This document discusses umbilical hernias, which occur when part of the abdominal contents bulge through a weakness in the abdominal wall at the umbilical region. Umbilical hernias are common in infants and can resolve spontaneously, but in adults they often require surgery. The document describes the causes, types, clinical features, and treatment options for umbilical hernias, including both open and laparoscopic surgical repair techniques.

1. UMBILICAL HERNIA

2. Hernia
Definition:A hernia is the bulging of part of the contents
of the abdominal cavity through a weakness in the
abdominal wall.

3. Causes of hernia
• Basic design weakness
• Weakness due to structures entering and leaving the abdomen
• Developmental failures
• Genetic weakness of collagen
• Sharp and blunt trauma
• Weakness due to ageing and pregnancy
• Primary neurological and muscle diseases
• Excessive intra-abdominal pressure

4. Types of hernia by complexity
• Occult – not detectable clinically; may cause severe pain
• Reducible – a swelling that appears and disappears
• Irreducible – a swelling that cannot be replaced in the abdomen,
high risk of complications
• Strangulated – painful swelling with vascular compromise,
requires urgent surgery
• Infarcted – when contents of the hernia have become
gangrenous, high mortality

5. Umbilical hernia
•The umbilical defect is present at birth but closes as the
stump of the umbilical cord heals, usually within a week
of birth
•This process may be delayed, leading to the
development of herniation in the neonatal period
•The umbilical ring may also stretch and reopen in adult
life

6. Umbilical hernia in children
•Occurs in up to 10% of infants, higher incidence
in premature babies
•Hernia appears within a few weeks of birth
•Symptomless
•Increases in size on crying and assumes a
classical conical shape
Incidence:
• Boys = Girls
• Black infants (8x) > White infants
Obstruction and/or strangulation are extremely uncommon below the age of 3 years

7. Treatment
• Conservative treatment is indicated under the age of 2
years when the hernia is symptomless. Parental
reassurance is all that is necessary.
• 95% will resolve spontaneously.
• If the hernia persists beyond the age of 2 years it is
unlikely to resolve and surgical repair is indicated.

8. Surgery
• Small curved incision is made immediately below
the umbilicus
• Neck of the sac is defined, opened and any
contents are returned to the peritoneal cavity
• Sac is closed and redundant sac is excised
• The defect in linea Alba is closed with
interrupted sutures.

9. Umbilical hernia in adults
Reopening of umbilical defect caused by conditions that
cause thinning and stretching of mid-line raphe (linea
alba)
 Repeated pregnancies - weaken abdominal wall
 Obesity - flabby abdominal muscle
 Ascites - especially in cirrhotic patients
PARAUMBILICALHERNIADefect in median raphe is immediately
adjacent to true umbilicus (usually above)

10. Cont..
• Round with well defined fibrous margin.
• Contents
Small umbilical hernia often contain extraperitoneal
fat or omentum
Larger hernia contain small or large bowel
Very large hernia have narrow neck of the sacprone
to become irreducible, obstructed and strangulated.

11. Clinicalfeatures
• Swelling in the umbilical region - increase on
coughing/straining
• Cough impulse - expansile impulse is present
• Patient may also have inguinal hernia
• Reducibility can be present
• Crescent-shaped appearance of the umbilicus
• Patient complaint of pain due to tissue tension, and
symptom of intermittent bowel obstruction
• Dermatitis in case of large hernia (due to thinned &
stretched of overlying skin)
Fig: Crescent shape umbilicus

12. Treatment
•As a result of the high risk of strangulation, surgery
should be advised in cases where the hernia contains
bowel.
•Small hernias may be left alone if they are
asymptomatic, but they may enlarge and require
surgery at a later date.
•Surgery may be performed open or laparoscopically.

13. Open umbilical hernia repair
Small defects less than 1 cm in size:
•closed with a simple figure-of-eight suture or
•repaired by a darn technique where a non-
absorbable, monofilament suture is crisscrossed
across the defect and anchored firmly to the fascia
all around

14. Cont..
Defects up to 2 cm
•Sutured primarily with minimal tension
•Classical repair by Mayo :
 A transverse incision is made and the hernia sac is dissected, opened and
its content reduced
 Any non viable tissue is removed
 The peritoneum is closed
 The defect in the anterior rectus sheath is extended laterally on both
sides and elevated to create an upper and lower flap (double breasted)

15. Cont..
Defects larger than 2 cm in diameter:
Mesh repair is recommended.The mesh may be placed in one of
several anatomical planes:
• Within the peritoneal cavity
• In the retromuscular space
• In the extraperitoneal space
• In the subcutaneous plane

16. Laparoscopic umbilical hernia repair
• Three ports are placed laterally on the abdominal wall
• The contents of the hernia are reduced by traction and external
pressure
• A disc of non-adherent mesh, is introduced and positioned on
the under surface of the abdominal wall, centered on the defect
• It is then fixed to the peritoneum and posterior rectus sheaths
using staples, tacks or sutures

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