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Adult umbilical hernia

True umbilical hernia:

The protrusion is through the umbilical scar, everting the umbilicus whose attenuated fibres are at the apex of the hernial sac
The cause is often secondary to an increase in the volume of contents of the abdominal cavity (e.g. obesity, ascites or large benign/malignant intra-abdominal tumours)

Para-umbilical hernia:

The weakest area of the scar is at the superior aspect between the umbilical vein and the upper margin of the umbilical ring
It is at this point that a para-umbilical hernia develops
The emerging sac displaces the umbilical scar which lies below and slightly to one side
More common than true umbilical hernias
Typically found in the obese middle-aged patient
Women are 5x more likely than men to suffer from a para-umbilical hernia
The neck of the hernia is often narrow. In consequence, tissues that enter have great difficulty leaving:

Adhesions form
Hernia becomes irreducible
The sac progressively acquires more contents and may become very large
The contents are usually omentum, often with small bowel or transverse colon

Unsurprisingly, these hernias are at great risk of strangulation

Clinical features – true umbilical hernia:

Symptoms:

Are often of an underlying cause (e.g. ascites) or there may merely be gross obesity
Very rarely, the patient will give a history which dates back to infancy or childhood

Signs:

Ascites may be obvious
The umbilicus is attenuated and sometimes paper-thin
Evidence of underlying malignancy should be sought (both in the abdomen as a whole and at the umbilical opening where a nodule or nodules may be palpable)

Clinical features – para-umbilical hernia:

Symptoms:

There is local pain and a swelling at the navel
Non-specific GI symptoms are common
Features of recurrent intestinal obstruction may have occurred

Signs:

The umbilicus assumes a crescent shape
Inspection and palpation reveal a swelling just above the umbilicus whose centre (in contrast to a true umbilical hernia) is not attached to the apex of the protrusion
However, in grossly obese patients, the swelling may not be obvious to the naked eye and moreover is barely palpable
In others, the hernia may be enormous
Usually it is (at least in part) reducible and there is a cough impulse

Management:

True umbilical hernia:

Any underlying cause should be sought and dealt with
In the rare event that nothing is found and the hernia is causing symptoms, it is treated as a para-umbilical hernia

Para-umbilical hernia:

Symptomatic hernias require treatment
There is a high risk of strangulation and repair should be advised, even in the absence of symptoms
The usual procedure is to mobilise the sac and its contents, return the latter to the abdomen, close the neck and repair the abdominal wall by overlapping its layers

Strangulated umbilical hernia:

The patient with severe abdominal pain and vomiting and a soft non-tender umbilical hernia is a diagnostic trap
The loculated nature of the hernia allows a strangulated portion of bowel (often of the Richter’s type) to go unnoticed clinically
In other instances, the local features of strangulation may be obvious
The operative approach is as for an elective case, and the strangulating contents are dealt with according to their state


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	Adult umbilical hernia True umbilical hernia: The protrusion is through the umbilical scar, everting the umbilicus whose attenuated fibres are at the apex of the hernial sac The cause is often secondary to an increase in the volume of contents of the abdominal cavity (e.g. obesity, ascites or large benign/malignant intra-abdominal tumours) Para-umbilical hernia: The weakest area of the scar is at the superior aspect between the umbilical vein and the upper margin of the umbilical ring It is at this point that a para-umbilical hernia develops The emerging sac displaces the umbilical scar which lies below and slightly to one side More common than true umbilical hernias Typically found in the obese middle-aged patient Women are 5x more likely than men to suffer from a para-umbilical hernia The neck of the hernia is often narrow. In consequence, tissues that enter have great difficulty leaving: Adhesions form Hernia becomes irreducible The sac progressively acquires more contents and may become very large The contents are usually omentum, often with small bowel or transverse colon Unsurprisingly, these hernias are at great risk of strangulation Clinical features – true umbilical hernia: Symptoms: Are often of an underlying cause (e.g. ascites) or there may merely be gross obesity Very rarely, the patient will give a history which dates back to infancy or childhood Signs: Ascites may be obvious The umbilicus is attenuated and sometimes paper-thin Evidence of underlying malignancy should be sought (both in the abdomen as a whole and at the umbilical opening where a nodule or nodules may be palpable) Clinical features – para-umbilical hernia: Symptoms: There is local pain and a swelling at the navel Non-specific GI symptoms are common Features of recurrent intestinal obstruction may have occurred Signs: The umbilicus assumes a crescent shape Inspection and palpation reveal a swelling just above the umbilicus whose centre (in contrast to a true umbilical hernia) is not attached to the apex of the protrusion However, in grossly obese patients, the swelling may not be obvious to the naked eye and moreover is barely palpable In others, the hernia may be enormous Usually it is (at least in part) reducible and there is a cough impulse Management: True umbilical hernia: Any underlying cause should be sought and dealt with In the rare event that nothing is found and the hernia is causing symptoms, it is treated as a para-umbilical hernia Para-umbilical hernia: Symptomatic hernias require treatment There is a high risk of strangulation and repair should be advised, even in the absence of symptoms The usual procedure is to mobilise the sac and its contents, return the latter to the abdomen, close the neck and repair the abdominal wall by overlapping its layers Strangulated umbilical hernia: The patient with severe abdominal pain and vomiting and a soft non-tender umbilical hernia is a diagnostic trap The loculated nature of the hernia allows a strangulated portion of bowel (often of the Richter’s type) to go unnoticed clinically In other instances, the local features of strangulation may be obvious The operative approach is as for an elective case, and the strangulating contents are dealt with according to their state
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