Operations for Umbilical, Linea Alba (Epigastric), and Spigelian Hernias

1. Umbilical Hernia

Anatomy and Pathology

Figure: A small adult umbilical hernia - the bulge typically lies slightly to one side of the umbilical depression, creating a crescent shape.

Umbilical Hernia in Children

• Occurs in up to 10% of infants; higher incidence in premature and Black infants
• Appears within weeks of birth; classic conical shape on crying
• Strangulation is extremely uncommon under age 3
• Treatment: Conservative under age 2 - 95% resolve spontaneously. Surgery if it persists beyond 2 years

Open Umbilical Hernia Repair (Adults)

1. Transverse incision over the hernia
2. Hernia sac dissected, opened, contents reduced
3. Peritoneum closed
4. Defect extended transversely in the linea alba
5. Fascial edges closed in an overlapping style - superior flap placed on top ("waistcoat over trousers")
6. Non-absorbable sutures used
7. Redundant skin excised for cosmesis

Current evidence advises mesh for all defects >2 cm and even for smaller defects, due to high recurrence rates with tissue-only repair.

Panel A: incision at the umbilicus. Panel B: isolation of the umbilical stalk and hernia. Panel C: dissection off the stalk and defect closure.

Laparoscopic Umbilical Hernia Repair

• A camera port and two working ports are placed laterally on the abdominal wall, well away from the defect
• Contents are reduced by traction and external pressure
• The falciform ligament above and median umbilical fold below may need to be taken down to create a smooth surface for mesh placement
• A disc of non-adherent (antiadhesive-coated) mesh designed for intraperitoneal use is introduced and centred on the defect
• Fixed to the peritoneum and posterior rectus sheaths using staples, tacks, or sutures

Mesh Placement Options (Open)

1. Onlay position - on top of the fascia (creates large subcutaneous flaps, higher SSI risk)
2. Preperitoneal position - dissection into preperitoneal plane, 3-5 cm overlap circumferentially; no fixation sutures needed (intra-abdominal pressure holds mesh); flat polypropylene sheet suitable
3. Intraperitoneal position - requires mesh with antiadhesive barrier; useful when peritoneum tears easily

Special Circumstances

• Pregnancy-related hernias: Advise weight loss and abdominal exercise first; avoid surgery before or during pregnancy
• Liver cirrhosis (Child's B/C): Very high perioperative mortality; if surgery is needed, use fine continuous sutures to minimise post-operative ascites leakage; mesh is relatively contraindicated

Emergency Repair of Umbilical Hernia

• Incarceration/strangulation frequent due to narrow fibrous neck
• Most performed open
• In established strangulation: avoid mesh (infection risk too high); perform suture repair; definitive mesh repair at a later date if necessary
• Multiloculated hernias may have strangulated bowel in one component while other areas appear soft

2. Epigastric Hernia (Hernia of the Linea Alba)

Anatomy and Pathology

Figure: Epigastric hernia with post-operative suture marks visible.

Clinical Features

• Typically in fit, healthy men, or older overweight individuals, postmenopausal women
• Can be very painful despite small size - fatty contents become "nipped," causing partial strangulation
• Often locally tender; may not be reducible
• May resemble a lipoma; cough impulse variable

Treatment

• Very small hernias may disappear spontaneously (infarction of the fat)
• Small-to-moderate hernias without a peritoneal sac: repair only if sufficiently symptomatic
• Hernias containing bowel: always repair

Surgery - Open

1. Vertical or transverse incision directly over the swelling, down to the linea alba
2. Protruding extraperitoneal fat is pushed back through the defect or excised (beware a small vessel in the hernia contents causing troublesome bleeding)
3. Small defects (<2 cm): Closed with non-absorbable sutures (adults) or absorbable sutures (children)
4. Larger defects / peritoneal sac present: Surgical approach identical to umbilical mesh repair
5. Mesh recommended for defects >2 cm; can be placed in onlay, preperitoneal, or intraperitoneal position (same principles as umbilical mesh repair)

From Fischer's Mastery: The fascia is cleared circumferentially for 1-2 cm and reapproximated in interrupted fashion with slowly absorbable or permanent suture.

Surgery - Laparoscopic

• Very similar to laparoscopic umbilical hernia repair
• The defect is hidden behind the falciform ligament, which must first be taken down from the undersurface of the abdominal wall
• It is critical to fully reduce the fatty contents - simply placing mesh under the linea alba will leave a palpable lump if extraperitoneal fat is not reduced

3. Spigelian Hernia

Anatomy and Pathology

Important note: A common misconception is that they protrude below the arcuate line due to deficiency of the posterior rectus sheath - in fact, the defect is almost always above the arcuate line.

Figure: Spigelian hernia in the left iliac fossa. Note the scar from a prior left inguinal hernia repair.

Clinical Features

Treatment

Open Repair

1. A skin crease incision is made over the hernia
2. No abnormality is visible until the external oblique aponeurosis is opened
3. The sac and contents are reduced and dealt with
4. The small defect in the Spigelian fascia is repaired by suture or mesh placed deep to the external oblique aponeurosis
5. The plane of mesh can be extended medially into the posterior rectus sheath if required
6. The external oblique aponeurosis is closed over the mesh

Laparoscopic Repair

• Useful when no sac is palpable
• In young patients with only extraperitoneal fat: no hernia will be seen from within the peritoneum; the peritoneum can be incised to explore the extraperitoneal plane, with the small defect closed by suture or mesh
• When an intraperitoneal sac is present: two main options:
  • IPOM (intraperitoneal onlay mesh) - being used less frequently due to intraperitoneal mesh risks
  • TAPP (transabdominal preperitoneal) - now more commonly preferred

Summary Comparison