PMID: 27792277]|
|||Rutkow IM, Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. The Surgical clinics of North America. 1998 Dec [PubMed PMID: 9927978]|
|||Moschcowitz AV, THE PATHOGENESIS OF UMBILICAL HERNIA. Annals of surgery. 1915 May; [PubMed PMID: 17863359]|
|||Fathi AH,Soltanian H,Saber AA, Surgical anatomy and morphologic variations of umbilical structures. The American surgeon. 2012 May [PubMed PMID: 22546125]|
|||Celdrán A,Bazire P,Garcia-Ureña MA,Marijuán JL, H-hernioplasty: a tension-free repair for umbilical hernia. The British journal of surgery. 1995 Mar [PubMed PMID: 7796013]|
|||Belghiti J,Durand F, Abdominal wall hernias in the setting of cirrhosis. Seminars in liver disease. 1997 [PubMed PMID: 9308126]|
|||Kulaçoğlu H, Current options in umbilical hernia repair in adult patients. Ulusal cerrahi dergisi. 2015 [PubMed PMID: 26504420]|
|||Forrest JV,Stanley RJ, Transverse colon in adult umbilical hernia. AJR. American journal of roentgenology. 1978 Jan [PubMed PMID: 413418]|
|||Jackson OJ,Moglen LH, Umbilical hernia. A retrospective study. California medicine. 1970 Oct [PubMed PMID: 5479354]|
|||Chevrel JP, [Inguinal, crural, umbilical hernias. Physiopathology, diagnosis, complications, treatment]. La Revue du praticien. 1996 Apr 15 [PubMed PMID: 8762240]|
|||Yang XF,Liu JL, Acute incarcerated external abdominal hernia. Annals of translational medicine. 2014 Nov [PubMed PMID: 25489584]|
|||Lassandro F,Iasiello F,Pizza NL,Valente T,Stefano ML,Grassi R,Muto R, Abdominal hernias: Radiological features. World journal of gastrointestinal endoscopy. 2011 Jun 16 [PubMed PMID: 21860678]|
|||Lindmark M,Strigård K,Löwenmark T,Dahlstrand U,Gunnarsson U, Risk Factors for Surgical Complications in Ventral Hernia Repair. World journal of surgery. 2018 Nov [PubMed PMID: 29700567]|
|||Mayo WJ, VI. An Operation for the Radical Cure of Umbilical Hernia. Annals of surgery. 1901 Aug [PubMed PMID: 17861015]|
|||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 (London, England). 2018 Mar 3 [PubMed PMID: 29459021]|
|||Gonzalez R,Mason E,Duncan T,Wilson R,Ramshaw BJ, Laparoscopic versus open umbilical hernia repair. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2003 Oct-Dec [PubMed PMID: 14626398]|
|||Berger D, [Laparoscopic IPOM technique]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2010 Mar [PubMed PMID: 20157687]|
|||Capitano S, Laparoscopic transabdominal preperitoneal approach for umbilical hernia with rectus diastasis. Asian journal of endoscopic surgery. 2017 Aug [PubMed PMID: 28727317]|
|||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. Annals of surgery. 2013 Jul [PubMed PMID: 23629524]|
|||Ahonen-Siirtola M,Vironen J,Mäkelä J,Paajanen H, Surgery-related complications of ventral hernia reported to the Finnish Patient Insurance Centre. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2015 Jun [PubMed PMID: 24820660]|
|||Bencini L,Sanchez LJ,Bernini M,Miranda E,Farsi M,Boffi B,Moretti R, Predictors of recurrence after laparoscopic ventral hernia repair. Surgical laparoscopy, endoscopy & percutaneous techniques. 2009 Apr [PubMed PMID: 19390279]|
|||Leonetti JP,Aranha GV,Wilkinson WA,Stanley M,Greenlee HB, Umbilical herniorrhaphy in cirrhotic patients. Archives of surgery (Chicago, Ill. : 1960). 1984 Apr [PubMed PMID: 6703901]|
|||[PubMed PMID: 26739977]|
|||[PubMed PMID: 25201555]|
|||[PubMed PMID: 27054138]|
|||[PubMed PMID: 17064250]|
|||[PubMed PMID: 26106284]|
|||Appleby PW,Martin TA,Hope WW, Umbilical Hernia Repair: Overview of Approaches and Review of Literature. The Surgical clinics of North America. 2018 Jun [PubMed PMID: 29754622]|
|||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 : the journal of hernias and abdominal wall surgery. 2018 Oct [PubMed PMID: 29589135]|