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Surgical Management of Umbilical Hernia

Joaquin A. Rodriguez, MD,


1
and Ronald A. Hinder, MD, PhD
2
U
mbilical hernia is a frequently encountered clinical
problem that is infrequently discussed critically in
the medical literature. Umbilical hernias were described
as early as the rst century, but it was not until 1740 that
WilliamCheselden reported the rst repair. In the United
States, Stoser performed the rst operation for an umbil-
ical hernia. It was, however, William Mayo who popular-
ized the vest-over-trousers overlapping repair in 1901
in his classic description of 19 patients treated with this
revolutionary procedure. There were few advances in
therapy during the next 100 years. A recent contribution
to the treatment of umbilical hernias has been the intro-
duction of mesh and the use of laparoscopic techniques.
ETIOLOGY AND PRESENTATION
The typical patient withanumbilical hernia is anoverweight
multiparous female between the ages of 35 and 50. Women
are affected with umbilical hernias 3 to 5 times more fre-
quently than men. Ascites may be a contributing factor and
makes the hernia more difcult to treat. The etiology of
herniation at the umbilicus is multifactorial, but chronically
increased intra-abdominal pressure and weakened fascial
tissue at the umbilicus are of utmost importance. The her-
nias canbe quite large, withfascial defects of 10to15cm, but
most are smaller than 5 cm in diameter. Omentum, colon,
and small bowel can all be encountered within the umbilical
hernia sac. Baccari describedthe presence of omentumalone
or in combination with small or large bowel in 60% of pa-
tients.
1
Small bowel alone and large bowel were found in4%
and 7%, respectively. Adhesions from the omentum and
bowel to the sac and the relatively small size of the fascial
defect comparedwiththe large amount of sac contents make
these hernias prone to incarceration.
CLINICAL PRESENTATION
Patients usually present to the physician with either a
complaint of pain or a lump at the umbilicus. The pain
can be described as a dragging sensation or can be quite
sharp and acute in nature when associated with coughing,
straining, or incarceration of abdominal contents. Al-
though 39% of patients are asymptomatic at the time the
hernia is discovered, 61% have experienced pain, pres-
sure, nausea, or vomiting. Of these, pain is the most com-
mon complaint, occurring in 44%of patients, followed by
pressure in 20% and nausea and vomiting in 9%. Physi-
cians should also realize that as the hernia enlarges it
tends to thin the overlying skin, which may lead to skin
ulceration from pressure necrosis. Furthermore, because
these hernias tend to occur in obese patients, the skin
overlying the hernia is prone to a weeping dermatitis and
a foul-smelling discharge from the combination of mois-
ture and friction between skin folds.
DIAGNOSIS
The diagnosis of umbilical hernia is usually made by ob-
taining a history of pain or a lump at the umbilicus, which
is usually conrmed on physical examination. The ap-
pearance of an outie instead of an innie of the umbi-
licus in an adult suggests an umbilical hernia. This is
conrmed by palpation of the incarcerated sac or protru-
sion of the sac through the fascial ring with straining
maneuvers. Occasionally, for morbidly obese patients on
whom it is difcult to perform an adequate abdominal
physical examination, the diagnosis can be conrmed by
a computed tomographic scan of the abdomen.
PATIENT SELECTION
AND METHODS OF REPAIR
Umbilical hernias are prone to incarceration and continue
to enlarge if untreated, and thus they should be consid-
ered for repair at presentation. The patient with a small,
at, asymptomatic umbilical hernia that has not changed
over a long time may be the exception to this rule and
should be re-examined at frequent intervals. How to re-
pair the hernia is a more difcult question. Small (3 cm)
rst-time hernias in nonobese patients may be repaired
primarily by suturing the fascial edges together. This can
be accomplished as an outpatient procedure and per-
formed under intravenous sedation with local inltration
of anesthetic. A tension-free repair with the vest-over-
trousers Mayo repair technique or simple approximation
of the two fascial edges can easily be performed with very
low morbidity. How often umbilical hernias recur is not
well established, but retrospective studies have shown
From the
1
Scott and White Clinic, Assistant Professor of Surgery, Texas A&M
University Health Science Center, Temple, TX; and
2
Mayo Clinic College of
Medicine, Department of Surgery, Mayo Clinic, Jacksonville, FL.
Address reprint requests to Joaquin A. Rodriguez, MD, 2401 South 31st Street,
Temple, TX 76508.
2004 Elsevier Inc. All rights reserved.
1524-153X/04/0603-0004$30.00/0
doi:10.1053/j.optechgensurg.2004.07.006
156 Operative Techniques in General Surgery, Vol 6, No 3 (September), 2004: pp 156-164
recurrence rates of 10% to 30%. In a recent prospective
randomized study from Spain, Arroyo et al
2
showed that
the recurrence rate after suture repair was 11% versus 1%
after prosthetic repair at a mean follow-up of 64 months.
This raises the question of whether every umbilical hernia
repair should be performed with mesh or whether mesh
should be used only in high-risk groups with recurrence.
Arroyo et al
2
did not show signicantly increased recur-
rence rates related to size greater or less than 3 cm (8%
and 5%, respectively) or to body mass index. However, we
can borrow from the literature on incisional and ventral
hernia repairs; it is replete with evidence that patients
who are morbidly obese or who have recurrent or large
hernias (4 cm) are at high risk for recurrence when
repaired without the use of prosthetic materials. Further-
more, wound complications and perhaps even recur-
rences are less if the prosthetic repair is performed lapa-
roscopically rather than through an open approach. Thus,
our recommendation for large (3 cm) and recurrent
hernias and for umbilical hernias occurring in morbidly
obese patients is to use a laparoscopic mesh repair.
SPECIAL CIRCUMSTANCES
Umbilical hernias are seen in 20% of patients with ascites.
Spontaneous rupture of the hernia with leakage of ascites is
infrequently seen, but it has a 10% to 20% mortality rate
when emergently repaired. Elective repair in patients with
uncontrolled ascites has a 2% mortality rate and a high rate
of recurrence; this repair is usually avoided or undertaken
with trepidation. Spontaneous rupture is preceded by skin
ulceration in 79% of patients and is an important clinical
sign. When skin ulceration is found, elective repair should
be attempted after the ascites is medically controlled. In
patients inwhomdiuretics anddietary modications are not
effective at controlling the ascites, surgical repair should be
combined with a peritoneovenous or transvenous intrahe-
patic portosystemic shunt for the control of ascites. The
transvenous intrahepatic portosystemic shunt procedure
has fewer complications than peritoneovenous shunting
and, though prone to occlusion, has been shown to improve
or control ascites inupto80%to90%of patients inthe short
term. Recurrence of ascites is directly related to the recur-
rence of hernia after surgery. Large defects should be re-
pairedwitha prosthesis anduse of antibiotic prophylaxis. In
contaminatedwounds where bowel strangulationandresec-
tionis required, the use of absorbable meshmay avoidbowel
stulas or chronic mesh infection, but it will result in a
recurrent hernia. An innovative approach has been reported
by Franklin and others.
3-19
This approach uses porcine
small intestinal submucosa mesh. Surgisis (Cook Surgical,
Bloomington, IN) is a naturally occurring extracellular ma-
trix that is easily absorbed. Its degradation is associated with
abundant newvessel growthandremodeling to a tissue with
strength that exceeds that of native tissue. In a preliminary
report of 25 patients, implantation of the Surgisis mesh in
infected elds at a mean follow-up of 15 months was asso-
ciated with only one wound infection (complicated by an
enterocutaneous stula). This stula was thought to be at a
site distant from the location of the mesh. In this short
follow-up period, no recurrent hernias were noted.
SURGICAL TECHNIQUE
Open Repair
This repair for small incisional hernias can easily be per-
formed as an outpatient procedure with intravenous se-
dation such as propofol, midazolam, or fentanyl and with
local inltration of an anesthetic such as 1% lidocaine.
The patient is placed in the supine position on the oper-
ating table with both arms abducted to 90. A single dose
of an intravenous rst-generation cephalosporin is ad-
ministered. The skin is sterilized and draped. The in-
fraumbilical skin is inltrated with local anesthetic, and a
curved incision is created around the umbilical depres-
sion (Fig 1).
The subcutaneous tissues are dissected off the rectus
sheath and linea alba to expose the hernia sac. The sac is
incised at its neck, and the sac is detached from the um-
bilical skin (Fig 2). The sac is opened, and adhesions from
the omentum or bowel are divided and the contents, if
viable, are returned to the peritoneal cavity. A small sac
may be invaginated without being opened. The sac is
excised, and the peritoneumis sutured with a 2-0 absorb-
able suture. The rectus sheath is dissected on its anterior
surface so that a 1.5- to 2.0-cm margin is visible around
the defect. Similarly, adhesions on the peritoneal surface,
just inside the fascial defect, are cleared for 360 to allow
visualization of the suture repair.
The fascial defect is closed transversely with inter-
rupted monolament 0 polypropylene or 0 ethibond su-
tures (Ethicon, Sommerville, NJ). Full-thickness bites are
placed 1 to 1.5 cm from the edge of the defect and left
untied until the nal suture is placed (Fig 3).
The sutures are tied individually (Fig 4). Meticulous
hemostasis is secured. The deep surface of the skin of the
umbilical cicatrix is tacked down to the fascial repair with
a 4-0 absorbable suture to preserve the natural appear-
ance of the umbilicus. The skin is closed with a running
4-0 subcuticular suture. A cotton ball is placed in the
umbilicus and a dressing applied.
In the Mayo repair, the incision and initial dissection
is similar. The closure of the fascial defect is performed
by imbricating the upper (vest) fascia over the lower
(trousers) fascia with two rows of interrupted non-
absorbable 0 sutures. The rst rowis placed high on the
vest and at the free edge of the trousers (Fig 5). The
free superior edge of the vest that overhangs the
trousers is then secured with a second layer of inter-
rupted nonabsorbable 0 sutures (Fig 6).
157 Surgical Management of Umbilical Hernia
TRADITIONAL REPAIR
1 Incision.
2 Dissection of neck of hernia sac.
158 Rodriguez and Hinder
3 Placement of fascial sutures.
4 Completed traditional repair.
5 Placement of sutures in Mayo repair.
6 Completed Mayo repair.
159 Surgical Management of Umbilical Hernia
Laparoscopic Repair
The patient is placed in the supine position with the left
arm tucked alongside the patient. Monitors are placed at
either side of the foot of the bed. Preoperatively, sequen-
tial leg compression devices are applied, and 5000 units of
subcutaneous heparin are administered for deep venous
thrombosis prophylaxis. Arst-generation cephalosporin
is administered intravenously. After general endotracheal
anesthesia is induced, the abdominal skin is sterilized and
draped. An orogastric tube and Foley catheter are placed.
An Ioban (3M Healthcare, St. Paul, MN) drape is applied.
A pneumoperitoneum is achieved with a Veress needle
insertion in the left upper quadrant just inferior to the
costal margin. A 10-mm port is then placed percutane-
ously at a point along the anterior axillary line but away
from the edge of the fascial defect of the hernia. One or
two additional 5-mm ports are placed under direct vision
away from the fascial defect on the left side of the abdo-
men (Fig 7). Care should be taken not to place a port in
close proximity to the anterior superior iliac spine be-
cause this bony prominence or a large thigh can hinder
the mobility of any instrument used through this port.
For large, complex, incarcerated hernias, a fourth trocar
can be placed under direct vision in the opposite side of
the abdomen.
A 30 laparoscope is placed through the 10-mm port.
Laparoscopic examination of the abdomen is performed,
and any abnormalities are noted. If there is no contraindica-
tion to proceed, the incarcerated contents are reduced. This
can be accomplished with a combination of blunt and sharp
dissection with scissors (Fig 8). Occasionally, the harmonic
scalpel is useful if the adhesions are particularly vascular. No
attempt is made to remove the hernia sac.
The abdominal wall is inspected for additional hernias.
If none are found, the umbilical fascial defect is sized by
passing a spinal needle transabdominally and marking the
edges on the Ioban drape (Fig 9). It is easy to overestimate
the size of the defect with a pneumoperitoneum; thus,
insufation pressure should be reduced to 8 to 10 mmHg
for this step. The undersurface of the abdominal wall is
cleared of any fatty deposits that would inhibit smooth
at application of the mesh.
LAPAROSCOPIC REPAIR
7 Port placement.
160 Rodriguez and Hinder
8 Reduction of hernia contents.
9 Sizing of hernia defect with 27-gauge spinal needle.
An appropriate size mesh is chosen to adequately close
the defect with an overlap of 3 cm circumferentially.
We use the Composix e/x or Composix Kugel mesh
(Davol, Cranston, RI), but many others are available. It
is important to have 3- to 5-cm overlap over the entire
fascial defect. Four sutures of 0 Prolene are placed
through the polypropylene side of the mesh at the 12,
3, 6, and 9 oclock positions. These are tied to the mesh
with three square knots. The mesh is then rolled and
inserted through the 10-mm port into the abdominal
cavity. Larger pieces of mesh require removal of the
port and placement directly through the skin opening.
The mesh is unrolled inside the abdomen and posi-
tioned with the polypropylene side against the abdom-
inal wall and the polytetrauoroethylene side down
toward the abdominal contents. The pneumoperito-
neum is again decreased to 10 mm Hg and with a
suture-passing instrument (Inlet Medical, Eden Prai-
rie, MN) the corresponding pairs of sutures are indi-
vidually pulled transabdominally through appropri-
ately placed 3-mm skin incisions. The sutures are
pulled tight, and the mesh is raised to the abdominal
wall (Fig 10). A 3- to 5-cm overlap is once again con-
rmed, and the anchoring sutures are tied in the sub-
cutaneous tissues. These sutures serve to both prevent
migration of the mesh and to center the mesh over the
fascial defect. An auto suture tacker (U.S. Surgical,
Norwalk, CT) is used to place tacks through the mesh
into the abdominal wall every 1.5 to 2.0 cm along the
periphery of the mesh (Fig 11). This allows the mesh to
be smoothed out and prevents the omentum from
insinuating itself between the mesh and the abdominal
wall. This maneuver is facilitated by pressing with the
opposite hand on the abdominal wall against the tack-
ing instrument. The pneumoperitoneum is released,
and the ports are removed. A layered fascial closure of
10 Tying of trans-fascial sutures in subcutaneous tissues.
162 Rodriguez and Hinder
the 10-mm port is performed. The skin is closed with
4-0 absorbable suture. A pressure dressing is applied
over the site of the fascial repair to prevent seroma
formation.
POSTOPERATIVE COURSE
Outpatient surgical treatment of small umbilical hernias
is usual. Once at home, patients are instructed to remove
the dressing in 24 hours. They are further instructed not
to lift objects greater than 10 lbs in weight and to avoid
strenuous activities for 2 weeks. Complications are rare
and usually consist of a wound seroma, hematoma, or
wound infection. Necrosis of the umbilical skin rarely
occurs. Patients with larger umbilical hernias repaired
laparoscopically generally have more pain, and a small
percentage need to be admitted for treatment of their pain
with narcotics. In the hospital, they are given clear liquids
on the day of the operation and a regular diet on the rst
postoperative day. They are instructed to maintain a pres-
sure dressing on the area for one week, because seroma is
a common occurrence. These do not require aspiration,
unless very symptomatic, because they usually resolve
spontaneously. Patients and other physicians need to be
advised that a lump at the site of the previous hernia may
be present and does not represent a recurrence. Rare com-
plications include unrecognized bowel injury and herni-
ation through trocar sites; they should be looked for in
patients who return with signicant pain. Wound com-
plications are minimal. Patients are allowed to resume
most normal activities by 10 days as tolerated.
CONTROVERSIES AND FUTURE AREAS
OF STUDY
Consensus does not exist with regard to the type of mesh
or the technique for mesh xation that yields the best
clinical results. Proponents of prosthetic materials with
little tissue ingrowth, such as Goretex (WL Gore, Flag-
staff, AZ), describe placing transabdominal anchoring su-
tures every 2 to 3 cm. Others believe that these transab-
dominal sutures are the cause of pain and are not needed
to anchor the prosthesis if a mesh with a high degree of
tissue ingrowth, such as Composix e/x (Davol) or pari-
etex (Sofradim, Wrentham, MA), is selected. Instead,
they argue it is quicker to anchor the mesh only with
11 Tacking of mesh.
163 Surgical Management of Umbilical Hernia
tacks. Both proponents have reported good individual
results, but no head-to-head comparative, randomized,
prospective studies exist with regard to the type of mesh,
type of xation or postoperative pain, complications, or
recurrence of hernia. Until such studies are available,
each surgeon will have to critically evaluate his/her own
technique and results.
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164 Rodriguez and Hinder