Umbilical Hernia

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Imaging Findings

• • 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

• • Epigastric hernia

  • Urachal cyst

  • Primary or metastatic abdominal wall neoplasm

Rule Out

• • Incarcerated or strangulated hernia

  • Abdominal wall tumor

• • 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

When to Admit

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

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

  • Weight loss in obese patients

  • Ascitic control in cirrhotic patients

Surgery

• • Repair can be performed laparoscopically or open

Indications

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

Contraindications

• • Cirrhotic patients with uncontrolled ascites

Treatment Monitoring

• • Clinical evidence of recurrence

Complications

• • Postoperative wound or mesh infection

  • Recurrence

References