When Should Adults Have Abdomibal Hernia Repair?

Ulus Cerrahi Derg. 2022; 31(3): 157–161.

Current options in umbilical hernia repair in adult patients

Received 2022 Oct 28; Accepted 2022 Dec seven.

Abstract

Umbilical hernia is a rather mutual surgical trouble. Elective repair later diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh tin can exist placed through either an open or laparoscopic approach with good 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 risk factors. Moreover, smoking may create a risk 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 Usa (two). Information technology has been reported that the share of umbilical and paraumbilical hernia repairs among all repairs for intestinal wall hernias increased from 5% to 14% in U.k. in the terminal 25 years (three). A similar ascension has been reported in a recent multicenter report from Turkey (four).

In general, umbilical hernias are more mutual in women than men; however, there are serial in which male person patients are more than frequent (v). Typically, a lump is observed around the omphalos. Hurting is the nigh mutual indication to visit a physician and undergo a repair (6). Recurrence may develop even in cases where a prosthetic mesh is used. Recurrent umbilical hernias oft tend to enlarge faster than primary ones and may comport as incisional hernias.

An umbilical hernia has a tendency to be associated with high morbidity and mortality in comparison with inguinal hernia because of the higher chance of incarceration and strangulation that crave an emergency repair. Although the number of articles with the title word "umbilical hernia" increased two.6-fold betwixt the periods 1991–2000 and 2001–2010, at that place however appears to be a certain discrepancy between its importance and the attention it has received in the literature (7). In this newspaper, the nature of the umbilical hernias is reviewed, and the electric current options for their surgical repair are discussed.

Anatomic Clarification

Many hernias in the umbilical region occur above or below the omphalus through a weak place at the linea alba, rather than directly through the umbilicus itself, and the natural history and handling practise not differ for these hernias. The European Hernia Society classification (8) for primary intestinal wall hernias defines the midline hernias from 3 cm in a higher place to 3 cm below the belly button as umbilical hernia (Figure one).

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Abdominal wall hernias from 3 cm in a higher place to three cm below the navel are defined as umbilical hernia according to the European Hernia Lodge Classification (8)

The borders of the umbilical canal are the umbilical fascia posteriorly, the linea alba anteriorly and medial edges of the 2 rectus sheaths on 2 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 exist preperitoneal fat tissue, omentum, and minor intestine in the bulk; a combination of those tin accept part. Large intestines are very rarely involved (10). The cervix 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 advised.

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 before surgery. Local anesthesia often provides maximum comfort for patients when it is accurately performed in open repairs. Some centers routinely utilise local anesthesia (five, xi, 12). However, inexperience with the local anesthetic technique may cause discomfort to patients with an increased recurrence charge per unit. Local anesthesia may too be challenging if the patient is obese and hernia is big and/or recurrent (xiii). In patients with ASA I or Ii scores and who have one of the specific difficulties higher up, the surgeon should amend choose general anesthesia to experience more secure because the quality of repair is the nearly important outcome measure.

Laparoscopic ventral hernia repair generally requires general anesthesia with endotracheal intubation. Furthermore, it tin can be feasible under spinal anesthesia with low-pressure level CO₂ pneumoperitoneum (fourteen).

Antibody Prophylaxis

Naturally, bellybutton is not a clean anatomical role of the trunk. The umbilical skin may not be cleaned of all bacteria even with the apply of mod antiseptic solutions. Therefore, the surgical site infection can be more than frequent following umbilical hernia repairs than that post-obit inguinal hernia repairs. A 10% superficial wound infection rate is non surprising fifty-fifty afterwards routine safety antibiotic apply. A recent written report reported a 19% infection charge per unit following open umbilical hernia repair (15). Kulacoglu et al. (5) reported 3% wound infection rate with antibiotic prophylaxis with cefazolin sodium that is administered 30 min before pare incision.

Deysine (14) recommended topical gentamicin in addition to preoperative intravenous prophylaxis to lower the infection rates later on hernia repairs. He reported no surgical site infections in hernia surgery subsequently setting this prophylaxis combination for 24 consecutive years. Although gentamicin is most effective against gram-negative bacteria, it is as well effective confronting staphylococci. Furthermore, it has been stated that gentamicin can demonstrate antimicrobial synergy with cefazolin for a more successful antibacterial effect (xvi).

Which Repair Technique?

There are mainly two repair options for umbilical hernias: suture and mesh. Simple principal suture repair tin be used for modest defects (<two–3 cm). The technique of overlapping abdominal wall fascia in a "vest-over-pants" way was described by William Mayo (17) and remained the nigh renowned surgical technique for a long time. There are few clinical studies with Mayo technique in the literature (half dozen, 12). High recurrence rates up to 28% have been reported (10).

Prosthetic materials are widely used today in the repair of all kind of abdominal hernias. Arroyo et al's (xviii) randomized clinical trial revealed that the recurrence rate was lower afterward mesh repair than that subsequently suture repair (1% vs. xi%) in a 64-month mean postoperative follow-upwardly. In a retrospective clinical series of 100 patients, the recurrence rates for the suture and mesh repair groups were eleven.five and 0%, respectively (p=0.007), with similar results in the infection rates in favor of mesh repair (19). A systematic review and meta-assay by Aslani and Chocolate-brown (xx) revealed that the use of mesh in umbilical hernia repair results in decreased recurrence and similar wound complication rates compared with tissue repair for chief umbilical hernias. Yet, many surgeons withal make his/her decision on the ground of the size of the umbilical/paraumbilical defect. Dalenbäck (21) suggested a tailored repair and stated that suture-based methods for defects <two cm tin provide acceptable recurrence rates (6%) in long-term follow-up. A postal questionnaire written report from Scotland revealed that surgeons preferred mesh repair for defects >5 cm, whereas similar preference rates for suture and mesh repairs were obtained for defects <2 cm (22).

Meshes tin be placed via both the open up and laparoscopic approaches. Surgeons in general prefer the near familiar technique or comply with the patients' preferences. Open onlay mesh placement is the easiest technique; withal, information technology requires subcutaneous dissection that may cause seroma or hematoma and eventually result in surgical site infection in some cases. Mesh can likewise be placed in a preperitoneal or sublay position (five, 11). This may require more surgical feel and skill merely avoids extensive subcutaneous dissection and reduces seroma formation and mayhap result in less recurrence. Onlay and sublay mesh placement tin exist washed at the same time in complicated or recurrent cases to provide more than reinforced repair. Some authors prefer 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. It tin can be performed with local anesthesia (23, 24). However, there is no controlled report to compare plug repair with other techniques. Also plug repairs accept the chance of migration and enterocutaneous fistula formation (25).

Laparoscopic umbilical hernia repair has been practiced since late 1990s (26, 27). Single-port repairs accept also recently been reported (28). Laparoscopic technique is basically a mesh repair; however, laparoscopic primary suture repair without prosthetic fabric has also been experienced (29). In dissimilarity, Banerjee et al. (30) compared the laparoscopic mesh placement without defect closure with laparoscopic suture and mesh in a clinical written report and reported a slightly lower recurrence rate in the latter group, particularly for recurrent hernias.

Today the utilization of laparoscopy for umbilical hernia repair remains relatively low in the world. Laparoscopy is preferred in simply a quarter of the cases (31). There are a few studies comparison open and laparoscopic repairs for umbilical hernias. Short-term outcomes from the American College of Surgeons National Surgery Quality Improvement Program recently revealed a potential decrease in the total and wound morbidity associated with laparoscopic repair for elective main umbilical hernia repairs at the expense of longer operative time and length of hospital stay and increased respiratory and cardiac complications (32). In their multivariate model, after controlling for body mass index, gender, the American Society of Anesthesiologists course, and chronic obstructive pulmonary illness, the odds ratio for overall complications favored laparoscopic repair (OR=0.lx; p=0.01). This difference was primarily driven by the reduced wound complication rate in laparoscopy group.

The Danish Hernia Database did non reveal pregnant differences in surgical or medical complication rates and in run a risk factors for a 30-day readmission between open and laparoscopic repairs (33). After open repair, independent risk factors for readmission were hernia defects >2 cm and tacked mesh fixation. After laparoscopic repair, female gender was the only contained take a chance factor for readmission.

Obese patients with umbilical hernia comprise a special group. A recent comparative study by Colon et al. (34) stated that laparoscopic umbilical hernia repair should be the preferred arroyo in obese patients. They establish a significant increase in wound infection charge per unit in the open mesh repair grouping when compared with the laparoscopic process (26% vs. 4%; p<0.05). They observed no hernia recurrence in the laparoscopic group, whereas the open group had 4% recurrence rate. In dissimilarity, Kulacoglu et al. (v) demonstrated that obese patients too require more than local anesthetic dose in open mesh repair.

A summary of current repair options for umbilical hernias are presented in Table 1.

Table 1.

A classification of current repair techniques for umbilical hernias

A. Prosthetic repairs

1. Open approach

a. Onlay mesh

b. Sublay/Preperitoneal mesh

c. Mesh plug

d. Bilayer prosthetic devices

2. Laparoscopic arroyo

a. Inlay mesh

b. Defect closure and mesh placement

B. Tissue–Suture repairs

1. Main suture

2. Mayo repair

Which Mesh?

Standard polypropylene mesh is the well-nigh frequently used prosthetic material particularly 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 "low-cal weight" mesh theoretically induces less foreign body response, results in improved intestinal wall compliance, causes less contraction or shrinkage of the mesh, and enables better tissue incorporation; nevertheless, their clinical advantages have non been clearly documented (35).

Newer bilayer prosthetic devices are designed for open intraperitoneal inlay placement. They have two sides, one is polypropylene and the other side is a non-adherent material to confront viscera. Two tails that are continued to the bilayer patch were sutured to fascial edges to avert migration. Promising early on results accept been reported; however, 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 college in comparison with that after classical sublay mesh placements mayhap because of the less controllable mesh deployment (39).

Bilayer polypropylene or partially reabsorbable meshes have also been used for umbilical hernias. They comprised 1 sublay and i overlay patch with a connector to eliminate migration. However, clinical outcomes after repairs with these devices have not been widely documented (40).

Option of mesh appears to exist more than important for laparoscopic repairs (41). Composite meshes are preferred materials in most institutions to avoid the risk of visceral adhesion into the mesh (42, 43). There are numerous composite or dual-side meshes in the market; 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 discover and a much more economical choice, its use in laparoscopic ventral hernia repairs, including umbilical hernias, has certain risks. Sarela (44) stated that the fiscal-cost to clinical-benefit ratio for the use of expensive composite meshes is unquantified and is likely to remain as such considering given the widespread acceptance of blended products, a randomized clinical comparison with unproblematic polypropylene mesh is unlikely to occur. In selected circumstances, it may be acceptable to use a simple mesh if this can be completely excluded from bowel by interposition of omentum; however, a blended mesh should be considered as the current standard of care.

Factors Influencing Recurrence

Several factors take been responsible for recurrence after umbilical hernia repairs. Yet, few studies presented an contained factor later multivariate analysis.

Big seroma and surgical site infection are classical complications that may result in recurrence. Obesity and excessive weight gain following repair are plain potential risk factors. The patient's BMI >xxx kg/m² and defects >2 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 take chances gene 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). Nonetheless, recent reports for elective repair are more promising, and at that place is tendency to perform constituent 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 because the hepatic reserve and patient's condition (50). Ascites control is the mainstay of postal service-operative direction.

CONCLUSION

Mesh repairs are superior to non-mesh/tissue-suture repairs in umbilical hernia repairs. Open and laparoscopic techniques have near similar efficacy. Local anesthesia is suitable for small-scale umbilical hernias and patients with reasonable BMI. Antibiotic prophylaxis appears to provide low wound infection charge per unit.

Footnotes

Peer-review: This manuscript was prepared by the invitation of the Editorial Board and its scientific evaluation was carried out by the Editorial Board.

Conflict of Involvement: No disharmonize of interest was declared by the authors.

Financial Disclosure: The authors declared that this report has received no financial back up.

REFERENCES

v. Kulacoglu H, Yazicioglu D, Ozyaylali I. Prosthetic repair of umbilical hernias in adults with local anesthesia in a day-case setting: a comprehensive report from a specialized hernia center. Hernia. 2012;16:163–170. http://dx.doi.org/10.1007/s10029-011-0888-8. [PubMed] [Google Scholar]

half dozen. Courtney CA, Lee Ac, Wilson C, O'Dwyer PJ. Ventral hernia repair: a study of current practice. Hernia. 2003;seven:44–46. [PubMed] [Google Scholar]

vii. Kulacoglu H, Oztuna D. Growth and trends in publications well-nigh abdominal wall hernias and the bear on of a specific journal on herniology: a bibliometric analysis. Hernia. 2011;xv:615–628. http://dx.doi.org/10.1007/s10029-011-0864-three. [PubMed] [Google Scholar]

12. Menon VS, Brownish TH. Umbilical hernia in adults: 24-hour interval case local anaesthetic repair. J Postgrad Med. 2003;49:132–133. [PubMed] [Google Scholar]

14. Tzovaras 1000, Zacharoulis D, Georgopoulou S, Pratsas K, Stamatiou 1000, Hatzitheofilou C. Laparoscopic ventral hernia repair under spinal anesthesia: a feasibility study. Am J Surg. 2008;196:191–194. http://dx.doi.org/10.1016/j.amjsurg.2007.07.028. [PubMed] [Google Scholar]

15. Farrow B, Awad Southward, Berger DH, Albo D, Lee Fifty, Subramanian A, et al. More than 150 consecutive open umbilical hernia repairs in a major veterans administration medical center. Am J Surg. 2008;196:647–651. http://dx.doi.org/10.1016/j.amjsurg.2008.07.018. [PubMed] [Google Scholar]

21. Dalenbäck J, Andersson C, Ribokas D, Rimbäck Yard. Long-term follow-upwards after elective developed umbilical hernia repair: low recurrence rates as well after non-mesh repairs. Hernia. 2013;17:493–497. http://dx.doi.org/10.1007/s10029-012-0988-0. [PubMed] [Google Scholar]

24. Brancato G, Privitera A, Gandolfo L, Donati G, Caglià P. Plug-technique for umbilical hernia repair in the adult. Minerva Chir. 2002;57:thirteen–16. [PubMed] [Google Scholar]

30. Banerjee A, Beck C, Narula VK, Linn J, Noria Due south, Zagol B, et al. Laparoscopic ventral hernia repair: does chief repair in addition to placement of mesh decrease recurrence? Surg Endosc. 2012;26:1264–1268. http://dx.doi.org/10.1007/s00464-011-2024-3. [PubMed] [Google Scholar]

31. Funk LM, Perry KA, Narula VK, Mikami DJ, Melvin WS. Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States. Surg Endosc. 2013;27:4104–412. http://dx.doi.org/10.1007/s00464-013-3075-iv. [PubMed] [Google Scholar]

32. Cassie Due south, Okrainec A, Saleh F, Quereshy FS, Jackson TD. Laparoscopic versus open up elective repair of principal umbilical hernias: short-term outcomes from the American College of Surgeons National Surgery Quality Comeback Program. Surg Endosc. 2014;28:741–746. http://dx.doi.org/ten.1007/s00464-013-3252-5. [PubMed] [Google Scholar]

37. Vychnevskaia K, Mucci-Hennekinne S, Casa C, Brachet D, Meunier K, Briennon 10, et al. Intraperitoneal mesh repair of small ventral abdominal wall hernias with a Ventralex hernia patch. Dig Surg. 2010;27:433–435. http://dx.doi.org/10.1159/000318783. [PubMed] [Google Scholar]

38. Hadi Hi, Maw A, Sarmah Southward, Kumar P. Intraperitoneal tension-gratuitous repair of small midline ventral abdominal wall hernias with a Ventralex hernia patch: initial experience in 51 patients. Hernia. 2006;10:409–413. http://dx.doi.org/10.1007/s10029-006-0127-10. [PubMed] [Google Scholar]

42. Nardi MJ, Millo P, Brachet Contul R, Fabozzi M, Persico F, Roveroni M, et al. Laparoscopic incisional and ventral hernia repair (LIVHR) with PARIETEX™ Composite mesh. Minim Invasive Ther Centrolineal Technol. 2012;21:173–180. http://dx.doi.org/10.3109/13645706.2012.671178. [PubMed] [Google Scholar]

43. Tollens T, Struyve D, Aelvoet C, Vanrijkel JP. Introducing the Proceed Ventral Patch as a new device in surgical management of umbilical and small ventral hernias: preliminary results. Surg Technol Int. 2010;xix:99–103. [PubMed] [Google Scholar]

45. Venclauskas L, Silanskaite J, Kiudelis G. Umbilical hernia: factors indicative of recurrence. Medicina (Kaunas) 2008;44:855–859. [PubMed] [Google Scholar]

46. Bencini L, Sanchez LJ, Bernini K, Miranda E, Farsi K, Boffi B, et al. Predictors of recurrence later on laparoscopic ventral hernia repair. Surg Laparosc Endosc Percutan Tech. 2009;19:128–132. http://dx.doi.org/10.1097/SLE.0b013e31819cb04b. [PubMed] [Google Scholar]

48. Eker HH, van Ramshorst GH, de Goede B, Tilanus HW, Metselaar HJ, de Man RA, et al. A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery. 2011;150:542–546. http://dx.doi.org/10.1016/j.surg.2011.02.026. [PubMed] [Google Scholar]

fifty. Choi SB, Hong KD, Lee JS, Han HJ, Kim WB, Vocal TJ, et al. Management of umbilical hernia complicated with liver cirrhosis: an abet of early on and elective herniorrhaphy. Dig Liver Dis. 2011;43:991–995. http://dx.doi.org/ten.1016/j.dld.2011.07.015. [PubMed] [Google Scholar]

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