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Home Operations Guide General Surgery Operation Howto Adult Umbilical and Para-umbilical hernia repair

Adult Umbilical and Para-umbilical hernia repair

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Written by M F Ahmad   
Tuesday, 02 August 2011 17:01

Introduction

The umbilicus is the scar that marks the connection between the foetus and placenta.

It lies at a variable point in the midline depending on patient habitus, in the linea alba.

A hernia is an abnormal protrusion of a viscus, or part of a viscus through a congenital or acquired defect.

In adults, most umbilical hernias are in fact para-umbilical, with the defect arising just above or below the cicatrix.

It is more common for hernias to occur just above the umbilicus, where the tissue consists of a thin layer of transversalis fascia. Inferiorly, there is slightly more reinforcement in the form of the obliterated umbilical vessels.

They can present in either the elective or emergency setting and the treatment can differ in each case.

Signs and Symptoms

Symptoms include a noticeable bulge around the umbilicus which is more prominent on standing and may disappear on lying down; pain; obstruction.

Signs range from a reducible lump with a positive cough impulse to the emergency presentation of an unstable, obstructed patient.

Painful, reducible hernias and strangulated, painful, irreducible hernias should be treated with early surgery.

Although most para-umbilical hernias contain omentum only, in the emergency setting, with an obstructed patient, one should be prepared to find incarcerated and potentially ischaemic bowel and perform a full laparotomy with bowel resection if necessary.

Consent

 

  • Infection (skin/mesh)
  • Haematoma
  • Recurrence
  • Bowel resection

 

 

Principle types of repair technique

 

  • In all cases, the aim is to perform a tension-free repair
  • Studies have shown that although primary repair remains a popular choice for small defects, mesh repair is superior in term of reduced recurrence rate1
  • There is no evidence to suggest that placement of a mesh increases post-operative infection rates1
  • Primary repair (herniorrhaphy) (for only the smallest of defects, <3cm)
  • Mesh-repair (hernioplasty) with a prolene or PTFE mesh (anatomical sites for the positioning of the mesh are: onlay, facsial, retromuscular-prefascial or preperitoneal)
  • Mayo’s ‘vest-over-pants’ repair

 

 

Pre-operative preparation

 

  • Mark out the margins of the hernia pre-operatively as when the patient is relaxed on-table, it may have reduced and you may not be able to see it
  • General anaesthetic
  • Supine position
  • Antibiotic prophylaxis in accordance with hospital guidelines

 

Incision and dissection

 

  • With a scalpel, make a curve-linear incision over the hernia. This cam be extended either side as required
  • Hold the skin edges either side using Littlewoods or Allis clamps
  • Deepen the incision through sub-cutaneous fat and aponeurosis
  • Insert a self-retaining retractor such as Travers or West’s to help
  • Take care not to enter the hernial sac
  • If iatrogenic peritoneal defects occur, make note and close them later with an absorbable suture such as 3’0 vicryl
  • Continue dissection to identify the margins of the hernial defect circumferentially, down to the hernial neck
  • If the hernia is small, preserve the umbilical skin by dissecting the sac off it
  • In cases of large hernias, it may be necessary to excise the umbilicus and associated skin
  • Skeletalise the sac from fatty tissue and clear an area of rectus sheath (the white, tough tissue) around it
  • Use a finger to sweep the peritoneum away from the under surface of the defect, taking care not to tear into the peritoneum
  • Inspect the contents of the sac. If freely reducible and there is no suspicion of ischaemia, proceed with repair
  • If in doubt, open the sac, placing the peritoneal edges in small artery clips
  • If the contents are thickened, fibrosed omentum, excise this using either diathermy or clips. If using clips, segmentally divide and ligate the ends using 3’0 vicryl
  • If ischaemic bowel is found, then proceed as if for resection

 

 

Repair

Close any peritoneal defects with a continuous suture, using an absorbable material such as 3’0 vicryl

 

Primary repair

 

  • This should be performed on only the smallest of defects (<3cm)2
  • Place interrupted sutures transversely across the defect using a non-absorbable material such as 0 prolene
  • Instead of tying each stitch immediately, place both ends in a clip
  • Place further sutures at evenly spaced points along the defect, again placing the ends of each in clips
  • Use the first suture placed to lift up the sheath away from the peritoneal contents. This helps to avoid iatrogenic bowel injuries that can occur
  • When all sutures are placed, tie them off

 

Mesh repair

 

  • It is my practice to place the mesh on top of the defect and secure it using interrupted sutures such as 3’0 PDS. Others may prefer to use a non-absorbable suture such as prolene
  • In either case, the sutures act to secure the mesh in place for long enough so that it can fibrose and scar down into place
  • During dissection, ensure adequate exposure of the rectus sheath all around
  • Take a bite of the sheath with your suture, then pass it through the mesh
  • Do not tie immediately, but instead place the ends of the suture in a clip, which can then be used to lift the sheath away from the peritoneal contents below
  • Place all the sutures in a similar fashion around the mesh, taking good bites of tissue
  • Tie off all the sutures

 

 

Mayo’s ‘vest over pants’ repair

 

  • The aim here is to overlap the upper and lower edges of the defect using a large non-absorbable suture such as 0’ prolene
  • This is used to place interrupted horizontal mattress sutures transversely across the defect
  • Starting on the lower edge, take full-thickness bite of the sheath 1cm from its edge
  • Then pass the needle under and through the upper leaf, bringing it out about 4cm from the edge
  • Now reverse the needle and take a bite from the upper leaf, about 2cm from the edge
  • Now pass the needle under the edge of the lower leaf, bringing it out close to the original entry point
  • Again, you may find it easier to clip the suture and use it to lift the sheath as you place all the other stitches before tying them off individually at the end
  • As the stitches are tied, the lower edge (‘pants’) is pulled under the upper edge (‘vest’), hence the name ‘vest over pants
  • When all the stitches are tied, a further layer of continuous sutures is placed between the edge of the upper and lower sheath

 

 

Closure

 

  • Ensure adequate haemostasis
  • The placement of ‘fat stitches’ is optional, but in large patients they can be used to close the potential space between sheath and skin. If placed, use an absorbable suture such as 3’0 vicryl
  • Securing the umbilicus to the sheath is another optional step
  • Skin closure is with an absorbable subcuticular suture such as 3’0 monocryl
  • It is not usual practice to leave a drain

 

 

Post-op care

Following simple, small hernia repairs patients can eat and drink in the immediate post-operative period and can go home the same day/following morning

 

References

1. Aslani N, Brown CJ. Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis. Hernia 2010;14:455-462

2. Asolati M, Huerta S, Sarosi G, Harmon R, Bell C, Anthony T. Predictors of recurrence in veteran patients with umbilical hernia: single center experience. Am J Surg 2006;192:627–630

 

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