Umbilical hernia repair

Definition

An umbilical hernia repair is a surgical procedure performed to fix a weakness in the abdominal wall or to close an opening near the umbilicus (navel) that has allowed abdominal contents to protrude. The abdominal contents may or may not be contained within a membrane or sac. The medical name for a hernia repair is herniorraphy.

Purpose

Umbilical hernias are usually repaired either to relieve discomfort or to prevent complications. It is not always necessary to fix an umbilical hernia. If the person is not in pain, the hernia is often not repaired. Complications may develop if pressure inside the abdomen resulting from daily activity pushes the abdominal contents further through the opening. They may then become twisted or strangulated. Strangulation is a condition in which the circulation to a section of the intestine (or other part of the body) is cut off by compression or constriction; it can cause extreme pain. If the strangulation persists, the tissue can die from lack of blood supply and lead to an infection.

Demographics

An umbilical hernia can occur in both men and women, and can occur at any age, although it is often present at birth. Umbilical hernias are found in about 20% of newborns, especially in premature infants. Umbilical hernias are more common in male than in female infants; with regard to race, they are eight times more common in African Americans than in Caucasians or Hispanics. While umbilical hernia is not a genetically determined condition, it tends to run in families. In the adult population, umbilical hernias are more common in overweight persons with weak abdominal muscles, and in women who are either pregnant or have borne many children. People with liver disease or fluid in the abdominal cavity are also at higher risk of developing an umbilical hernia.

Description

Repair of an abdominal hernia involves a cut, or incision, in the umbilical area. Most herniorrhaphies take about two hours to complete. After the patient has been given a sedative, the anesthesiologist will administer a local, spinal, or general anesthetic. The type of anesthesia used depends on the patient's age, general health, and complexity of the procedure. The incision is usually made underneath the belly button. The herniated tissues are isolated and pushed back inside the abdominal cavity. A hernia repair may be done using traditional open surgery or with a laparoscope. A laparoscopic procedure is performed through a few very small incisions. The hole in the abdominal wall may be closed with sutures, or by the use of a fine sterile surgical mesh. The mesh provides additional strength. Some surgeons may choose to use the mesh when repairing a larger hernia. A hernia repair done with a mesh insert is called a tension-free procedure because the surgeon does not have to put tension on the layer of muscle tissue in order to bring the edges of the hole together.

Diagnosis/Preparation

Diagnosis

In children, umbilical hernias are often diagnosed at birth, usually when the doctor feels a lump in the area around the belly button. The hernia may also be diagnosed

Baby with an umbilical hernia (A). To repair, the hernia is cut open (B), and the contents replaced in the abdomen. Connecting tissues, or fascia, are sutured closed (D), and the skin is repaired (D). (

Illustration by GGS Inc.

)

Umbilical hernias in adults occur more often in pregnant women and obese persons with weak stomach muscles. They may develop gradually without producing any discomfort, but the patient may see a bulge in the abdomen while bathing or getting dressed. Other patients consult their doctor because they have felt the tissues in the abdomen suddenly give way when they are having a bowel movement. In an office examination, the patient may be asked to lie down, lift the head, and cough. This action increases pressure inside the abdomen and causes the hernia to bulge outward.

A hernia that has become incarcerated or strangulated is a medical emergency. Its symptoms include:

• nausea
• vomiting
• abdominal swelling or distension
• pale complexion
• weakness or dizziness
• extreme pain

When a hernia is present at birth, some surgeons may opt for a "wait and see" approach, as umbilical hernias in children often close by themselves with time. If the hernia has not closed by the time the child is three or four years old, then surgery is usually considered. If the hernia is very large, surgery may be recommended.

Repair of an umbilical hernia in an adult is usually considered elective surgery . The patient's surgeon may recommend the procedure, however, on the grounds that hernias in adults do not close by themselves and tend to grow larger over time.

Preparation

Adults scheduled for a herniorraphy are given standard blood tests and a urinalysis . They should not eat breakfast on the morning of the procedure, and they should wear loose-fitting, comfortable clothing that they can easily pull on after the surgery without straining their abdomen.

Aftercare

Aftercare will depend in part on the invasiveness of the surgery, whether laparoscopic or open; the type of anesthesia; the patient's age; and his or her general medical condition. Immediately after the procedure, the person will be taken to the recovery area of the surgical center, where nurses will monitor the patient for signs of excessive bleeding, infection, uncontrolled pain, or shock. Hernia repairs are usually performed on an outpatient basis, which means that the patient can expect to go home within a few hours of the surgery. Adult patients, however, should arrange to have a friend or relative drive them home. If possible, someone should stay with them for the first night.

The nurses will provide the patient with instructions on incision care . The specific instructions will depend on the type of surgery and the way in which the incision was closed. Sometimes a see-through dressing is placed on the wound that the patient can remove about three days after the procedure. It may be necessary to keep the dressing dry until some healing has taken place. Very small incisions may be closed with Steri-strips rather than sutures.

Risks

There are surgical and anesthesia-related risks with all surgical procedures. The primary surgical risks include bleeding and infection. Anesthesia-related risks include reactions to the specific anesthetic agents that are used; interactions with over-the-counter and herbal preparations; and respiratory problems. The greatest risk associated with umbilical hernia is missing the diagnosis. Additional risks include the formation of scar tissue and recurrence of the hernia.

Normal results

Umbilical hernia repair is usually considered an uncomplicated procedure with a relatively short recovery period. A study reported in the December 2002 issue of the American Journal of Surgery found that patients who had laparoscopic surgery with the use of a surgical mesh had fewer complications and reoccurrences of a hernia than those with the traditional open surgery. However, laparoscopic surgery took somewhat longer to perform, possibly because the laparoscopic approach is often used for larger repairs.

Morbidity and mortality rates

In general, there are few complications with hernia repair in children. The most serious complication is surgical injury to the bladder or intestine; fortunately, this complication is very rare—about one in 1000 patients. The recurrence rate is between 1% and 5%; recurrence is more likely in patients with very large hernias. The rate of infection is less than 1%. In the adult population, a November 2001 study reported in the American Journal of Surgery found a 5% mortality in elderly patients undergoing emergency hernia repairs.

Alternatives

There are no medical or surgical alternatives to an umbilical hernia repair other than watchful waiting. Since umbilical hernias present at birth often close on their own, intervention can often be delayed until the child is several years old. There is some risk that the hernia will enlarge, however, which increases the risk of incarceration or strangulation.

Resources

BOOKS

"Congenital Anomalies: Gastrointestinal Defects." Section 19, Chapter 261 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Delvin, David. Coping with a Hernia . London, UK: Sheldon Press, 1998.

PERIODICALS

Manthey, David, MD. "Hernias." eMedicine , June 22, 2001 [June 6, 2003]. http://www.emedicine.com/EMERG/topic251.htm .

Wright, B.E., et al. "Is Laparoscopic Umbilical Hernia Repair with Mesh a Reasonable Alternative to Conventional Repair?" American Journal of Surgery 184 (December 2002): 505-508.

ORGANIZATIONS

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (913) 906-6000. http://www.aafp.org . E-mail: fp@aafp.org

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000; FAX: (847) 434-8000. http://www.aap.org . E-mail: kidsdoc @aap.org

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-3231. (312) 202-5000; FAX: (312) 202-5001. http://www.facs.org .

OTHER

American College of Surgeons. About Hernia Repair . http://www.facs.org/public_info/operation/hernrep.pdf .

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

This procedure is performed by a general surgeon or a pediatric surgeon. It is usually performed on an outpatient, or ambulatory, basis in a hospital. After a few hours of recovery in the surgical center, the patient is able to return home.

QUESTIONS TO ASK THE DOCTOR

• How soon can my child return to normal activities?
• How soon can I return to work and my other normal activities?
• When can I drive?
• What should I do to take care of the incision?
• How many times have you performed this surgery?
• What kinds of complications are there to this procedure?
• What kinds of complications have your patients experienced?