Umbilical Hernia
“Omphalos was the center
stone in the Temple of Apollo at Delphi. The term was modified to name
the center point of a newborn infant, from which the term umbilical cord
emanated. In Latin, umbodenoted
the ornamental stud at the center of a shield, from which the term for
the umbilicus area was derived. The Anglo-Saxon, nafe,meaning
hub of a wheel, was converted to navel.”
An
umbilical hernia is a protrusion around the navel (umbilicus) that may
contain part of the intestine and/or the fatty membrane found inside the
abdomen (omentum). Hernias often protrude through areas of muscle
weakness such as around the navel. This is the area where blood vessels
from the mother supply the developing fetus with nutrients through the
umbilical cord. After birth, the umbilical cord is severed, leaving the
bellybutton as its lifetime reminder. Umbilical hernias in babies
(congenital) usually resolve spontaneously by ages 1 to 2.
An adult umbilical hernia (acquired) occurs when the connective tissue
(fascia) of the abdominal wall becomes weak around the area of the
navel. The weakening occurs over a period of years until eventually the
abdominal contents, encased in a sac, protrude through the abdominal
wall, and a bulge forms around the umbilicus. A newly formed umbilical
hernia is usually small and contains only the fatty omentum. However, as
more of the abdominal contents (transverse colon, small intestine,
greater omentum) push into the sac, the umbilical hernia can grow in
size.
A reducible hernia can easily be returned to the abdominal cavity. When
the hernia can no longer be reduced, it is called “incarcerated”; these
hernias have a high risk for losing the blood supply that keeps the
tissue alive (strangulation). For that reason, repair of an umbilical
hernia is recommended as soon as possible after it is discovered.
Risk: Umbilical
hernias are most common in infants. In an adult, any condition that
causes buildup of pressure against the abdominal wall may contribute to
umbilical hernia formation. This includes extreme obesity,
heavy lifting, accumulation of abdominal fluids (ascites),
coughing, straining with urination or defecation, chronic
obstructive pulmonary disease (COPD),
or even multiple
pregnancies.
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History: Individuals
with umbilical hernia report a central mid-abdominal bulge that
may expand when the individual coughs or strains the abdomen.
Pain in the area of the hernia is not uncommon with coughing or
straining. A careful review of symptoms should seek other
medical conditions that may be associated with increased
intra-abdominal pressure.
Physical exam: The
presence of an umbilical hernia is identified by a bulge or a
palpable defect at the level of the umbilicus. There may be
discoloration of the skin overlying the hernia.
Tests: The
diagnosis is made based on the history and physical exam, and
tests are usually not needed. However, the physician may use CT imaging, ultrasound,
or x-ray aided
by contrast material to visualize the herniated contents. |
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A small umbilical hernia that is easily pushed back into the
abdomen (reduced) in an adult of normal weight may be watched
closely, particularly if the individual is a poor surgical risk
or elderly. Repair of umbilical hernias is recommended in all
other adults. Large umbilical hernias are often treated with the
Mayo procedure, which uses an implanted polyurethane mesh to
provide support and hold the herniated sac inside the abdomen. |
Umbilical
hernia repair in the adult is indicated for incarceration, a small neck
in relation to the size of the hernia, ascites, chromatic skin change,
or rupture. The approach to management of an umbilical hernia in a child
relates to the natural history of umbilical hernias and their importance
in adulthood. Most umbilical hernias close spontaneously in children
during the preschool-aged period. Therefore, repair of an umbilical
hernia is not indicated in children younger than 5 years unless the
child has a large proboscoid hernia with thin, hyperpigmented skin or is
undergoing an operation for other reasons or if the hernia causes
familial or social problems. The size of the fascial defect rather than
the size of the external protrusion predicts potential for spontaneous
closure. Walker demonstrated that fascial rings measuring less than 1 cm
in diameter usually close, while rings larger than 2 cm seldom close
spontaneously. Therefore, many pediatric surgeons will repair umbilical
hernias with large fascial defects (>2.5 cm) earlier than the smaller
counterparts.
The umbilicus is
a natural hernial opening in the abdominal wall. It can develop a hernia
at any age. In children, umbilical hernias are the third most common
disorder after hydroceles and inguinal hernias. The hernia is present in
about one to every five birth, the incidence in black infants being up
to eight times higher than in white infants. Predisposing factors are a
low birth weight and prematurity. A familial predisposition appears in 9
to 12%, but no genetic pattern of inheritance has been identified. In
children most umbilical hernias are asymptomatic beside the obvious
cosmetic defect. Infantile umbilical hernias rarely enlarge over time
and will disappear in 90% of children by the age of 2 years. The
spontaneous resolution appears to be directly influenced by the size of
the umbilical ring. Defects with an umbilical ring larger than 1.5 cm
are unlikely to resolve spontaneously. Complications such as
strangulation of omentum or intestine and evisceration are seldom and
occur approximately in 4% of cases. Indication for surgical repair are
occurrence of complaints and complications or a persistence of the
hernia beyond the age of 2 years. If the fascial defect is less then 1.5
cm in diameter or is asymptomatic a herniorrhaphy may be delayed until
the child is 5 years old.
Umbilical hernias
in adults are indirect herniations through the umbilical canal, and
there have a high tendency to incarce-rate and strangulate and do not
resolve spontaneously. Most of these patients are women.
Because the risk
of incarceration rises to 30%, operation is advised. Management includes
operative therapy with repositioning of the hernial content and
continuous suture, using local anesthesia in elective repair in adults
or general anesthesia in children or in an emergency situation.
An exception are
acquired umbilical hernias, that may occur in patients with acute
abdominal distension. Reasons for an acute elevation of the
intra-abdominal pressure include ascites from cirrhosis, congestive
heart failure or nephrosis. Patients undergoing peritoneal dialysis also
have a high incidence of these hernias. As the majority of these
patients have serious underlying problems, a surgical repair is not
indicated unless complications, such as incarceration or spontaneous
rupture, occur.
Mayo’s procedure for
Umbilical hernia
William Mayo used first time an overlapping procedure for umbilical
hernia repair in 1895.mayo advocated his technique of overalapping
theadjucent tisues in vertical plane.
Indications of Umbilical hernia surgery
1. Discomfort and pain at the umbilicus
2. Protrusion at umbilicus
3. Association with inguinal hernia
4. Strangulation
5. Obstruction
6. Incarceration
7. Damaged and ulcerated overlying skin
Absolute contraindications for surgery:-
· Obesity
· Ascites
· Chronic cardiovascular of thoracic disease
The surgery;-
1.The Open Technique of Repair
A.
Position of patient:-
Supine position on operating table and draping is done to adequately
expose the umbilicus and surrounding area in case if incision has to
extended .
B. Incision:-Incision is planned according to size of hernia. A circumlinear incision is employed for hernias around the size of 2-3 cms. For larger size hernias than this ; the incision needs to be modified as the extension of the circumlinear incision on the lateral boundary of umbilicus. The incision will cover all area around umbilicus and esection of umbilicus can be done by prior consent from the patient with this type of incision.Thelateral boundaries of the incision should be decided by the surgeon according to size of hernia.
C. Progression of incision:- removal of redundant fat and skin is done to deepen the incision. The muscular aponeurosis is exposed by dissection. With the help of electrocautery the incision is deepened not to harm the blood supply of the skin at right angle to fibres of aponeurosis.
D. Neck of sac:- “ Trick of the trade here is to identify the neck of the sac first and incise it”Upon dissection to the level of muscular aponeurosis the sac is freed of the fat nd tissue to determine its margins. The aponeurosis is also cleared off the tissue and margins are clearcut visualized. Then the sac is opened at neck and the contents are visualized. Adhesions are frequently present in the sac with the visceral organs likeomentum and intestines. Adhesions should be dissected and freed by careful ligation.The important thing to remember here is the partially ischaemic omentum should not be left in peritoneal cavity; but excised. Bowel if present in the sac should be carefully preserved intact otherwise post operative fistula will follow. Return of organs in sac to perineal cavity should be done after satisfying haemostasis. While dissecting the sac it should be taken affirmatively that the adhesions are always present more at the neck than fundus and one should insert the finger into the sac at the neck incision and start separating the adhesions and not at fundus.
E. Sac closure:- Closure of the sac is commenced after the above mentioned procedure. Sac should be closed with absorbable sutures and returned to abdomen after haemostasis.
F. Enlarging the aponeurosis:- The aponeurotic defect is enlarged 1-3 cms on either side in a transverse line to facilitate the repair and for the insertion of prosthetic mesh. This does not apply to PHS ( Prolene Hernia System).
G.
Defect Repair:- a)
pure tissue repair:- mayo’s technique is employed to repair the defect
by pure tissue repair method. This involves holding of the structures
like margins of the opening , aponeurosis, posterior rectus sheath and
peritoneum in haemostats. The deep sutures are placed with round body
needle of the non-absorbable sutures like polypropylene. The suture
enters the upper flap from without, between 2-3 cms from its margin .
The needle is then grasped on the deep surface of the upper flap ,
passed across the defect
and then from the outside to the lower flap . Then the needle is pulled
back through the lower flap, across the defect and through the deep
surface of the upper flap. The suture thus placed is held in a clip .
many more such sutures are inserted and held untied until all are in
place. Once all have been
placed then tied. After the sutures have all been placed the flaps are
brought together , the upper being railroaded down the sutures until it
lies overlapping the lower flap. The sutures are now tied , fixing the
tissues firmly together. A
triple layer , double throw
knot is used. wWhen all the knots are complete the ends are cut. The
edge of the upper flap is sutured to the anterior surface of the lower
flap using the polypropylene sutures after placement of the suction
drain in the between the two flaps.
Theumbilicus is reposited and sutured to muscular aponeurosis
with absorbable sutures . Underlying fascia and fat layer are sutured in
separate layers with absorbable sutures. Skin is closed with sutures or
staples.B) Prosthetic repair of the defect;-Flat Polypropylene or other
biomaterial mesh is used to give support to the umbilicus after the
repir of the defect to prevent recurrence. As mayo’s repair has high
failue rates this is now widely used .
The mesh is placed in onlay and inlay fashion. This involves the
placement of the mesh above the repair of the defect which is
called an onlay mesh repair. The onlay mesh of appropriate size
is placed over the repaired defect and sutured to the aponeurosis with
continuous non absorbable sutures along the circumference of the mesh .
The mesh can be cut to made fit in the defective area
at least covering 3-4 cms around the defect.
Rest of the procedure is followed to close the incision. The
inlay mesh is used on the principle of PASCAL. The inlay mesh serves
more for the support of the abdominal contents. This mesh is put into
the defect behind the posterior aponeurotic sheath by clearing
the space between the peritoneum and the posterior rectus sheath. The
mesh is placed there and held in place with four main principle sutures
with non absorbable material from inside out fashion. The knots are
securely and firmly tightened and it should be tension free. Then the
defect is closed in transverse fashion with running continuous suture of
polypropylene. Rest of the procedure follows. This inlay mesh is very
useful for preventing the recurrence in most of the patients.
H. Repair with Prolene Hernia System ( PHS):- This PHS is revolutionizing the Umbilical hernia surgery in today’s world. There are now scientific evidences regarding the use of PHS in this surgery without recurrences. This system prevents recurrence in most of the cases and gaining popularity very fast.
Incision:- For small to medium sizes hernias incision can be placed circumlinear inside the umbilicus. Like the incision for laparoscopic port insertion. Incision is deepened till surgeon faces the aponeurosis.
Sac:- the sac is dealt with as described in previous topic. Closure of the sac is done and returned to the abdomen.
Repair with PHS;- At the time of dissection the margins of the defect are cleared off any tissue by surgeon. Then the finger or a rolled gauze piece is inserted into the pre-peritoneal space to create the adequate space for placement of the PHS device. The size of the device is chosen according to the defect size. The blunt and blind dissection by finger or gauze piece is commenced with a sweeping like action. The preperitoneal space is created on either side of the defect facilitating at least 4-6 cms of free space. Haemostasis is highly important here. The peperitoneal space must be dissected more than that is needed for the plug so that the underlay will lay open and flat. It is best to ensure that THAT PORTION OF THE PRODUCT IS FLAT BECAUSE any wrinkle of any flat mesh can incite the development of adhesions in that area. Once this is placed the overlay will lie over the linea alba and the anterior rectus sheath. The overlay part of PHS can be cut short to cover only defect and the edges of the overlay are sutured to the margins of the defect ;with interrupted non absorbable sutures. Rest of the closure process of the incision can be left to surgeons choice.
PHS
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Laparoscopic Repair
There is no consensus on the best technique for the repair of umbilical
hernia in adults. The role of laparoscopic hernioplasty of umbilical
hernia remains controversial. Laparoscopic onlay patch hernioplasty is a
safe and efficacious technique for the repair of umbilical hernia.
Compared to Mayo repair, the laparoscopic approach confers the
advantages of reduced postoperative pain, shorter hospital stay, and a
diminished morbidity rate.