Overview
Definition:
Laparoscopic preperitoneal umbilical hernia repair is a minimally invasive surgical technique to correct an umbilical hernia by placing a mesh prosthesis in the preperitoneal space
This approach aims to provide tension-free repair and reduce recurrence rates compared to open techniques, especially for larger or recurrent hernias.
Epidemiology:
Umbilical hernias are common, particularly in infants and in obese adults or multiparous women
Adult umbilical hernias are more often symptomatic and may require surgical repair
Laparoscopic repair is generally favored for hernias larger than 2-3 cm or in cases of recurrent hernias.
Clinical Significance:
While small umbilical hernias may be asymptomatic, larger ones can cause pain, discomfort, and cosmetic concerns
The primary surgical goal is to prevent incarceration and strangulation, which are serious complications
Laparoscopic preperitoneal repair offers advantages like reduced postoperative pain, faster recovery, and lower recurrence rates.
Indications
Absolute Indications:
Symptomatic umbilical hernia
Incarcerated or strangulated umbilical hernia
Large or recurrent umbilical hernia.
Relative Indications:
Hernia > 2-3 cm in diameter
Wunsch for faster recovery and reduced pain
Previous open hernia repair with recurrence
Association with other laparoscopic procedures.
Contraindications:
Uncorrected coagulopathy
Severe cardiopulmonary disease precluding laparoscopy
Extensive intra-abdominal adhesions preventing safe port placement
Active infection at the surgical site.
Diagnostic Approach
History Taking:
Detailed history should include duration and nature of symptoms (pain, bulge, discomfort), onset of bulge, presence of complications (incarceration, strangulation), previous hernia repairs, comorbid conditions (obesity, COPD, ascites), and occupation.
Physical Examination:
Examination should focus on the umbilicus, palpating for a defect, noting its size, reducibility, and any signs of incarceration (tenderness, erythema)
Palpate for expansibility with cough or Valsalva maneuver
Assess for other abdominal wall defects.
Investigations:
Generally, no specific laboratory investigations are required for uncomplicated umbilical hernias
Imaging, such as ultrasound or CT scan, may be considered to assess hernia contents, rule out other abdominal pathology, or evaluate large or recurrent hernias, especially if incarceration is suspected.
Differential Diagnosis:
Other anterior abdominal wall masses such as lipomas, desmoid tumors, endometriomas, or ventral hernias at other locations
Umbilical abnormalities like omphalitis or urachal cysts should also be considered.
Surgical Management
Preoperative Preparation:
Informed consent, ABO group and crossmatch (if large or recurrent), NPO status, prophylactic antibiotics (e.g., cefazolin), bowel preparation if indicated, and management of comorbidities like ascites or COPD
Anesthesia considerations for laparoscopic surgery are crucial.
Laparoscopic Technique:
Typically performed under general anesthesia
Three ports are usually inserted: one umbilical (optical trocar), one supraumbilical midline, and one periumbilical or suprapubic
The preperitoneal space is dissected bluntly and with the aid of a balloon dissector or by direct visualization
The hernia sac is reduced, and a large pore polypropylene or composite mesh is placed to cover the defect with at least 3-5 cm overlap
The mesh is secured with tackers or fibrin glue
The peritoneal flap is then reconstituted
Ports are removed, and fascia at the umbilical port site is closed if >10mm.
Mesh Choice:
Synthetic, large-pore polypropylene mesh is commonly used for its cost-effectiveness and rigidity
Composite meshes (e.g., dual mesh with ePTFE layer) may be preferred in cases with bowel contact to reduce adhesion formation, though controversy exists
The mesh should be appropriately sized to ensure adequate overlap.
Intraoperative Considerations:
Careful dissection to avoid injury to surrounding structures (epigastric vessels, bladder)
Adequate mesh coverage is paramount
Management of unexpected findings like adhesions or incarcerated bowel
Secure fixation of the mesh to prevent migration.
Postoperative Care
Pain Management:
Multimodal analgesia including IV/oral opioids, NSAIDs, and paracetamol
Local anesthetic infiltration at port sites can also be beneficial.
Activity Restrictions:
Encourage early ambulation
Advise to avoid heavy lifting and strenuous activities for 4-6 weeks, depending on the extent of the repair and mesh fixation
Gradual return to normal activities.
Diet:
Diet as tolerated, usually starting with clear liquids and advancing to a regular diet
Adequate hydration is important.
Discharge Criteria:
Patient is hemodynamically stable, able to tolerate oral intake, ambulate independently, and manage pain with oral analgesics
No signs of surgical site infection or other complications.
Complications
Early Complications:
Bleeding (port sites, preperitoneal space), port site infection, seroma formation, urinary retention, nausea and vomiting, ileus, mesh infection, bowel injury, vascular injury
Incarceration can occur if mesh dislodged.
Late Complications:
Chronic groin pain (if mesh extends laterally), mesh migration, mesh rejection, recurrence of hernia, entero-cutaneous fistula, abdominal wall rigidity, and cosmetic concerns related to port sites.
Prevention Strategies:
Meticulous surgical technique, adequate mesh overlap and fixation, use of composite mesh if indicated, proper port site closure, prophylactic antibiotics, and patient education on postoperative care and activity
Early recognition and management of complications are key.
Prognosis
Factors Affecting Prognosis:
Hernia size, patient's comorbid conditions (obesity, ascites, COPD), surgeon's experience, and technique used
Laparoscopic preperitoneal repair generally has lower recurrence rates and faster recovery than open repairs for larger hernias.
Outcomes:
Excellent outcomes are expected with appropriate patient selection and surgical technique
Recurrence rates for laparoscopic preperitoneal repair are typically low (1-3%)
Most patients experience significant pain relief and return to normal activities within weeks.
Follow Up:
Routine follow-up is typically at 2-4 weeks postoperatively to assess wound healing and patient recovery
Long-term follow-up is generally not required unless symptoms of recurrence or complications arise.
Key Points
Exam Focus:
The preperitoneal space is the key anatomical location for mesh placement
Indications for laparoscopic vs
open repair, mesh type and fixation methods, and management of complications are high-yield
Differentiate between direct and indirect inguinal hernia repair principles when comparing to preperitoneal umbilical hernia repair.
Clinical Pearls:
Adequate mesh overlap (3-5 cm) is critical for preventing recurrence
Secure fixation of the mesh, especially in patients with increased intra-abdominal pressure (ascites, obesity), is important
Consider composite mesh in cases of potential bowel contact to minimize adhesion formation.
Common Mistakes:
Insufficient mesh overlap, inadequate fixation of the mesh, injury to intra-abdominal structures during dissection, failure to close fascial defects >10mm at port sites, and neglecting management of predisposing factors for hernia recurrence.