An umbilical hernia is usually a congenital defect, although a variation may follow surgery such as the placement of an incision or laparoscopic port in this region. The increased susceptibility to strangulation of an umbilical hernia in an adult necessitates repair as the patient’s condition permits.
Repair of an umbilical hernia in the very young child is rarely indicated, since 80% of these fascial defects will 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 the index finger, the hernia should be repaired before school age.
This defect is usually seen in either children or obese adults, and the preoperative preparation depends entirely upon the patient’s general condition and age. Obese patients are placed on a diet. A general medical assessment is indicated. The patient may be placed on a low-residue diet for a day or two and the bowels emptied with a mild cathartic. 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.
Spinal anesthesia may be preferred in large hernias because of the excellent relaxation it provides; however, inhalation anesthesia can be used if not contraindicated. Inhalation anesthesia is the method of choice for children.
The patient is 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.
A curved incision placed superiorly or inferiorly about the umbilicus is most commonly used (figure 1). A vertical incision that curves around the umbilicus may be necessary for very large hernias. The umbilicus proper should be retained in the skin flap. The incision is made to the hernia sac. 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 is carried down to the level of the linea alba and anterior sheaths of the rectus muscle.
Most commonly, omentum is contained within the sac, but small and large bowel may also be present. Frequently the omentum will have formed ...