Introduction:
An umbilical hernia represents a sac protruding out of the abdomen. The European Hernia Society defines it as a midline hernia occurring about one inch above or below the umbilicus (navel). It is a frequent surgical issue among people. Umbilical hernia patients can feel a lump around the umbilicus. It occurs both in children and adults.
What Are the Causes of an Umbilical Hernia?
Hernia happens because of increased abdominal pressure. Risk factors include obesity, abdominal tumors, ascites (fluid collection in the abdomen), and multiple pregnancies. The small intestine, fat tissue, and peritoneum (membrane lining the abdomen and organs) are mostly involved. Large intestine involvement is rare.
What Type of Anesthesia Is Required for an Umbilical Hernia Repair Surgery?
The three types of anesthesia are local, spinal, and general. The surgeon should choose the type of anesthesia based on the procedure and patient. Each type of anesthesia has its pros and cons. Local anesthesia (LA) is frequently used in many centers. If the surgery is performed correctly, LA offers maximum patient comfort. However, inexperience with the anesthesia technique can lead to disease recurrence. Another disadvantage is that it can not be used in recurrent hernia, large hernia, or hernia in an obese patient.
Spinal (SA) and general anesthesia (GA) is used for laparoscopic hernia repair (laparoscopy uses a camera and small incisions). SA is also used for small hernia repair. GA ensures the best quality of anesthesia for patients in which LA is contraindicated.
What Are the Surgical Options for Umbilical Hernia Repair Surgery?
In children, surgery is required if the hernia does not close by the age of three or four. Pain and an uncomfortable bulge is the most common reason for repair. Another factor is aesthetic reasons. Sometimes, a small part of the intestine or fat tissue gets stuck in the hernia. It is called incarceration. This condition is very painful. Also, urgent surgery is essential if the blood supply to the hernia is cut off (strangulation), as it leads to nausea, vomiting, and diarrhea.
An umbilical hernia is repaired through an open, laparoscopy, or robotic surgery. An incision is made near the navel, where the hernia pouch is located and separated from the intestine. The sac is removed, and the muscle wall is reinforced to prevent a recurrence. The repair is done using two techniques: prosthetic and suture.
Suture Repair: It is indicated for small hernias (lesser than one inch). Suturing is based on the principle of primary wound closure. In primary wound closure, sutures are closely placed for wound approximation at the surgical site. Another suture repair technique is the mayo repair. It is done in a ‘vest-over-pants’ fashion in which two-layer closure can be achieved.
Prosthetic Repair: It is also called hernioplasty. A surgical mesh is a medical tool to strengthen weak tissue. Mesh repair is used for hernias greater than four centimeters. It is a more accepted technique because mesh repair is related to a lower recurrence rate than suture repair. However, postoperative complications and chronic pain are more as it requires a wider surgical dissection. In addition, due to a long operative time, this technique may lead to contamination and foreign body reaction. Mesh repair can be done with both open surgery and laparoscopic methods. Many materials are used in mesh repairs, such as polypropylene, polyester, prolene, and teflon. However, a composite mesh is preferred that uses two different materials together.
Open Approach:
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Mesh Placement: Conventional open surgery repair consists of onlay, inlay, and sublay mesh placement. The onlay technique employs a polypropylene mesh placed over the defect. It is the most accepted and easiest technique. In the inlay method, the mesh is placed between the hernia and connective tissue to close the defect. The sublay technique involves placing the mesh under the defect. It needs more surgeon experience but reduces recurrence.
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Mesh Plug Repair: It can be performed under LA. Prolene mesh is commonly used. The mesh plug is inserted in the hernia as a ‘cigarette stub.’ Larger hernias require a double mesh plug.
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Bilayer Prosthetic Device: These contain polypropylene glycol on one side and a non-adherent material toward organs. It is then sutured to the connective tissue to avoid migration. However, these prostheses are costly.
Laparoscopic Surgery: It is a minimally invasive and low-risk surgical procedure. Hence, large incisions and the use of drains can be avoided. Some major benefits are minimal postoperative complications, faster recovery, and lower recurrence rates. In addition, a laparoscopic repair can be done with or without a mesh.
Robotic Umbilical Hernia Repair: A robotic system (DaVinci Xi robotic system) is used in this newer technique. It ensures minimal postoperative complications over open surgery.
What Are the Advantages of Umbilical Hernia Repair Surgery?
Umbilical hernia repair has many advantages.
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Surgery is the definitive treatment for hernia. Unfortunately, it is true as the hernia can not close independently.
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It is usually an outpatient procedure in which the patients return to their daily activities very soon.
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Surgery reduces hernia complications. Pain, discomfort, and bowel blockage are prevented with surgery.
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It removes any bulge or lump in the abdomen. Hence, it offers pleasing aesthetic results, especially in laparoscopic surgery.
What Are the Risks and Complications of Umbilical Hernia Repair Surgery?
Though umbilical hernia repair is a reliable surgery, some associated risks are:
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Infection: Surgical site infection is more common because the umbilicus is not a clean body part. Hence, antibiotic prophylaxis is recommended to prevent any infection. Usually, gentamicin is preferred as it is a broad-spectrum antibiotic.
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Recurrence: Recurrence occurs due to surgical site infection and seroma formation. Seroma is a collection of fluid at the site of surgery. It commonly occurs as a complication with the mesh repair technique. Weight gain, smoking, and ascites are other factors for recurrence.
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Hematoma: Another complication of the surgery is the collection of blood around the hernia site, known as a hematoma.
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Intestinal Injury: An uncommon risk is an injury to the small or large intestine.
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Mesh Related: Some potential complications are mesh migration, shrinkage, adhesion, intestinal obstruction, and perforation.
The factors which affect the surgery outcome are poorly controlled diabetes mellitus, obesity, smoking, and chronic obstructive pulmonary disease (a type of lung condition).
Conclusion:
A prompt diagnosis is important for an umbilical hernia repair. Surgery is the advised option for patients to decrease untoward risks and complications. It is a convenient procedure with a favorable outcome. Patients recover in a month and can resume daily activities. However, recurrence might happen in a few individuals.
