How Are Umbilical Hernias Repaired
Ulus Cerrahi Derg. 2022; 31(3): 157–161.
Electric current options in umbilical hernia repair in adult patients
Received 2022 October 28; Accepted 2022 Dec 7.
Abstract
Umbilical hernia is a rather common surgical trouble. Elective repair after diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh can be placed through either an open or laparoscopic approach with practiced clinical results. Standard polypropylene mesh is suitable for the open up onlay technique; however, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may result in recurrence. Obesity, ascites, and excessive weight gain following repair are obviously potential take a chance factors. Moreover, smoking may create a take a chance for recurrence.
Keywords: umbilical hernia, hernia repair, mesh, laparoscopy
INTRODUCTION
Umbilical hernia is a rather common surgical problem. Approximately 10% of all master hernias comprise umbilical and epigastric hernias (1). Approximately 175,000 umbilical hernia repairs are annually performed in the U.s.a. (2). Information technology has been reported that the share of umbilical and paraumbilical hernia repairs among all repairs for abdominal wall hernias increased from v% to 14% in UK in the last 25 years (3). A like rise has been reported in a contempo multicenter study from Turkey (4).
In general, umbilical hernias are more than common in women than men; all the same, there are serial in which male patients are more frequent (5). Typically, a lump is observed effectually the umbilicus. Pain is the most common indication to visit a dr. and undergo a repair (6). Recurrence may develop even in cases where a prosthetic mesh is used. Recurrent umbilical hernias often tend to overstate faster than primary ones and may carry as incisional hernias.
An umbilical hernia has a trend to exist associated with high morbidity and mortality in comparison with inguinal hernia because of the higher hazard of incarceration and strangulation that require an emergency repair. Although the number of articles with the title word "umbilical hernia" increased two.6-fold between the periods 1991–2000 and 2001–2010, there even so appears to exist a certain discrepancy betwixt its importance and the attention it has received in the literature (vii). In this newspaper, the nature of the umbilical hernias is reviewed, and the current options for their surgical repair are discussed.
Anatomic Description
Many hernias in the umbilical region occur above or below the umbilicus through a weak place at the linea alba, rather than direct through the umbilicus itself, and the natural history and treatment practise not differ for these hernias. The European Hernia Society classification (8) for primary abdominal wall hernias defines the midline hernias from 3 cm higher up to iii cm below the navel every bit umbilical hernia (Figure one).
Abdominal wall hernias from 3 cm higher up to 3 cm below the umbilicus are defined equally umbilical hernia according to the European Hernia Society Nomenclature (eight)
The borders of the umbilical canal are the umbilical fascia posteriorly, the linea alba anteriorly and medial edges of the two rectus sheaths on two sides. Herniation happens due to increasing intra-abdominal pressure. Predisposing factors include obesity, multiple pregnancies, ascites, and abdominal tumors (9). The content of the hernia sac may be preperitoneal fatty tissue, omentum, and small-scale intestine in the majority; a combination of those can accept function. Large intestines are very rarely involved (10). The neck of the umbilical hernia is usually narrow compared with the size of the herniated mass, hence, strangulation is mutual. Therefore, an elective repair after diagnosis is brash.
Anesthesia
All three types of anesthesia (local, general, and spinal) are suitable in most cases. The patient and surgeon should brand a decision regarding the type of anesthesia to be used earlier surgery. Local anesthesia frequently provides maximum condolement for patients when it is accurately performed in open repairs. Some centers routinely use local anesthesia (5, 11, 12). However, inexperience with the local coldhearted technique may cause discomfort to patients with an increased recurrence rate. Local anesthesia may also be challenging if the patient is obese and hernia is big and/or recurrent (13). In patients with ASA I or 2 scores and who have 1 of the specific difficulties higher up, the surgeon should better cull general anesthesia to experience more than secure considering the quality of repair is the near of import outcome measure.
Laparoscopic ventral hernia repair by and large requires general anesthesia with endotracheal intubation. Furthermore, it tin be feasible under spinal anesthesia with low-pressure COii pneumoperitoneum (14).
Antibody Prophylaxis
Naturally, umbilicus is not a make clean anatomical part of the body. The umbilical pare may not exist cleaned of all bacteria even with the use of modernistic antiseptic solutions. Therefore, the surgical site infection tin can be more frequent following umbilical hernia repairs than that following inguinal hernia repairs. A 10% superficial wound infection rate is not surprising fifty-fifty later routine prophylactic antibiotic use. A recent study reported a nineteen% infection rate post-obit open umbilical hernia repair (15). Kulacoglu et al. (5) reported 3% wound infection rate with antibiotic prophylaxis with cefazolin sodium that is administered thirty min before skin incision.
Deysine (14) recommended topical gentamicin in addition to preoperative intravenous prophylaxis to lower the infection rates after hernia repairs. He reported no surgical site infections in hernia surgery subsequently setting this prophylaxis combination for 24 consecutive years. Although gentamicin is nearly effective against gram-negative bacteria, it is also effective against staphylococci. Furthermore, information technology has been stated that gentamicin can demonstrate antimicrobial synergy with cefazolin for a more successful antibacterial effect (16).
Which Repair Technique?
There are mainly 2 repair options for umbilical hernias: suture and mesh. Simple primary suture repair can be used for pocket-size defects (<2–3 cm). The technique of overlapping abdominal wall fascia in a "vest-over-pants" manner was described by William Mayo (17) and remained the most renowned surgical technique for a long time. In that location are few clinical studies with Mayo technique in the literature (6, 12). High recurrence rates upwardly to 28% have been reported (x).
Prosthetic materials are widely used today in the repair of all kind of abdominal hernias. Arroyo et al's (eighteen) randomized clinical trial revealed that the recurrence rate was lower subsequently mesh repair than that after suture repair (1% vs. xi%) in a 64-calendar month hateful postoperative follow-upwardly. In a retrospective clinical series of 100 patients, the recurrence rates for the suture and mesh repair groups were 11.v and 0%, respectively (p=0.007), with similar results in the infection rates in favor of mesh repair (19). A systematic review and meta-analysis past Aslani and Brown (20) revealed that the use of mesh in umbilical hernia repair results in decreased recurrence and like wound complication rates compared with tissue repair for primary umbilical hernias. However, many surgeons still make his/her decision on the basis of the size of the umbilical/paraumbilical defect. Dalenbäck (21) suggested a tailored repair and stated that suture-based methods for defects <two cm can provide acceptable recurrence rates (vi%) in long-term follow-up. A postal questionnaire study from Scotland revealed that surgeons preferred mesh repair for defects >five cm, whereas like preference rates for suture and mesh repairs were obtained for defects <two cm (22).
Meshes tin be placed via both the open and laparoscopic approaches. Surgeons in general adopt the well-nigh familiar technique or comply with the patients' preferences. Open onlay mesh placement is the easiest technique; however, it requires subcutaneous dissection that may cause seroma or hematoma and eventually effect in surgical site infection in some cases. Mesh tin can likewise be placed in a preperitoneal or sublay position (5, xi). This may require more surgical experience and skill just avoids extensive subcutaneous dissection and reduces seroma formation and maybe result in less recurrence. Onlay and sublay mesh placement tin be done at the same time in complicated or recurrent cases to provide more reinforced repair. Some authors adopt leaving fascial margins without approximation; however, suture closure before onlay mesh or after preperitoneal mesh is recommended.
Furthermore, mesh plug repair was described for umbilical hernias. Information technology can exist performed with local anesthesia (23, 24). Withal, there is no controlled study to compare plug repair with other techniques. Besides plug repairs accept the risk of migration and enterocutaneous fistula formation (25).
Laparoscopic umbilical hernia repair has been good since late 1990s (26, 27). Unmarried-port repairs have too recently been reported (28). Laparoscopic technique is basically a mesh repair; nonetheless, laparoscopic primary suture repair without prosthetic material has likewise been experienced (29). In contrast, Banerjee et al. (xxx) compared the laparoscopic mesh placement without defect closure with laparoscopic suture and mesh in a clinical study and reported a slightly lower recurrence rate in the latter group, peculiarly for recurrent hernias.
Today the utilization of laparoscopy for umbilical hernia repair remains relatively depression in the world. Laparoscopy is preferred in simply a quarter of the cases (31). There are a few studies comparison open up and laparoscopic repairs for umbilical hernias. Brusque-term outcomes from the American College of Surgeons National Surgery Quality Improvement Programme recently revealed a potential decrease in the total and wound morbidity associated with laparoscopic repair for constituent primary umbilical hernia repairs at the expense of longer operative time and length of infirmary stay and increased respiratory and cardiac complications (32). In their multivariate model, afterward decision-making for body mass alphabetize, gender, the American Gild of Anesthesiologists class, and chronic obstructive pulmonary disease, the odds ratio for overall complications favored laparoscopic repair (OR=0.60; p=0.01). This divergence was primarily driven by the reduced wound complication rate in laparoscopy group.
The Danish Hernia Database did not reveal significant differences in surgical or medical complication rates and in hazard factors for a thirty-day readmission between open and laparoscopic repairs (33). Later open up repair, independent run a risk factors for readmission were hernia defects >2 cm and tacked mesh fixation. After laparoscopic repair, female gender was the merely independent risk factor for readmission.
Obese patients with umbilical hernia comprise a special grouping. A contempo comparative study by Colon et al. (34) stated that laparoscopic umbilical hernia repair should be the preferred approach in obese patients. They found a significant increase in wound infection rate in the open mesh repair group when compared with the laparoscopic process (26% vs. iv%; p<0.05). They observed no hernia recurrence in the laparoscopic group, whereas the open grouping had four% recurrence charge per unit. In contrast, Kulacoglu et al. (5) demonstrated that obese patients also crave more local anesthetic dose in open mesh repair.
A summary of current repair options for umbilical hernias are presented in Table 1.
Table 1.
A nomenclature of current repair techniques for umbilical hernias
| A. Prosthetic repairs |
| one. Open up approach |
| a. Onlay mesh |
| b. Sublay/Preperitoneal mesh |
| c. Mesh plug |
| d. Bilayer prosthetic devices |
| 2. Laparoscopic approach |
| a. Inlay mesh |
| b. Defect closure and mesh placement |
| B. Tissue–Suture repairs |
| i. Primary suture |
| 2. Mayo repair |
Which Mesh?
Standard polypropylene mesh is the about frequently used prosthetic material especially in open onlay repairs. Lightweight macroporous meshes are also in use. Both types of meshes are suitable for onlay and sublay placement. Reducing the density of polypropylene and creating a "calorie-free weight" mesh theoretically induces less foreign torso response, results in improved abdominal wall compliance, causes less contraction or shrinkage of the mesh, and enables meliorate tissue incorporation; however, their clinical advantages take not been clearly documented (35).
Newer bilayer prosthetic devices are designed for open intraperitoneal inlay placement. They have two sides, 1 is polypropylene and the other side is a non-adherent fabric to face viscera. Two tails that are connected to the bilayer patch were sutured to fascial edges to avoid migration. Promising early results have been reported; withal, these prostheses are expensive, and prospective randomized comparative studies have non yet been conducted (36–38). It has been reported that recurrence after this kind of bilayer prosthesis is higher in comparison with that later on classical sublay mesh placements possibly because of the less controllable mesh deployment (39).
Bilayer polypropylene or partially reabsorbable meshes accept also been used for umbilical hernias. They comprised 1 sublay and one overlay patch with a connector to eliminate migration. Nonetheless, clinical outcomes later on repairs with these devices accept non been widely documented (40).
Choice of mesh appears to be more of import for laparoscopic repairs (41). Blended meshes are preferred materials in near institutions to avoid the take chances of visceral adhesion into the mesh (42, 43). In that location are numerous composite or dual-side meshes in the marketplace; the results of the clinical and experimental studies testing their strength, durability, and safety regarding both recurrence and adhesion formation widely differ.
Although standard polypropylene mesh is easy to find and a much more economical choice, its use in laparoscopic ventral hernia repairs, including umbilical hernias, has certain risks. Sarela (44) stated that the financial-cost to clinical-benefit ratio for the use of expensive blended meshes is unquantified and is probable to remain equally such because given the widespread credence of composite products, a randomized clinical comparing with simple polypropylene mesh is unlikely to occur. In selected circumstances, information technology may exist adequate to use a elementary mesh if this tin can be completely excluded from bowel by interposition of omentum; still, a composite mesh should be considered every bit the current standard of care.
Factors Influencing Recurrence
Several factors have been responsible for recurrence after umbilical hernia repairs. Nevertheless, few studies presented an contained factor afterward multivariate analysis.
Large seroma and surgical site infection are classical complications that may result in recurrence. Obesity and excessive weight proceeds post-obit repair are obviously potential risk factors. The patient's BMI >xxx kg/mii and defects >ii cm have been reported as possible factors for surgical failure (45). Moreover, smoking may create a risk for recurrence (46).
Ascites is a well-known run a risk factor for recurrence. Traditionally, umbilical hernia in patients with cirrhosis and with uncontrolled ascites was associated with significant mortality and morbidity and a significantly greater incidence of recurrence (47). However, recent reports for elective repair are more promising, and at that place is trend to perform elective repair to avoid emergency surgery for complications associated with very high bloodshed and morbidity rates (48, 49). Early elective repair of umbilical hernias in patients with cirrhosis is advocated considering the hepatic reserve and patient's condition (l). Ascites control is the mainstay of post-operative direction.
CONCLUSION
Mesh repairs are superior to non-mesh/tissue-suture repairs in umbilical hernia repairs. Open up and laparoscopic techniques accept almost similar efficacy. Local anesthesia is suitable for modest umbilical hernias and patients with reasonable BMI. Antibiotic prophylaxis appears to provide depression wound infection charge per unit.
Footnotes
Peer-review: This manuscript was prepared by the invitation of the Editorial Lath and its scientific evaluation was carried out past the Editorial Lath.
Disharmonize of Interest: No conflict of interest was alleged by the authors.
Financial Disclosure: The authors declared that this study has received no financial back up.
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Articles from Ulusal Cerrahi Dergisi/Turkish Periodical of Surgery are provided here courtesy of Turkish Surgical Clan
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605112/
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