Examination of Para-Umbilical Hernia (PUH)

Definition

A para-umbilical hernia (PUH) is the commonest acquired umbilical hernia in adults. The defect lies in the linea alba adjacent to (not through) the umbilical ring - most often just above it, so the lower half of the sac is covered by the umbilicus itself. It differs from a true umbilical hernia, which protrudes through the umbilical scar directly.

Typical Patient Profile (Before Examination)

Middle-aged or elderly patient
Obese women are most commonly affected
Associated causes: pregnancy, ascites, chronic cough, bowel distension, ovarian cyst, fibroids (raised intra-abdominal pressure)

Clinical Photograph

Small adult umbilical/para-umbilical hernia showing a protrusion just above the umbilicus

Note the bulge slightly eccentric to the umbilical depression, creating a crescent-shaped appearance - typical of PUH.

Examination Sequence

1. POSITION & EXPOSURE

Patient supine, abdomen fully exposed from xiphisternum to groin
Later ask to stand or cough to accentuate the swelling

2. INSPECTION

Feature	Finding in PUH
Site	Immediately above (or occasionally below) the umbilicus, in the midline or just off it
Shape	Hemispherical or lobulated; umbilicus appears distorted or pushed aside
Appearance of umbilicus	Everted or obliterated; crescent-shaped asymmetry to the umbilical depression
Skin	Usually normal; in very large hernias - thin, shiny skin; rarely ulceration
Size	Varies widely from fingertip to large multilobular mass
On coughing/straining	Swelling becomes more prominent - visible expansile impulse
Ask patient to stand	Swelling increases in size due to gravity

3. PALPATION

a. Surface and edge

Surface is smooth; edge is distinct (except in very obese patients)
Edge is firm and fibrous - this is the edge of the linea alba defect

b. Consistency / content

Content	Feel	Percussion
Omentum	Firm / doughy	Dull
Bowel	Soft	Resonant

c. Cough impulse

Place fingers over the swelling and ask the patient to cough
A positive cough impulse (expansile, transmitted thrust) confirms it is a hernia

d. Reducibility

Attempt gentle reduction with the patient lying down
Many PUHs are irreducible - the omentum or bowel becomes adherent to the sac, or the narrow neck prevents reduction
If reducible: the firm fibrous edge of the defect in the linea alba can then be felt as a well-defined ring

e. Neck of sac

Narrow neck relative to sac size - this is why strangulation risk is higher than inguinal hernias
Assess whether the neck can be felt above the swelling (localises the defect to just above the umbilicus)

f. Tenderness

Mild discomfort is common
Acute severe tenderness + irreducibility = obstruction or strangulation

4. PERCUSSION

Resonant if content is bowel (gas-containing)
Dull if content is omentum or fluid

5. AUSCULTATION

Bowel sounds heard over the swelling = bowel in the sac
Absence of bowel sounds in an irreducible hernia with tenderness raises concern for strangulation

6. TRANSILLUMINATION

Negative (does not transilluminate) - confirms solid/bowel content, not a cyst

7. CHECK FOR COMPLICATIONS

Complication	Signs
Irreducibility	Cannot be manually reduced; most common in PUH
Obstruction	Abdominal distension, vomiting, absolute constipation; bowel sounds may be hyperactive over sac
Strangulation	Tense, tender, irreducible hernia; skin may become red/purple; systemic signs of sepsis

8. COMPLETE EXAMINATION

Examine all other hernial orifices (inguinal, femoral, incisional)
Look for cause of raised intra-abdominal pressure: ascites (shifting dullness, fluid thrill), abdominal mass, distension
Diastasis recti - assess separation of the recti (common in obese/multiparous patients; may coexist)
General examination: BMI, liver disease signs (for ascites), cardiorespiratory status (for surgical fitness)

Summary of Key Diagnostic Features of PUH

Middle/old age; obese woman
Swelling immediately above (occasionally below) umbilicus - umbilicus obliterated or distorted
Surface smooth; edge firm and distinct (fibrous ring of linea alba)
Content - omentum (firm, dull) or bowel (soft, resonant)
Often irreducible - omentum gets adherent or neck is narrow
Positive cough impulse when reducible
Intermittent pain is a common symptom (narrow neck causes tissue tension)
Strangulation is less common than obstruction, but neck is narrow so risk exists

Sources: S Das - A Manual on Clinical Surgery, 13th Ed.; Bailey and Love's Short Practice of Surgery, 28th Ed.

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