Umbilical Hernia In Adults

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Umbilical hernias in adults can be a cause of considerable morbidity and if complications supervene they can lead to death. Umbilical hernias are much less frequent in the adult population than inguinal hernias and account for 0.03% of the hernia operations performed in the UK. Of the patients with umbilical hernias, 90% are women, invariably women who are overweight and multiparous. Umbilical hernias have a high risk of incarceration. When these hernias incarcerate and strangulate, they frequently contain transverse colon and/or stomach. Strangulated umbilical hernias have a considerable morbidity dictated by the age of the patient and concomitant disease, atherosclerosis, obesity and diabetes mellitus.

Most patients with umbilical hernias complain of a painful protrusion at the umbilicus. This discomfort is indication enough for operation. In many patients, this protrusion may be asymptomatic but will be discovered by the primary physician or general practitioner on routine physical examination. Frequently, it is found in association of an inguinal hernia by the surgeon. Absolute indications for surgery include obstruction and strangulation. Irreducibility is not an absolute indication for surgery: many long-standing umbilical hernias have many adhesions in a loculated hernia and are thus irreducible. In larger hernias the overlying skin may become damaged and ulcerated. Skin complications may dictate the need for operation after the skin sepsis has been controlled. Surgery is advised for all umbilical hernias unless there are strong contraindications, which include obesity, chronic cardiovascular or respiratory disease, or ascites (umbilical hernias can be manifestations of cirrhotic or malignant peritoneal effusions). In even these situations, however, the need for surgery may dictate that the procedure be performed after adequate pre-operative preparation of the patient.

Umbilical hernias are an important complication of cirrhosis and ascites; the ascites should be controlled either medically or with a shunt before hernia repair is undertaken. Umbilical herniation is sometimes a consequence of chronic ambulatory peritoneal dialysis (CAPD). In all patients that are to initiate CAPD, any hernia that is found prior to the insertion of the catheter must be repaired.

The overlapping fascial operation as described by Mayo can be used successfully in patients where there are no risk factors (Fig. 14.15). However, the use of a prosthetic biomaterial for the repair of the larger defects has been associated with a lowered rate of recurrence. There are few reports in the literature of the results of the repair of this type of hernia.

The use of the laparoscopic repair of these hernias has also been reported with acceptable results and may become a viable alternative to the repair of this hernia:

• Early diagnosis and repair represents optimal management for umbilical hernia.

• A large incarcerated umbilical hernia in an obese patient represents a considerable operative risk.

• An asymptomatic umbilical protrusion in a patient with ascites does not warrant surgical intervention.

Figure 14.16. Incisional hernia repair using a mesh onlay.

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