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Umbilical Hernia
Introduction
The European Hernia Society defines umbilical hernias as ventral abdominal hernias located within 3 cm above or below the umbilicus. They account for 6% to 14% of all adult abdominal wall hernias and are second in frequency only to inguinal hernias.[1][2][3] In infants, umbilical hernias occur in 10% to 15% of cases and often resolve spontaneously by age 2.[4] Umbilical hernias that persist beyond age 5 or measure more than 1.5 cm in diameter may require surgical repair. This activity focuses exclusively on umbilical hernias in adults. Please refer to StatPearls' companion resource, "Pediatric Umbilical Hernia," for the evaluation and management of umbilical hernias in children.
The European and American Hernia Societies classify adult umbilical hernias by size: small (<1 cm), medium (1–4 cm), and large (>4 cm) in diameter.[4] The hernia sac typically contains preperitoneal fat or omentum but may also include a portion of the small intestine or, less commonly, the colon.[5][6]
Many individuals are diagnosed with an umbilical hernia during routine physical examinations. If the hernia is asymptomatic, expectant management is often preferred over surgical repair. However, 65% of adult patients with an umbilical hernia eventually require surgery, with 3% to 5% of these cases needing emergency intervention.[5] Individuals with asymptomatic hernias should be counseled on the signs and symptoms of incarceration and strangulation and advised on safe lifting techniques.
Surgical repair of an umbilical hernia is indicated in cases of pain, functional impairment, or hernia enlargement. The choice of surgical approach depends on the size of the hernia and patient-specific factors, including comorbidities, body mass index, and the presence of other abdominal wall hernias. Elective repairs may be performed under local anesthesia with sedation or general anesthesia, while urgent surgery typically requires general anesthesia.
Etiology
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Etiology
Approximately 90% of adult umbilical hernias are acquired.[1] Umbilical hernias are more common in individuals with obesity, metabolic syndrome, ascites, or a history of multiple pregnancies.[3][7] Certain configurations of the umbilical ring can also influence the formation of an umbilical hernia.[8] Chronic or repetitive increases in intra-abdominal pressure elevate the risk of developing an umbilical hernia, and there may be an association between the use of umbilical-site laparoscopic trocars and hernia occurrence. Other predisposing factors for adult umbilical hernias include connective tissue disorders, ethnic background, Beckwith-Wiedemann syndrome, Trisomy 21, and poor nutrition.[7][9][10][11][12]
Epidemiology
The overall incidence of umbilical hernias in adults ranges from 23% to 50%. The prevalence peaks between the ages of 31 and 40 in women and between 61 and 70 in men. Umbilical hernias are three times more common in women, largely due to the effects of pregnancy, childbirth, and a higher prevalence of obesity. However, despite the higher incidence in women, 70% of surgical repairs are performed on men.[13][14][3] Approximately 175,000 umbilical hernia repairs are performed annually in the United States, with an estimated 20 million performed worldwide.[15]
Pathophysiology
Stretching of the abdominal musculature and excess adiposity can separate muscle fibers and weaken the aponeuroses, thereby facilitating the development of umbilical hernias.[3][7] Umbilical hernias commonly occur at sites of fascial weakness, such as the thinned linea alba adjacent to the umbilicus or where the umbilical vessels—particularly the umbilical vein—penetrate the abdominal wall.[7][5][16] Patients with umbilical hernias often lack an intact umbilical fascia, and the round ligament of the liver may be abnormally attached to the lower margin of the umbilical ring.[8] Additional contributing factors include conditions that chronically increase intra-abdominal pressure, such as ascites, chronic constipation, and heavy lifting. Up to 20% of patients with cirrhotic ascites develop an umbilical hernia.
The diameter of the hernia defect’s neck may be narrow relative to the size of the hernia sac, with a lifetime risk of incarceration and strangulation between 1% and 3%.[5] During the pathophysiological progression to strangulation, venous drainage is compromised first, followed by arterial inflow, resulting in infarction of the omentum and bowel.
History and Physical
Adult umbilical hernias are common and often asymptomatic, especially when measuring 1 cm or less. Many umbilical hernias are discovered incidentally during routine physical examinations or abdominal imaging performed for unrelated reasons. Patients may notice a bulge during activities that increase intra-abdominal pressure, such as exercise or changes in posture. Men are more likely to present with painful hernias that limit activity, whereas women tend to have larger, often asymptomatic hernias.[1][4] Up to 90% of pregnant women may develop an umbilical hernia; however, treatment is typically unnecessary unless the hernia becomes symptomatic or incarcerated.[17] Pain is the most common complaint among patients with symptomatic umbilical hernias, reported by 44%. Patients may also experience activity limitations due to discomfort or episodes of nausea and vomiting associated with an intermittent bulge.[18]
Whenever possible, patients with a suspected umbilical hernia should be examined in the supine position. In asymptomatic individuals, the hernia can often be elicited with a Valsalva maneuver and is typically reducible. The fascial edges may be palpable, allowing for estimation of the size of the hernia defect. Any additional abdominal wall defects or signs of systemic disease should also be documented.[17] Large umbilical hernias may become nonreducible due to loss of domain.[19]
Patients with symptomatic hernias often present with an apparent protrusion at the umbilicus. When the hernia is incarcerated or strangulated, the bulge becomes irreducible, tender, and often discolored. These patients may appear ill, exhibiting symptoms such as active emesis, tachycardia, and hypotension. Many patients have a history of intermittent pain and hernia protrusion that resolved spontaneously.[20]
Evaluation
The evaluation of a patient with a presumptive umbilical hernia is predominantly clinical. The physical examination should start with a careful inspection of the anterior abdominal wall. Skin changes such as discoloration, ulceration, or thickening may indicate strangulation.[21]
Patients presenting with an incarcerated hernia should undergo a manual reduction attempt via gentle and steady pressure. If the reduction is successful and the patient remains stable, they may be discharged with a referral for elective surgery. However, if the hernia is nonreducible or there is concern for compromised intra-abdominal contents, urgent surgical consultation is necessary.
Imaging is recommended for patients with suspected umbilical hernias when physical examination findings are inconclusive. Ultrasonography is an efficient and cost-effective tool; in one study, it identified umbilical hernias in approximately 25% of the adult population.[13] However, its effectiveness is limited in patients with large hernias or significant obesity, and it is highly dependent on the operator. Computed tomography (CT) offers more detailed visualization, allowing confirmation of one or more hernias, delineation of their borders and contents, and identification of any additional intra-abdominal pathology.[22]
Magnetic resonance imaging (MRI) has a sensitivity of 92% and a specificity of 95% for diagnosing abdominal wall hernias, making it a useful option when ultrasound and CT findings are inconclusive.[23] However, MRI exams take longer to perform, may be unavailable in emergency or smaller facilities, and are less cost-effective than other imaging modalities.
Patients with reducible umbilical hernias who appear well typically do not require laboratory testing. However, patients who appear ill or require surgical intervention for incarcerated or strangulated hernias should, at minimum, be evaluated for leukocytosis with a complete blood count.
Treatment / Management
Nonoperative management may be considered for asymptomatic patients with umbilical hernias, as the annual risk of strangulation in these cases is less than 1%.[24] When opting for nonoperative management, comorbidities such as obesity or ascites—which can complicate emergency surgery—should be carefully evaluated. Hernias that are symptomatic or increasing in size should undergo surgical repair.[4][21][25]
Relative contraindications to umbilical hernia repair include Child-Pugh class B and C cirrhosis with uncontrolled ascites, active infection, anticoagulation, and coagulopathy. However, several studies have demonstrated that elective repair can be safely performed in most cirrhotic patients—including those with ascites—when using minimally invasive techniques and thorough preoperative planning. The reported mortality rate for umbilical hernia repair in patients with uncontrolled ascites is approximately 2%, and the recurrence rate remains high.[26][27][28][29] (B2)
Preoperative planning helps reduce hernia recurrence as well as overall morbidity and mortality. Although research specifically focused on umbilical hernia repair is limited, studies across various surgical procedures have shown that abstaining from smoking for at least 4 weeks before surgery and reducing body mass index to below 30 kg/m2 can significantly lower the risk of surgical site infections and other complications.[4]
Surgical Repair
Umbilical hernias measuring 2 cm or less in diameter are typically suitable for primary repair. During an open primary repair, a curvilinear incision is made just below the umbilicus. The hernia sac is carefully dissected down to the fascial layer, and the surrounding fascia is circumferentially cleared. The sac may be excised or inverted, and the fascial defect is closed primarily using nonabsorbable sutures. The umbilical fascia is then anchored to the underlying tissue to restore the native umbilical contour, and the subcutaneous tissue is closed in multiple layers.[30]
For umbilical hernias measuring 2 cm or more in diameter, herniorrhaphy with mesh is preferred. Primary suture repair without mesh for hernias of this size is associated with a recurrence rate of 10% to 14%.[4][31][32][33][34] Mesh can be placed either beneath the fascia (underlay) or over it (onlay) and should be securely sutured in place to ensure stability. While a 3-cm overlap is acceptable, a 5-cm overlap is more commonly used to reduce recurrence.[35] Onlay mesh placement is technically simpler but is associated with higher rates of seromas, hematomas, and surgical site infections. In contrast, preperitoneal or underlay mesh placement is associated with lower recurrence rates and fewer wound complications.[5] Fascial closure is recommended either before onlay mesh placement or after preperitoneal mesh placement.[32] The overall recurrence rate for umbilical hernias after mesh repair ranges from 0% to 3%.[33][34][36] Polypropylene mesh can cause intraperitoneal adhesions and should therefore be placed in a preperitoneal position.[4][37] In cases involving exposed intra-abdominal contents or contaminated fields, coated or biodegradable mesh may be appropriate alternatives.[5][38](A1)
Laparoscopic umbilical hernia repair is advantageous for patients with morbid obesity, multiple abdominal wall defects, concurrent intra-abdominal pathology, or recurrent hernias; however, it does not permit multilayered subcutaneous repair. In some patients, the physiological effects of laparoscopy may pose unacceptable risks. Trocar site hernias remain a theoretical concern, particularly in individuals with attenuated tissue.[39] During laparoscopic umbilical hernia repair, ports should be placed lateral to the defect, with at least one port large enough to allow mesh insertion.[40] The hernia sac is carefully dissected free from the abdominal wall using a combination of cautery and gentle traction. After reduction, the contents of the hernia sac should be visually inspected. The hernia defect is measured laparoscopically using umbilical tape, and the mesh is secured to the abdominal wall with tacks or sutures at multiple points, ensuring several centimeters of overlap beyond the fascial edge. Mesh placement should be inspected during the release of the distending gas. Robotic hernia repair is an option at some facilities and may facilitate easier mesh fixation to the anterior abdominal wall. However, this approach often requires longer operative time and may be less cost-effective.[41] (B2)
Emergent herniorrhaphy is indicated in cases of incarceration or strangulation. These procedures are often more technically challenging and may necessitate resection of nonviable intra-abdominal contents, such as bowel or omentum. Whenever feasible, mesh closure should be used during emergent repairs.[42]
Differential Diagnosis
Several conditions can present as a periumbilical mass. Subcutaneous lesions are often freely mobile within the subcutaneous tissue, and no fascial defect is typically palpable. Pathologies such as a urachal remnant or abscess may present with drainage. Masses due to lymphoma or metastatic disease may appear irregular, exhibit necrosis, and be fixed to surrounding structures.
Alternative diagnoses to umbilical hernia include, but are not limited to:
- Abscess
- Desmoid tumor (Please see StatPearls' companion resource, "Desmoid Tumor," for more information.)
- Granuloma
- Hemangioma
- Hematoma
- Keloid
- Lipoma
- Lymphoma
- Primary hydatid cyst of the umbilicus [43]
- Urachal anomaly or tumor
- Umbilical endometriosis [44]
- Umbilical sebaceous cyst [45]
- Metastatic disease
Prognosis
Several factors influence the outcome of umbilical hernia repair, including defect size, tobacco use, and comorbid conditions. An American Society of Anesthesiologists (ASA) score of 3 or higher, failure to use mesh in hernias larger than 2 cm, history of tobacco use, liver failure, and diabetes are all associated with poorer surgical outcomes.[46] The risk of surgical complications increases by 1% for every 1 millimeter increase in the size of the fascial defect.[47] In patients with liver failure, the Model for End-Stage Liver Disease (MELD) score helps estimate risk; postoperative complications rise by 13.8% for each 1-point increase in the MELD score above the mean level of 8.5.[48][47]
Complications
Complications are more prevalent following open repairs without mesh placement and include surgical site infections, hematomas, and early recurrence.[49][50][51][52] Independent risk factors for recurrence include wound infection, diabetes, tobacco use, morbid obesity, and uncontrolled ascites.[2][53][54]
Complications related to mesh placement include seromas, adhesions, bowel injury, foreign body reactions, and mesh infection or migration. In some cases, mesh removal may be necessary to manage these complications. Antibioma formation is a rare complication characterized by an undrained abscess encased in a fibrous shell, resulting from antimicrobial treatment without surgical drainage.[55]
Postoperative and Rehabilitation Care
Simple and non-emergent umbilical hernia repairs are typically performed as same-day procedures. Postoperative care focuses on pain management, early ambulation, wound protection, and pulmonary hygiene. While lifting is restricted for several weeks, light activity is encouraged. Stool softeners may be prescribed to prevent constipation, especially when patients are taking opioid pain medications. Patients should avoid swimming or submerging the wound for 2 weeks and follow the wound care instructions specific to the dressing.
Deterrence and Patient Education
Umbilical hernias are frequently encountered in routine clinical practice. Primary care providers and emergency department clinicians are often the first to evaluate patients with both symptomatic and asymptomatic presentations. An interprofessional team approach is essential to ensure that patients receive appropriate education, management, and timely referrals when needed.
Pearls and Other Issues
Umbilical hernias are commonly repaired using synthetic, nonabsorbable mesh materials, such as polypropylene, polyethylene terephthalate polyester, or expanded polytetrafluoroethylene.[56] However, the choice of mesh depends on the anatomical placement and the presence of contamination or infection. Synthetic, slowly absorbable mesh is used to minimize postoperative adhesions and is preferred in infected or contaminated fields where nonabsorbable materials are contraindicated. Examples include, but are not limited to, polyglycolic acid with trimethylene carbonate, polyglactin, and poly-4-hydroxybutyrate.[57] These mesh materials typically degrade within 1 to 3 months and are associated with higher rates of recurrence.[29]
Biologic mesh is used for repair in classes III and IV contaminated surgical fields. These meshes are derived from human cadaveric skin or animal sources such as skin, pericardium, or intestinal submucosa. The cellular components are removed from the biologic mesh, leaving a collagen matrix that promotes the formation of new collagen and fibrous tissue while minimizing scarring and the risk of infection.[58][57]
Enhancing Healthcare Team Outcomes
Effective management of umbilical hernias requires a coordinated interprofessional healthcare team, including emergency department personnel, primary care providers, surgeons, and nurses, to help prevent complications and reduce morbidity associated with untreated umbilical hernias. Identifying and optimizing patients with elevated surgical risk factors is essential before surgery. Surgical risk evaluation should involve clear communication and collaboration among all healthcare team members, including primary care physicians, internal medicine specialists, gastroenterologists, general surgeons, and anesthesiologists. Postoperative education on diet, glucose control, and smoking cessation is also critical to reducing the risk of recurrence. Although most patients experience favorable outcomes following umbilical hernia repair, recurrence still occurs in approximately 1% to 3% of cases, even when mesh is used for repair.[59][60]
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