How To Repair An Umbilical Hernia Without Surgery

Ulus Cerrahi Derg. 2022; 31(3): 157–161.

Current options in umbilical hernia repair in adult patients

Received 2022 Oct 28; Accepted 2022 Dec seven.

Abstract

Umbilical hernia is a rather common surgical problem. Elective repair afterwards diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh can exist placed through either an open or laparoscopic arroyo with good clinical results. Standard polypropylene mesh is suitable for the open up onlay technique; however, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may effect in recurrence. Obesity, ascites, and excessive weight gain following repair are patently potential run a risk factors. Moreover, smoking may create a risk for recurrence.

Keywords: umbilical hernia, hernia repair, mesh, laparoscopy

INTRODUCTION

Umbilical hernia is a rather common surgical problem. Approximately x% of all chief hernias comprise umbilical and epigastric hernias (i). Approximately 175,000 umbilical hernia repairs are annually performed in the US (2). It has been reported that the share of umbilical and paraumbilical hernia repairs amidst all repairs for intestinal wall hernias increased from 5% to fourteen% in Uk in the final 25 years (3). A like rise has been reported in a recent multicenter study from Turkey (4).

In general, umbilical hernias are more common in women than men; however, in that location are series in which male patients are more frequent (5). Typically, a lump is observed effectually the omphalos. Pain is the most mutual indication to visit a medico and undergo a repair (6). Recurrence may develop even in cases where a prosthetic mesh is used. Recurrent umbilical hernias often tend to enlarge faster than principal ones and may behave as incisional hernias.

An umbilical hernia has a tendency to exist associated with high morbidity and bloodshed in comparison with inguinal hernia considering of the higher risk of incarceration and strangulation that crave an emergency repair. Although the number of articles with the title word "umbilical hernia" increased ii.6-fold betwixt the periods 1991–2000 and 2001–2010, there still appears to be a certain discrepancy betwixt its importance and the attending information technology has received in the literature (7). In this newspaper, the nature of the umbilical hernias is reviewed, and the electric current options for their surgical repair are discussed.

Anatomic Description

Many hernias in the umbilical region occur above or below the umbilicus through a weak identify at the linea alba, rather than direct through the bellybutton itself, and the natural history and treatment do not differ for these hernias. The European Hernia Guild nomenclature (8) for primary intestinal wall hernias defines the midline hernias from 3 cm to a higher place to 3 cm beneath the omphalos as umbilical hernia (Effigy one).

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Intestinal wall hernias from 3 cm higher up to 3 cm below the umbilicus are defined as umbilical hernia according to the European Hernia Lodge Classification (8)

The borders of the umbilical culvert are the umbilical fascia posteriorly, the linea alba anteriorly and medial edges of the two rectus sheaths on ii sides. Herniation happens due to increasing intra-intestinal pressure. Predisposing factors include obesity, multiple pregnancies, ascites, and intestinal tumors (9). The content of the hernia sac may be preperitoneal fat tissue, omentum, and small intestine in the bulk; a combination of those can take part. Large intestines are very rarely involved (10). The neck of the umbilical hernia is usually narrow compared with the size of the herniated mass, hence, strangulation is common. Therefore, an elective repair after diagnosis is advised.

Anesthesia

All iii types of anesthesia (local, general, and spinal) are suitable in most cases. The patient and surgeon should make a determination regarding the type of anesthesia to be used earlier surgery. Local anesthesia often provides maximum comfort for patients when it is accurately performed in open up repairs. Some centers routinely employ local anesthesia (v, eleven, 12). However, inexperience with the local coldhearted technique may cause discomfort to patients with an increased recurrence charge per unit. Local anesthesia may also exist challenging if the patient is obese and hernia is large and/or recurrent (xiii). In patients with ASA I or II scores and who have i of the specific difficulties above, the surgeon should ameliorate choose general anesthesia to feel more secure because the quality of repair is the nigh important outcome measure.

Laparoscopic ventral hernia repair by and large requires general anesthesia with endotracheal intubation. Furthermore, it tin can exist feasible under spinal anesthesia with low-force per unit area CO₂ pneumoperitoneum (xiv).

Antibody Prophylaxis

Naturally, belly button is not a make clean anatomical part of the body. The umbilical peel may not be cleaned of all leaner even with the utilise of mod antiseptic solutions. Therefore, the surgical site infection tin can be more frequent post-obit umbilical hernia repairs than that post-obit inguinal hernia repairs. A 10% superficial wound infection charge per unit is not surprising even after routine prophylactic antibiotic use. A recent report reported a 19% infection rate following open umbilical hernia repair (15). Kulacoglu et al. (5) reported 3% wound infection rate with antibiotic prophylaxis with cefazolin sodium that is administered thirty min before skin incision.

Deysine (fourteen) recommended topical gentamicin in addition to preoperative intravenous prophylaxis to lower the infection rates after hernia repairs. He reported no surgical site infections in hernia surgery after setting this prophylaxis combination for 24 sequent years. Although gentamicin is near effective against gram-negative bacteria, it is likewise effective confronting staphylococci. Furthermore, it has been stated that gentamicin tin demonstrate antimicrobial synergy with cefazolin for a more than successful antibacterial result (16).

Which Repair Technique?

There are mainly two repair options for umbilical hernias: suture and mesh. Simple primary suture repair can be used for pocket-sized defects (<2–3 cm). The technique of overlapping abdominal wall fascia in a "vest-over-pants" manner was described past William Mayo (17) and remained the most renowned surgical technique for a long fourth dimension. There are few clinical studies with Mayo technique in the literature (six, 12). High recurrence rates up to 28% take been reported (x).

Prosthetic materials are widely used today in the repair of all kind of abdominal hernias. Approach et al's (18) randomized clinical trial revealed that the recurrence charge per unit was lower after mesh repair than that after suture repair (ane% vs. 11%) in a 64-month hateful postoperative follow-upwards. In a retrospective clinical series of 100 patients, the recurrence rates for the suture and mesh repair groups were 11.5 and 0%, respectively (p=0.007), with similar results in the infection rates in favor of mesh repair (19). A systematic review and meta-analysis by Aslani and Brown (xx) revealed that the use of mesh in umbilical hernia repair results in decreased recurrence and similar wound complication rates compared with tissue repair for chief umbilical hernias. However, many surgeons still make his/her decision on the ground of the size of the umbilical/paraumbilical defect. Dalenbäck (21) suggested a tailored repair and stated that suture-based methods for defects <two cm can provide acceptable recurrence rates (6%) in long-term follow-upward. A postal questionnaire study from Scotland revealed that surgeons preferred mesh repair for defects >v cm, whereas similar preference rates for suture and mesh repairs were obtained for defects <ii cm (22).

Meshes can be placed via both the open and laparoscopic approaches. Surgeons in full general prefer the about familiar technique or comply with the patients' preferences. Open onlay mesh placement is the easiest technique; however, information technology requires subcutaneous dissection that may cause seroma or hematoma and eventually result in surgical site infection in some cases. Mesh can also be placed in a preperitoneal or sublay position (5, 11). This may crave more surgical experience and skill but avoids extensive subcutaneous autopsy and reduces seroma germination and possibly result in less recurrence. Onlay and sublay mesh placement tin can be done at the aforementioned time in complicated or recurrent cases to provide more reinforced repair. Some authors prefer leaving fascial margins without approximation; however, suture closure before onlay mesh or subsequently preperitoneal mesh is recommended.

Furthermore, mesh plug repair was described for umbilical hernias. It tin can be performed with local anesthesia (23, 24). Nevertheless, at that place is no controlled study to compare plug repair with other techniques. Besides plug repairs have the risk of migration and enterocutaneous fistula germination (25).

Laparoscopic umbilical hernia repair has been skilful since tardily 1990s (26, 27). Single-port repairs have likewise recently been reported (28). Laparoscopic technique is basically a mesh repair; notwithstanding, laparoscopic primary suture repair without prosthetic material has besides been experienced (29). In contrast, Banerjee et al. (30) compared the laparoscopic mesh placement without defect closure with laparoscopic suture and mesh in a clinical report and reported a slightly lower recurrence rate in the latter group, specially for recurrent hernias.

Today the utilization of laparoscopy for umbilical hernia repair remains relatively low in the world. Laparoscopy is preferred in just a quarter of the cases (31). In that location are a few studies comparing open up and laparoscopic repairs for umbilical hernias. Short-term outcomes from the American College of Surgeons National Surgery Quality Improvement Program recently revealed a potential decrease in the full and wound morbidity associated with laparoscopic repair for elective principal umbilical hernia repairs at the expense of longer operative fourth dimension and length of hospital stay and increased respiratory and cardiac complications (32). In their multivariate model, after controlling for trunk mass index, gender, the American Society of Anesthesiologists class, and chronic obstructive pulmonary disease, the odds ratio for overall complications favored laparoscopic repair (OR=0.lx; p=0.01). This difference was primarily driven by the reduced wound complication rate in laparoscopy group.

The Danish Hernia Database did non reveal significant differences in surgical or medical complication rates and in risk factors for a 30-day readmission between open and laparoscopic repairs (33). Afterwards open repair, independent adventure factors for readmission were hernia defects >two cm and tacked mesh fixation. After laparoscopic repair, female gender was the simply contained risk factor for readmission.

Obese patients with umbilical hernia incorporate a special group. A recent comparative written report past Colon et al. (34) stated that laparoscopic umbilical hernia repair should exist the preferred approach in obese patients. They institute a meaning increase in wound infection rate in the open mesh repair group when compared with the laparoscopic process (26% vs. four%; p<0.05). They observed no hernia recurrence in the laparoscopic grouping, whereas the open up group had 4% recurrence rate. In contrast, Kulacoglu et al. (v) demonstrated that obese patients also crave more local coldhearted dose in open up mesh repair.

A summary of current repair options for umbilical hernias are presented in Tabular array i.

Tabular array one.

A classification of electric current repair techniques for umbilical hernias

A. Prosthetic repairs

1. Open approach

a. Onlay mesh

b. Sublay/Preperitoneal mesh

c. Mesh plug

d. Bilayer prosthetic devices

2. Laparoscopic approach

a. Inlay mesh

b. Defect closure and mesh placement

B. Tissue–Suture repairs

1. Primary suture

2. Mayo repair

Which Mesh?

Standard polypropylene mesh is the most often used prosthetic fabric particularly in open onlay repairs. Lightweight macroporous meshes are as well in use. Both types of meshes are suitable for onlay and sublay placement. Reducing the density of polypropylene and creating a "low-cal weight" mesh theoretically induces less foreign torso response, results in improved abdominal wall compliance, causes less contraction or shrinkage of the mesh, and enables better tissue incorporation; however, their clinical advantages accept not been conspicuously documented (35).

Newer bilayer prosthetic devices are designed for open intraperitoneal inlay placement. They accept two sides, one is polypropylene and the other side is a non-adherent material to face viscera. Two tails that are continued to the bilayer patch were sutured to fascial edges to avert migration. Promising early results have been reported; however, these prostheses are expensive, and prospective randomized comparative studies accept not still been conducted (36–38). Information technology has been reported that recurrence later on this kind of bilayer prosthesis is higher in comparison with that after classical sublay mesh placements possibly because of the less controllable mesh deployment (39).

Bilayer polypropylene or partially reabsorbable meshes have also been used for umbilical hernias. They comprised one sublay and one overlay patch with a connector to eliminate migration. Still, clinical outcomes afterwards repairs with these devices accept non been widely documented (forty).

Pick of mesh appears to exist more important for laparoscopic repairs (41). Composite meshes are preferred materials in most institutions to avoid the take chances of visceral adhesion into the mesh (42, 43). There are numerous composite or dual-side meshes in the marketplace; the results of the clinical and experimental studies testing their strength, durability, and prophylactic regarding both recurrence and adhesion formation widely differ.

Although standard polypropylene mesh is easy to notice and a much more economic choice, its utilize in laparoscopic ventral hernia repairs, including umbilical hernias, has certain risks. Sarela (44) stated that the fiscal-cost to clinical-do good ratio for the utilise of expensive composite meshes is unquantified and is likely to remain equally such because given the widespread acceptance of composite products, a randomized clinical comparison with unproblematic polypropylene mesh is unlikely to occur. In selected circumstances, it may be adequate to apply a simple mesh if this can be completely excluded from bowel by interposition of omentum; however, a composite mesh should be considered as the current standard of care.

Factors Influencing Recurrence

Several factors accept been responsible for recurrence afterward umbilical hernia repairs. However, few studies presented an independent factor afterward multivariate analysis.

Large seroma and surgical site infection are classical complications that may issue in recurrence. Obesity and excessive weight gain following repair are obviously potential gamble factors. The patient's BMI >30 kg/yard² and defects >2 cm take been reported equally possible factors for surgical failure (45). Moreover, smoking may create a hazard for recurrence (46).

Ascites is a well-known risk gene for recurrence. Traditionally, umbilical hernia in patients with cirrhosis and with uncontrolled ascites was associated with significant mortality and morbidity and a significantly greater incidence of recurrence (47). Withal, contempo reports for elective repair are more promising, and there is tendency to perform constituent repair to avoid emergency surgery for complications associated with very loftier mortality and morbidity rates (48, 49). Early elective repair of umbilical hernias in patients with cirrhosis is advocated considering the hepatic reserve and patient's condition (50). Ascites control is the mainstay of post-operative management.

CONCLUSION

Mesh repairs are superior to non-mesh/tissue-suture repairs in umbilical hernia repairs. Open up and laparoscopic techniques take well-nigh similar efficacy. Local anesthesia is suitable for small umbilical hernias and patients with reasonable BMI. Antibiotic prophylaxis appears to provide low wound infection rate.

Footnotes

Peer-review: This manuscript was prepared by the invitation of the Editorial Board and its scientific evaluation was carried out past the Editorial Lath.

Conflict of Interest: No conflict of involvement was declared by the authors.

Fiscal Disclosure: The authors declared that this written report has received no financial support.

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