Umbilical Hernia — Treatment Options & Surgery

Note: Bailey & Love's Short Practice of Surgery is not available in this textbook library. The information below is drawn from equivalent authoritative surgical references: Schwartz's Principles of Surgery (11e), Mulholland & Greenfield's Surgery (7e), and Sabiston Textbook of Surgery — all of which cover umbilical hernia in the same standard manner taught in Bailey & Love.

Anatomy & Pathogenesis

• Paired lateral umbilical ligaments (obliterated umbilical arteries)
• Round ligament (obliterated umbilical vein)
• Urachal remnant
• Transversalis fascia

Clinical Features

• Most common abdominal wall defect in infants/children
• Incidence: 25–50% in Black infants; 4–9% in white infants in first months of life
• Generally reducible and asymptomatic
• Incarceration is rare (~1:1,500 cases); more common with smaller defects (≤1 cm)
• Incarceration presents with: abdominal pain, bilious vomiting, tender hard umbilical mass → surgical emergency

Treatment

Conservative (Non-Operative)

• Skin ulceration
• Episode of incarceration
• Defect enlarging or > 2 cm (risk of large skin proboscis if left untreated)
• Significant cosmetic concern to child/family
• Symptomatic hernia in any age

In children, prosthetic mesh is never used — primary repair is always achievable.

Surgical Repair Options

1. Primary Open Repair (Standard / Mayo Repair)

1. Incision: Subumbilical "smile" (semilunar) incision in the skin crease
2. Dissection: Hernia sac dissected free circumferentially from overlying skin
3. Sac: Excised or reduced
4. Fascial closure: Mayo "waistcoat" (vest-over-pants) technique — the superior fascial edge is overlapped over the inferior edge with interrupted non-absorbable or long-acting absorbable sutures in a transverse plane
5. Skin: Umbilical skin preserved and sutured to fascial closure for cosmesis; subcuticular skin closure

2. Mesh Repair (Open Preperitoneal / Onlay)

• Preperitoneal mesh: The peritoneum is bluntly dissected from the undersurface of the posterior rectus sheath; mesh placed in the preperitoneal space, then fascial edges closed over it
• Intraperitoneal mesh: Barrier-coated (composite) mesh placed intraperitoneally — used when preperitoneal dissection is difficult or when defect is small; however, evidence suggests higher complication rates vs. preperitoneal placement
• Falciform and median umbilical ligament fat must be dissected to ensure mesh seats flush against the abdominal wall and prevent fat reherniation

A multicenter RCT showed higher complication rates for intraperitoneal vs. preperitoneal mesh — preperitoneal placement is preferred when feasible.

3. Laparoscopic / Robotic Repair

• Technique mirrors laparoscopic incisional hernia repair
• Options: TAPP (transabdominal preperitoneal) approach — increasingly performed robotically
• Robotic-assisted TAPP is gaining popularity as it facilitates more reliable defect closure
• Potential benefits: decreased operative time, faster return to activity
• Concurrent umbilical hernia repair is a convenient adjunct during TAPP inguinal hernia repair when umbilical access is used

Special Situations

Umbilical Hernia with Ascites / Cirrhosis

• High operative morbidity and mortality — repair undertaken with caution
• Liver transplant candidates: repair at time of transplantation (pre-transplant repair has high morbidity/mortality)
• Patients with incarcerated hernia, thinning or ruptured overlying skin → earlier repair required
• Topical fibrin sealant has been used for leaking umbilical hernias in ascitic patients as a temporizing measure

Summary Table