Summary

An Umbilical Hernia is a protrusion of abdominal contents through a defect in the linea alba at the umbilicus. In adults, these are almost always "acquired" due to increased intra-abdominal pressure (IAP) and are biologically distinct from the congenital umbilical hernias seen in newborns. Technically, most adult "umbilical" hernias are Paraumbilical, emerging through the linea alba just superior or inferior to the umbilical cicatrix, whereas true umbilical hernias (through the scar itself) are rare in adults.

Key Facts

• Prevalence: Very common. 2% of adult population.
• Gender: Female > Male (3:1) due to pregnancy stretching the linea alba.
• Risk Stratification:
  • Small (<1cm): Contains Omentum. Risk of pain/incarceration.
  • Large (>4cm): Contains Bowel. Risk of obstruction.
• The "Mayo Repair": The classic "overlap" repair. largely abandoned for mesh in defects > 1cm due to recurrence.

Clinical Pearls

"The Smiling Umbilicus": In a normal abdomen, the umbilicus is inverted. In a large hernia or ascites, it everts (the "outie").

Strangulation Risk: Umbilical hernias have a higher risk of strangulation than inguinal hernias because the defect (neck) is often small, rigid, and fibrous (the linea alba), acting like a garrote around the bowel loop.

The Cirrhosis Trap: Never repair an umbilical hernia in a patient with uncontrolled ascites unless it is strangulated. The wound will leak fluid ("Flood Syndrome") and never heal, leading to peritonitis and death.

The Linea Alba

• A fibrous band running from Xiphisternum to Pubis.
• Formed by the fusion of the aponeuroses of the external oblique, internal oblique, and transversus abdominis.
• Weak Point: The umbilical ring is a natural defect where the umbilical vessels passed in fetal life.

Richet's Fascia

• A thickening of the transversalis fascia behind the umbilicus.
• Relation to Hernia: Variation in the strength of Richet's fascia determines if a hernia forms.
• Content:
  • Hernia Sac: Peritoneum.
  • Hernia Content:
    1. Omentum: Most common. Often adherent (incarcerated).
    2. Small Bowel: In larger defects.
    3. Colon: Rare (Transverse colon).

The "Physics of Failure" (Laplace's Law)

Why do simple sutures fail?

• Mechanism: The abdominal wall is under constant tension (hoop stress).
• Sutures: Pulling healthy tissue together under tension causes ischemia at the suture line. The sutures "cheese-wire" through the muscle, enlarging the hole.
• Mesh: Distributes tension across a wide area (Pascal's Principle). This is why "Tension-Free Repair" is the Gold Standard.

Causes of raised Intra-Abdominal Pressure (IAP).

The "Sister Mary Joseph" Nodule

A sign of doom.

• Definition: Metastatic nodule at the umbilicus.
• Origin: Usually Stomach, Ovary, Colon, or Pancreas (Intra-abdominal malignancy).
• Mechanism: Spread via lymphatics or the Falciform ligament.
• Action: Do NOT repair it. Biopsy it. Look for the primary cancer.

The Urachus Connection

Embryology Remnant.

• Anatomy: Connection between the bladder and umbilicus.
• Pathology: Can form a cyst or sinus (weeping umbilicus).
• Red Flag: If the umbilicus is wet/smelly, rule out Urachal Sinus or Patent Urachus before fixing the "hernia".
• Risk: Adenocarcinoma of the Urachus (Rare).

Differential: The Spigelian Hernia

The "Stealth Hernia".

• Location: Higher up constriction lateral to rectus muscle (Linea Semilunaris).
• Features: Often interparietal (hidden under aponeurosis). High risk of strangulation because neck is tight.
• Diagnosis: Often missed on exam. Needs CT.
• Management: Repair mandatory.

3. Incisional/Port-Site Hernia:
   • Through a previous surgical scar (e.g. Laparoscopic port site at umbilicus).
   • Note: Biologically different. High failure rate if treated simply. Needs mesh.

The "Fat Apron" (Panniculus)

A surgical challenge.

• Problem: Massive overhanging skin fold covers the hernia site. Make it a wet, fungal-infected environment.
• Risk: Incision through panniculus has 50% infection rate.
• Solution: Panniculectomy (Tummy Tuck) at the same time? Controversial (high complication rate). Better to retract it or lose weight.

Special Type: Parastomal Hernia

Hernia around a stoma (Colostomy/Ileostomy).

• Incidence: Huge (50% of stomas develop a hernia).
• Difficulty: Extremely hard to fix without moving the stoma.
• Management: Usually conservative (Support Belt) unless obstructing. Surgery involves "Sugarbaker" intraperitoneal mesh repair.

Divarication of Recti (Diastasis Recti)

The "Fake Hernia".

• Anatomy: Widening of the linea alba (stretch), but no defect (hole) in the fascia.
• Clinical: Ridge/bulge appears from xiphisternum to umbilicus when doing a sit-up (Tyre-bulge).
• Diagnosis: Ultrasound confirms intact fascia.
• Management: Conservative. Physiotherapy (Core strength). Surgery (Plication) is cosmetic only and rarely funded.
• Trap: Repairing a small umbilical hernia in a patient with massive divarication has high failure rate.

By Anatomy

1. True Umbilical: Through the cicatricial scar. (Infants).
2. Paraumbilical: Through the linea alba adjacent to the scar. (Adults).
   • Note: Often indistinguishable clinically. We treat them the same.

By Complexity (EHS Classification)

• Small: < 1 cm.
• Medium: 1-4 cm.
• Large: > 4 cm.

Ventral Hernia Working Group (VHWG) Grading

Risk Stratification for Infection/Recurrence.

History

• Lump: "Pops out when I stand up."
• Pain: Dragging sensation.
• Red Flags:
  • "It won't go back in" (Incarceration).
  • "It's gone red and painful" (Strangulation).
  • "I'm vomiting and constipated" (Obstruction).

Examination Steps

1. Inspect: Standing up. Look for the lump. Check for skin erythema (sign of dead bowel underneath).
2. Palpate: Check for tenderness.
3. Cough Impulse: Ask patient to cough. The lump expands.
4. Reducibility: Ask patient to lie flat. Try to gently massage the lump back in.
   • Irreducible: Means incarceration. Does not mean immediate surgery unless tender.

• Pros: Can relieve drag/gravity pain in elderly/unfit patients.
• Cons: Does not cure the hernia. Can cause pressure sores if tight. Cannot use if hernia is irreducible (strangulation risk).
• Verdict: Only for "Watchful Waiting" patients who are not surgical candidates.

The "Umbilicoplasty" (Belly Button Reconstruction)

It's not just a hole closure.

• The Ideal Umbilicus: Inverted, superior hooding, midline.
• Technique: Anchoring the skin flap to the fascia (Quill stitch) to recreate the "inversion".
• Risk: Losing the umbilicus (Necrosis) creates a flat abdomen (Kyle XY look). Warn patients.

Enhanced Recovery (ERAS) Protocol

Getting home same day.

• Pre-Op: Carb loading drink (Pre-load). No prolonged fasting.
• Intra-Op: Local anaesthetic infiltration (Chirocaine) into the wound. Minimise opioids.
• Post-Op: Eat/Drink immediately. Mobilise within 1 hour.
• Discharge: When pain controlled and passing urine.

Pre-Operative Optimization (Crucial)

Why we say "lose weight first".

• Obesity (BMI > 35): Doubles the recurrence rate. Triples the infection rate.
  • Goal: BMI < 30. (Consider Ozempic / Bariatric referral first).
• Smoking: Vasoconstriction causes poor wound healing. Must stop 4 weeks prior.
  • The Mechanism: Nicotine reduces microvascular blood flow by 40%. Carbon Monoxide reduces Oxygen delivery. This leads to wound dehiscence and mesh infection.
• Diabetes: Hba1c < 60 mmol/mol mandatory to reduce infection risk.

Obesity Management Algorithm

Standard of care.

1. BMI < 30: Proceed to surgery (Open or Lap).
2. BMI 30 - 35: Counsel on weight loss. Proceed if symptomatic. Laparoscopic preferred (lower wound infection risk).
3. BMI 35 - 40: Do Not Operate (Elective). Risk of recurrence is >30%. Refer to Medical Weight Management / Ozempic.
4. BMI > 40: Bariatric Surgery first. Fix hernia 12 months later (during tummy tuck).

The WHO Surgical Safety Checklist

Stopping errors before they happen.

• Sign In: Patient ID, Site Marked (Arrow on tummy), Allergies checked.
• Time Out: "Stop the line". Everyone introduces themselves. Confirm procedure: "Umbilical Hernia Repair".
• Antibiotics: Given <60 mins before cut (e.g. Co-amoxiclav).
• Sign Out: Instrument count correct? (Don't leave a forcep inside).

Emergency Management: Strangulation

The dead bowel.

1. Resuscitate: IV Fluids, NG Tube (decompress stomach), Antibiotics (Cefuroxime/Metronidazole).
2. Consent: Warn about "Bowel Resection" and Stoma.
3. Incision: Generous incision. Open the sac carefully (bloody fluid = bad sign).
4. Assess Viability:
   • Pink: Viable. Reduce.
   • Dusky: Apply warm swabs for 5 mins. If pinks up -> Viable.
   • Black: Dead -> Resect.

1. Primary Suture Repair (Defects < 1cm)

• Technique: Simple interrupted sutures (Prolene 0 or 1) to close the linea alba.
• Mayo Repair: "Vest-over-pants" overlap.
  • Status: Obsolete. High recurrence rate (overlap creates tension). Do not do this.
• Simple Suture: Acceptable for tiny defects (<1cm).

Deep Dive: Mesh Types Matrix

The "Mesh Debate": Synthetic vs Biological

• Synthetic (Polypropylene):
  • Pros: Cheap, permanent, strong.
  • Cons: Adhesions if touches bowel (Erosion). High infection risk in contaminated fields.
• Biological (Porcine Dermis):
  • Pros: Resists infection (can be used in infected fields).
  • Cons: Expensive. Degrades over time (Recurrence risk). Often used only as a salvage bridge.
• Composite (Dual-Sided):
  • One side non-stick (PTFE/Parietex) for bowel contact, one side porous for tissue ingrowth. Standard for IPOM.

Historical Note: The "Mayo" Repair

Why we stopped doing it.

• Technique: Overlapping the fascia ("Double breasting") like a coat.
• Logic: Supposed to be stronger (two layers).
• Reality: It creates High Tension.
• Outcome: Sutures pull through the fascia (Cheese-wiring). Recurrence rates 10-20% vs 1% for Mesh.
• Conclusion: Only use for tiny defects (<1cm) where mesh is overkill.

2. Mesh Repair (Defects > 1cm)

Mesh halves the recurrence rate.

• Onlay: Mesh placed on top of the fascia. (Easy, but high seroma/infection risk).
• Sublay (Retromuscular): Mesh placed behind the rectus muscles. The Gold Standard for larger hernias.
• Preperitoneal: Mesh placed between peritoneum and fascia.

Open vs Laparoscopic: The Decision Matrix

How we choose.

4. Component Separation Technique (TAR)

Transversus Abdominis Release.

• Indication: Massive midline defects where the rectus muscles cannot be pulled together.
• Technique:
  • The posterior rectus sheath is incised.
  • The Transversus Abdominis muscle is released laterally.
  • This allows the posterior layer to slide medially ("Advance") to close the hole without tension.
• Outcome: Allows closure of defects 10-15cm wide.

5. Classification

Intraperitoneal Onlay Mesh.

• Indication: Obese patients or recurrent hernias or >4cm.
• Technique:
  1. Ports placed laterally (flank).
  2. Hernia contents reduced.
  3. Special "Dual-sided" mesh (coated to prevent bowel adhesion) is tacked to the ceiling of the abdomen covering the hole.

6. The Robotic Revolution (R-TAPP)

The future?

• TAPP: Trans-Abdominal Pre-Peritoneal.
• Technique: The Robot (Da Vinci) sutures the mesh to the ceiling of the abdomen behind the peritoneum.
• Benefit: No tacks (less pain) + Mesh is covered (no adhesions).
• Cost: Very high. Reserved for complex recurrent hernias.

The Consent Form (What to write)

Legal protection.

• Procedure: Open/Lap Umbilical Hernia Repair +/- Mesh.
• Risks:
  • Bleeding: Bruising/Hematoma.
  • Infection: Wound or Mesh (might need removal).
  • Recurrence: 5% risk.
  • Damage: To bowel (enterotomy) - risk of stoma.
  • Pain: Chronic groin/abdo pain.
  • Scars: Keloid.
  • Seroma: Fluid swelling.

The "Seroma Dilemma"

To drain or not to drain?

• Scenario: 2 weeks post-op, patient has a fluid lump.
• Rule: NEVER aspirate (needle) a seroma unless infection is suspected (Red/Hot).
• Reason: Sticking a needle introduces skin bacteria to the mesh -> Mesh infection -> Explant.
• Management: Wait. Most reabsorb in 6-12 weeks.

Immediate

• Seroma: Fluid collection in the dead space where the hernia sac was. Very common (10%). Usually resolves. Do not stick a needle in it (introduces infection).
• Hematoma: Bruising.
• Wound Infection: Risk for mesh infection.

Deep Dive: Mesh Infection

The Surgeon's Nightmare.

• Incidence: 1-2%.
• Pathogen: Typically Staph Aureus (Biofilm formation).
• Presentation: Chronic sinus discharging pus months/years later.
• Management:
  • Antibiotics: Rarely work (Biofilm).
  • MAC (Monitor): Sometimes settles.
  • Excision: Total removal of the infected mesh is usually required. This leaves a massive recurrent defect.
  • Salvage: Vacuum Dressing (VAC) -> Delayed closure.

Long Term

• Recurrence:
  • Suture repair: 10-15%.
  • Mesh repair: 1-5%.
• Chronic Pain: Mesh entrapment of nerves.

"Loss of Domain"

When the hernia is bigger than the abdomen.

• Definition: >20% of abdominal contents reside outside the abdomen in the hernia sac.
• Problem:
  • The abdominal cavity shrinks (muscles contract).
  • Reducing the contents back inside causes Abdominal Compartment Syndrome (High pressure -> Kidney failure / Ventilator failure).
• Management:
  • Pre-op: Botox injection into lateral muscles (to relax them).
  • Progressive Pneumoperitoneum: Blowing air into abdomen weeks before surgery to stretch it.

High stakes surgery.

• Problem: Ascites pushes the hernia out. Liver failure causes coagulopathy (bleeding). Poor nutrition causes poor healing.
• Risk: "Flood Syndrome". If the wound opens, litres of ascites drain out -> Peritonitis -> Death.
• Protocol:
  1. Medical Management First: Diuretics, Spinrolactone, Salt restrict.
  2. TIPS Procedure: To lower portal pressure.
  3. Surgery: ONLY if strangulated or controlled ascites. Use absorbable sutures? No, use permanent. Leave a drain? No (infection track).

Q: Can I lift weights afterwards? A: No heavy lifting (>10kg) for 6 weeks. Walking is fine immediately.

Q: Will it come back? A: There is a small chance (1-5%). Keeping your weight stable and not smoking helps prevent recurrence.

Q: I am pregnant and have a hernia. When should I fix it? A: Post-partum. Fixing it during pregnancy is futile (it breeds recurrence) and risky. Wait until 6 months after delivery.

• Why wait 6 months?: The abdominal wall needs time to shrink back to normal size. Repairing while tissues are stretched leads to failure.

Post-Op Return to Activity Plan

Gradual return.

Q: Can I drive? A: You can drive when you can perform an "Emergency Stop" without hesitation/pain. Usually 1-2 weeks.

Discharge Checklist (Going Home)

• Pain Control: Analgesia supply (Paracetamol/Codeine).
• Wound: Dry dressing. Spare dressings provided.
• Bowels: Laxatives prescribed (Codeine causes constipation).
• Emergency: Number to call if fever/vomiting.
• Sick Note: 2 weeks off work signed.

Q: When can I shower? A: Next day. The wound is waterproof after 24 hours. No baths (soaking) for 2 weeks.