detailed presentation on umbilical hernia for Ug and Pg students

1. By,
Dr. Kiran Maindale (MS general surgery)
Guided by:
Dr. Yogesh Badwe (Ms, PhD)

2.  An umbilicqal hernia is a health condition
where the abdominal wall behind the navel is
damaged.
 The buldge can often be pressed back
through the hole in abdominal wall, and may
pop out when coughing or otherwise acting
to increase intra-abdomial pressure.

3.  Umbilical hernia is herniation at the site of
umbilicus.
 Paraumbilical hernia is herniation at the
midline 3 cm below or above the umbilicus
..… Europian hernia society

6.  Basically there are three types of umbilical
hernia are seen:
 1. EXOMPHALOS:
 It is developmental anamoly due to failure of
whole or part of the miidgut to return to the
abdominal cavity during early foetal life. So
the organs remain protruded being covered
by membrane;
 Which contents
 1.amniotic membrane
 2. whortans gelly
 3. iiner layer of peritoneum

9.  1. exomphalos minor:
 Where the sac is relatively small and to its
summit is attached the umbilical cord.
treatment: just twist of cord and retained by
ferm strapping.
 1. exomphalos major:
 Umblical cord is attached to the inferior
aspect of large swelling containing samll and
large intestine and the portion of liver.
treatment: emergency surgery advised.to
avoid bursting of abdomen.

10.  This is from weak umbilical scar, neonal sepsis
 It is symptomless
 Bulge seen when baby is crying
 More often in male child than female 2:1 ratio
 Initially spherical but if size increases it become
conical.
 Strangulation is extrmely rare.
 Treatment: 90% cases it cures spontaniously
within 12 to 18 months
 If not cured surgical intervention after 5 yrs.
 Counselling of parents.

11.  Its protrusion through the linia alba just
above the umbilicus(supraumbilical) or
infraumbilical
 Contents:
 Greater omentum, small intestine transverse
colon
 Majority of cases sac is loculated and
adhesions of omentum to fundus.
 Seldom reducible.
 Females are far major victims 5:1 ratio.

12.  infantile/ congenital hernia:
 Delay in closure of ring
 Neonal sepsis
 Failure to return coils
 Aquired umbilical/ paraumbilical hernia:
 Obesity
 Multiple pregnancies
 Ascitesabdominal tumours
 Heavy excersise

13.  Infantile umbilical hernia:
 Upto 10% of infants higher in premature
babies
 Symptomless and appear within few weeks of
birth.
 Umbilical mass
 Increase on crying toa classical conical shape
 Stragulation is extremely rare below 3 yrs.

14.  Female>males, commonly overweight
 Mass above and below umbilicus,protruding
through umbilicus
 Crescent shape of umbilicus
 Painless or dragging pain due tissue
tension/obstruction
 Firm and dull on percussion-omentocele
 Soft and Resonant on percussion- enterocele
 Mostly non reducible
 Sometimes reducible
 Expansile cough impulse in reducible cases.

15.  Irreducibility
 Incarceration
 Bowel obstruction
 Strangulation
 Skin ulceration
 Burst abdomen in case of exomphalos major.

16.  Congenital umbilical hernia
 Parentral reasuareance
 90% resolve itself
 Coin strapping ( outdated)
 If persist beyond 2 yrs surgical correction
advised.

17.  1. if defect is less than 1cm
 Simple figure eight suture after reducing
contents in cavity
 Repaired by darn technique.

18. 2.defect upto 2cm:
 Mayo’s vest over pants repair
 Mesh plasty for tensionless repairand
reinforcementof wall.
 Apronectomy(excision of excess skin after
mayos repair)

19.  Transeverse curviline incison
 Hernia sac was identified and desected off
 Adhesions were seperated
 Sac was opened contents were reduced
 Non viable tissue removed
 Peritoneum closed
 Defect in anterior rectus sheath extended
laterallyon both sides.
 Elevated to create flaps(upper and lower)
 Double bresting was done
 Suction drain was kept

22.  Defect is more than 2 cm:
 Mesh repair is recommended.
 1.within peritoneal cavity;(UNDERLAY)
Tissue seperating meshtrough the defect
fixed with overlap of 5cm
 2.extraperitonealspace ; (preperitoneal)
 Plane below posterio rectus sheath
developed
 Care to be taken to avoid button holing in
peritoneum.
 Linia alba closed over mesh

23.  Retromuscular(sublay): linia alba opened
vertically.
 Posterior rectus sheath sutured together
 Rectus muscle elevatedto form retromuscular
space for mesh.
 Mesh overlaps midline by 5 cm laterally.
 Maximum diameter of mesh is 10cm
 Most secure method.

24.  INLAY mesh: applied by plugs
Having high recurrence rate.
 ONLAYmesh repair:
Subcuticular
Simplest open repair
Close linia alba vertically
Mesh placed on anterior rectus sheath
Prone to infection
Seroma is major complication
 Posterior and anterior componant seperation:
In giant and complex hernia.

27.  Pneumoperitonum created.
 2mm ports were inserted on lateral sides
lower abdomen and on on upper 10mm.
 Contents of hernia were reduced by traction
and external pressure.
 Non adherant mesh for intraperitoneal use
was fixed to peritoneum and posterior rectus
sheathusing staples, tracks or sutures.

29.  In cases of simple incarseration without
cliniacal evedence ofstrangulationrepair may
be attempted laproscopically
 Mostly open surgery.
 Open suture repair.
 No mesh plasty is advised.
 2stage repair may be advised.

30.  Large seroma
 Surgical site infection
 Patients bmi more than 30 and defect more
than 2 cm
 Cirhosis with uncontrolled ascites
 Wrong surgical technique.

31.  Use of mesh repair results decresed
recurrence rates for primary umbilical
hernias
 For multiple comorbidity alwys repaire with
mesh.
 There is high possibility of fewest ssi and
recurrence in sublay repair.
 Topical gentamycinin addition to
preoperative intravenous prophylaxis to
lower infection rates.