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Essential Features

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  • • Bulge elicited by the Valsalva maneuver at the umbilicus

    • Main complaint associated with umbilical hernias is the cosmetic appearance

    • Patients may note discomfort or a heaviness sensation associated with the hernia bulge

    • The hernia sac usually contains only pre-peritoneal fat although small bowel or other abdominal viscera may be present

    • Classification of incisional hernias

    • –Reducible: Visceral contents of the hernia sac able to retract into the abdominal cavity

      –Incarcerated: Visceral contents cannot be returned to the abdominal cavity

      –Strangulated: Incarcerated hernia where the blood flow to the entrapped viscera is compromised

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Epidemiology

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  • • Common in children (especially blacks), where spontaneous umbilical hernia closure by age 3 is the norm

    • Develop not infrequently in cirrhotic patients with uncontrolled ascites

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Clinical Findings

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Symptoms and Signs

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  • • Asymptomatic umbilical bulge most common presentation

    • Patients may complain of a discomfort, fullness or heaviness associated with the hernia bulge

    • Progressive enlargement of the defect is common

    • Hernia bulge may or may not be reducible

    • Incarcerated hernias are exquisitely painful to palpation

    • Patients with a strangulated hernia may present with an acute abdomen

    • Small bowel obstructive symptoms may be present with incarcerated umbilical hernias

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Imaging Findings

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  • • Plain films are typically normal

    • US can be used to detect fascial defects as well as differentiate between an incarcerated umbilical hernia and a solid mass

    • Abdominal pelvic CT scan is excellent in the detection of umbilical hernias and characterization of involved viscera; CT is particularly useful in diagnosing acute incarceration in the morbidly obese where physical exam is difficult and unreliable

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Diagnostic Considerations

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  • • Epigastric hernia

    • Urachal cyst

    • Primary or metastatic abdominal wall neoplasm

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Rule Out

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  • • Incarcerated or strangulated hernia

    • Abdominal wall tumor

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Work-up

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  • • Thorough history and physical exam usually will accurately diagnosis umbilical hernia

    • Abdominal CT scan when diagnosis is in doubt or to anatomically define the adjacent intestinal viscera in complicated cases

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When to Admit

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  • • Depends on magnitude of repair and comorbidities; patients may require postoperative hospitalization

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Treatment and Management

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  • • Minimize or eliminate medications deleterious to wound healing such as corticosteroids

    • Weight loss in obese patients

    • Ascitic control in cirrhotic patients

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Surgery

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  • • Repair can be performed laparoscopically or open

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Indications
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  • • Umbilical hernias should be fixed in all patients without medical contraindications

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Contraindications
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  • • Cirrhotic patients with uncontrolled ascites

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Treatment Monitoring

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  • • Clinical evidence of recurrence

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Complications

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  • • Postoperative wound or ...

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