An umbilical hernia is usually a congenital defect that presents gradually over time. Most commonly, patients sense a bulge in their “bellybutton” that often causes discomfort with activity, coughing, laughing, or straining.
Repair of an umbilical hernia in the very young child is rarely indicated because 80% of these fascial defects close by the age of 2 years. In addition, the incidence of incarceration and strangulation within an umbilical hernia in this age group is extremely low. However, if supportive measures such as the keystone type of strapping during infancy have failed and the fascial ring is sufficiently large to admit an index finger, the hernia should be repaired before school age.
This defect can be seen in either children or adults, and the preoperative preparation depends on the patient’s general condition and age. Obese patients are referred for medical weight loss. In general, elective repair of an umbilical hernia should be avoided in morbidly obese individuals because of the high risk of recurrence. In addition, these patients can inadvertently be started on a “path of failure” with multiple subsequent operations unless their underlying weight is addressed. A general medical assessment is indicated. Repair is delayed in the presence of acute respiratory infection, chronic cough, or infection about the navel. Special attention is given to cleaning of the navel.
Anesthesia via a laryngeal mask airway is often sufficient for most small to medium-sized umbilical hernias. If the patient is unable to tolerate repair via laryngeal mask, then general anesthesia should be used. General anesthesia is the method of choice for children.
Patients are placed in a comfortable supine position.
The skin is prepared in the usual manner after the umbilicus has been carefully cleaned. This may require cotton applicators saturated with antiseptic to reach any deep crevices. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
A curved incision placed superiorly or inferiorly about the umbilicus is used most commonly (FIGURE 1). Alternatively, a vertical incision placed within the umbilicus also can be used based on cosmesis and the exposure necessary (FIGURE 1). For larger umbilical hernias, a vertical incision can be extended to allow for additional exposure. The hernia sac is readily dissected away from the umbilical skin and surrounding subcutaneous tissues. The sac is easily mobilized, except for its attachment to the back of the umbilical skin. This is dissected carefully so as not to create a buttonhole that may put the repair at risk for infection. The neck of the herniated sac is then dissected from adjacent tissues by a combination of blunt and sharp dissection, which ...