About 10 to 12% of abdominal wall hernias are umbilical hernias. Their development is associated with increase in intra-abdominal pressure and weakness of the fascia at the umbilicus level. These hernias have a narrow neck, which is a disposition for high risk incarceration and strangulation. The small bowel, omentum and colon make up the contents of the hernial sac.
There are two types of umbilical hernia:
Direct or true umbilical hernia ??? The protrusion is symmetrical through the umbilical ring. This is an infantile hernia normally occurring in infants or neonates. Its cause is associated with the failure of closure of the umbilical ring; the structures don???t fuse with the umbilical foramen causing the formation of a patent umbilical ring. Typically these defects close when the child turns about 5 years of age.
Indirect or paraumbilical hernia ??? protrusion is either above the umbilicus or below it; normally occurs in adults. The mesenteric fat pushes through the weak area of the ligaments close to the navel.
Signs and symptoms
- Pain and lump at the umbilicus
- Pressure sensation
Complications associated with umbilical hernias
- Ulceration of the skin
- Rupture of the hernia – most common with paraumbilical hernias
- Defect > 1 cm
Treatment of umbilical hernias
Before opting for elective surgery, patient has to be examined for ascites and treated before the surgery. In case of obesity, the patient should be counseled for dietary restrictions. Effective medical management would be with diuretics and weight loss before surgery.
Physical examination will reveal the presence of a lump or protrusion at the umbilicus. The fascial defect is palpated, which is smaller than the hernial sac. The hernia can also be visualized by increasing the intra-abdominal pressure with strain. A laparoscopic surgery is considered for:
- Defects > 4 cm
- Patients with recurrent hernias
- Obese patients
- A polypropylene or PTFE (polytetrafluoroethylene) mesh is commonly used equipment. A mesh is considered for defects > 4 cm.
- General anaesthesia is administered
- A curvilinear transverse incision is made not exceeding 180 deg. (large hernias may require an elliptical incision to excise excess skin)
- Electrocautery along with a fine-tipped instrument is used to excise the abundant skin overlying the hernia
- With the help of an incision in the aponeurosis, which is extended longitudinally, the sac is encircled and excised from the edges of the fascia and transected from the base of the umbilicus
- The hernial contents are reduced and sac opened to inspect contents
- Scar tissues and adhesions are lysed
- The adherent omentum is resected
- A mesh (sublay, onlay or underlay) is placed
- Wound is closed with running subcuticular suture
- In case of an onlay mesh, it is sutured to the fascia just above the peritoneum with 3 cm overlaps