This document provides information on umbilical, paraumbilical, and incisional hernias. It discusses the anatomy, classification, features, and treatment options for each type of hernia. Umbilical hernias are common in newborns and infants and can be congenital or acquired. Paraumbilical hernias typically present as swellings in adults, especially females. Incisional hernias occur through weak surgical scars from prior abdominal operations. All three types are generally treated with surgical repair or mesh placement, depending on hernia size and characteristics.

1. Umbilical, Paraumbilical &
Incisional hernia- Revision
UG Batch - 2017
Date - 4/10/21
Dr. Ankita Singh
Assistant Professor
Department of Surgery

2. UMBILICAL HERNIA

3. Anatomy
• Umbilical ring
– Complex structure
– Related to linea alba, falciform ligament, obliterated
urachus & umbilical fascia (richet's fascia)
• Level of L4 and L5 vertebral disc.
– Lower position in infants
• Water shed area for venous and lymphatic
drainage
– Above umbilicus it drains to axillary vein or
lymphatics;
– Below to inguinal area

4. Anatomy..
• Umbilical skin is supplied by T10 spinal cord
• Meeting point of four folds of embryonic
plate and three systems
– GI (vitellointestinal), urinary (urachus), and
vascular (umbilical vessels).
• Umbilical hernia develops due to
– Absence of umbilical fascia or
– Incomplete closure of umbilical defect
• Weakest part in the umbilical cicatrix is upper
part where hernia begins.

6. Classification
• Congenital
– Newborn common males
– Infants
• Acquired
– Adults common females

8. Umbilical hernias of Newborn
• 20% of newborns
• Umbilical hernia
– Common africans
– Cause:
• Herniation through a weak umbilical scar (cicatrix).
• Omphalocele/exomphalos
– Major or minor
– Cause:
• Failure of all or a part of the gut to return to coelomic
cavity during early fetal life

10. Exomphalos
• Features:
– Sac-
• very thin
• 3 layers: amniotic membrane, wharton’s jelly,
peritoneal layer
– Sac may get ruptured during birth

11. Exomphalos..
• Aetiology:
– Usually neonatal sepsis
– Associated with
• Down’s, Beckwith-Weidman syndrome etc.
• Congenital cardiac/genitourinary anomalies (70%)
– Ascites

12. Exomphalos..
• Diagnosis:
– Can be confirmed in-utero by USG
– Amniocentesis & chromosomal analysis
– Clinically after birth
*Abdominal wall muscle is normally developed but peritoneal
layer is hypoplastic.

13. Exomphalos..
• Types:
Exomphalos Minor Major
Sac Small Large
Defect size <5cm >5cm
Umbilical cord
attachment
Summit Inferiorly
Content Usually small bowel Small & large bowel, liver
Primary closure Possible Not possible
Prognosis Good Poor

15. Exomphalos..
• Management:
– Primary closure for E. minor
– E. major:
• Immediate surgery & simultaneous resuscitation
• Measures needed
– Prevention & correction of dehydration
– Prevention of hypothermia & aspiration
– Control of sepsis
– Nutrition, correction of dyselectrolymia, coagulopathy
– Evaluation of other anomalies
– Definitive surgery: component separation/ bagota bag
followed by definitive closure.

16. Umbilical hernias of Infants &
children
• Common in males
• Cause:
– Herniation through a weak umbilical cicatrix
• Commonly due to neonatal sepsis
• Associated with
– Down’s, B W Syndrome, Ascites

17. Clinical features
• Presents with a swelling in the umbilical
region within first few months after birth
• Size increases during crying
• Hemispherical in shape
• Defect can be felt with finger
• If irreducible/ obstruction
– Presents with pain, distension, vomiting

18. Treatment
• Initially conservative
– Most resolve spontaneously
• Can be hastened by adhesive strapping across
the abdomen
• Surgery
– Indications
• persists even after age of two years
• defect more than 2 cm
• Acquired/adult umbilical hernia

19. Treatment..
• Surgical options
– Primary closure (<2cm): open vs. lap
• Mayo’s repair
• Smead Jone’s repair
• Huges modification
– Mesh repair- (>2cm)
• Sublay preferred
• Open vs. lap
– Umbillectomy
– Open dual PTFE & polypropylene mesh

20. PARAUMBILICAL HERNIA

21. Paraumbilical hernia
• This term is dropped
• Supra/ infraumbilical location
– Protrusion or herniation through linea alba
• Common in adults
– More so in females

22. Paraumbilical hernia- Features
• Swelling:
– Smooth surface, well defined, soft, resonant, non
tender, expansile cough impulse
• Often attains a large size & sags downwards
– Associated dragging pain
• Neck of the sac is relatively narrow
• Contents are usually
– Omentum, small bowel, sometimes large bowel

23. Paraumbilical hernia- Features..
• Large hernias
– Tendency to go for adhesion, irreducibility,
obstruction, strangulation

24. Paraumbilical hernia- Treatment
• Surgery:
– Primary repair
– Retro-rectus mesh hernioplasty: gold standard
– Umbillectomy
– Mayo’s operation
• “vest on pant”
– Additional panniculectomy

25. INCISIONAL HERNIA

26. Incisional hernia
• Herniation through weak abdominal surgical
scar
• Importance of history:
– Details of previous surgery
• Whether surgery was an emergency or elective
• History of wound infection, wound dehiscence,
• Tension sutures placed or not
• Duration
– History of pain, irreducibility and details of
precipitating factors
– Other precipitating factors are similar to inguinal
hernia

27. Incisional hernia- Aetiology
• Incision type
• Closure type
• Suture material
• Emergency vs. elective surgery
• Pus drainage through main incision
• Increased IAP
• Age, nutrition, comorbidities/disease &
drugs

28. Incisional hernia- Aetiology
• Incision type
• Closure type
• Suture material
• Emergency vs. elective surgery
• Pus drainage through main incision
• Increased IAP
• Age, nutrition, comorbidities/disease &
drugs

29. Incisional hernia- Features
• Lump in scar region
– Usually well defined
– Expansile cough impulse
• Often enterocele; may be accompanied by
omentocele
• Defect
• Complicated
*Common- lower abdomen
#small to loss of domain
^Midline hernias expel more content

30. Incisional hernia- Investigation
• Clinical diagnosis
• Investigations
– to look for precipitating cause/s
– Fitness for surgery

31. Incisional hernia- Treatment
• Preoperative preparation
– Optimization
• Surgical options:
– Primary repair
– Mesh repair with/out primary repair
• Different planes
• Open or laparoscopically
– Component separation with/without mesh
– Named procedures-
• Cattell’s, Keel, double breasting, Nuttall’s, Rive’s
Stoppa’s operation

35. Incisional hernia- Treatment..
• Prosthetic repair:
– Universally accepted gold standard treatment
– Types:
• Polypropylene
• PTFE, e- PTFE
• Dacron
• Dual mesh
• Biological grafts

36. Incisional hernia- Complications of
surgery
• SSI
• Meshoma
• Hematoma
• Abscess
• Sinus, enterocutaneous fistula
• Paralytic ileus
• Abdominal compartment syndrome
• Recurrence

39. Dhanyawaad!
Any queries?