Overview
Definition:
Open mesh repair of an umbilical hernia is a surgical procedure to correct an outward protrusion of abdominal contents through the umbilical ring, utilizing a synthetic or biological mesh to reinforce the abdominal wall
This technique is commonly employed for larger or recurrent umbilical hernias, or when primary tissue repair is deemed insufficient.
Epidemiology:
Umbilical hernias are common, particularly in infants, but can persist or develop in adults
Adult umbilical hernias occur in approximately 2-5% of the population
Factors such as obesity, multiparity, chronic cough, and ascites increase the risk of development and recurrence, making surgical repair a frequent procedure.
Clinical Significance:
Umbilical hernias can cause discomfort, cosmetic concerns, and in severe cases, lead to complications like incarceration or strangulation, which are surgical emergencies
Open mesh repair offers a durable solution, reducing recurrence rates compared to primary tissue repair, and is crucial knowledge for surgical residents preparing for DNB and NEET SS examinations.
Indications
Indications For Surgery:
Symptomatic hernias (pain, discomfort, interference with daily activities)
Large hernias that are cosmetically unacceptable or pose a risk of complications
Incarcerated or strangulated hernias (emergent indication)
Recurrent umbilical hernias after previous repair
Her-in-hernia defects larger than 2-3 cm in adults.
Contraindications:
Absolute contraindications are rare but include severe comorbidities making anesthesia unsafe, active infection at the surgical site, or inability to adhere to postoperative care
Relative contraindications include extreme obesity, active smoking, and poor nutritional status, which increase complication and recurrence risks and may necessitate preoperative optimization.
Preoperative Assessment:
Thorough patient history including symptom severity, duration, and any previous hernia repairs
Physical examination to assess hernia size, reducibility, and presence of complications
Assessment of comorbidities like obesity, diabetes, cardiovascular, and pulmonary disease
Smoking cessation counseling and optimization of BMI are recommended when possible.
Preoperative Preparation
Patient Counseling:
Informed consent regarding the procedure, potential risks (infection, bleeding, mesh-related issues, recurrence, chronic pain), benefits, and expected recovery
Discussion of anesthesia options (general, spinal).
Anesthesia Considerations:
General anesthesia is typically preferred for open mesh repair to ensure patient comfort and allow for optimal abdominal wall relaxation, facilitating accurate mesh placement
Spinal anesthesia may be considered in select patients.
Surgical Site Preparation:
Prophylactic antibiotics are administered intravenously (e.g., Cefazolin) approximately 30-60 minutes before skin incision to reduce the risk of surgical site infection
The surgical area is prepped and draped in a sterile fashion.
Procedure Steps
Incision And Dissection:
A curvilinear or transverse incision is made around or through the umbilical stalk, extending superiorly or inferiorly as needed to achieve adequate exposure
The dissection proceeds through subcutaneous tissue to expose the fascial defect of the umbilical hernia
The sac contents are reduced back into the peritoneal cavity.
Hernia Sac Management:
The hernia sac is dissected from the surrounding tissues
If the sac is redundant or contains significant omentum, it may be resected or reduced
Care is taken to avoid injury to underlying bowel or other intra-abdominal structures.
Mesh Placement:
A synthetic mesh (e.g., polypropylene, dual-layer composite mesh for intraperitoneal placement) is selected based on defect size and surgeon preference
The mesh is typically cut to size and placed over the fascial defect, ensuring adequate overlap (at least 5 cm beyond the defect edges)
It can be secured with sutures, tacks, or simply held in place by fascial closure and intra-abdominal pressure.
Fascial Closure:
The anterior rectus sheath or abdominal fascia is closed securely with a non-absorbable or long-lasting absorbable suture material, creating a tension-free repair
This closure also helps to fix the mesh in place and obliterate the preperitoneal space.
Wound Closure:
Subcutaneous tissues are approximated, and the skin is closed with sutures or staples
A drain is typically not required unless significant dissection or oozing is anticipated
A sterile dressing is applied.
Postoperative Care
Pain Management:
Postoperative pain is managed with analgesics, often starting with intravenous opioids and transitioning to oral medications
Multimodal analgesia including NSAIDs can be effective.
Activity Restrictions:
Patients are encouraged to mobilize early to prevent DVT and pneumonia
Strenuous activity, heavy lifting (typically >10 lbs or 5 kg), and vigorous exercise are restricted for 4-6 weeks, or as guided by surgeon preference and patient recovery.
Monitoring:
Vital signs are monitored closely
Patients are observed for signs of infection (fever, wound redness, discharge), bleeding (hematoma), urinary retention, and bowel obstruction
Early detection of complications is crucial.
Diet:
A regular diet is usually resumed once bowel sounds return and nausea/vomiting subsides
Adequate hydration is encouraged.
Complications
Early Complications:
Surgical site infection (SSI) which can affect the mesh
Hematoma or seroma formation
Wound dehiscence
Urinary retention
Ileus
Pulmonary complications (atelectasis, pneumonia).
Late Complications:
Chronic pain (mesh-related or incisional)
Mesh infection or extrusion
Seroma formation
Recurrence of the hernia
Bowel obstruction due to adhesions
Mesh migration or shrinkage
Sensitization to mesh material.
Prevention Strategies:
Strict aseptic technique during surgery
Prophylactic antibiotics
Meticulous hemostasis
Appropriate mesh selection and fixation
Adequate fascial closure
Patient counseling on activity restrictions and wound care
Prompt management of any early complications.
Prognosis
Factors Affecting Prognosis:
Size and complexity of the hernia
Presence of comorbidities (obesity, diabetes)
Patient adherence to postoperative instructions
Surgeon's experience
Type of mesh used and fixation method.
Outcomes:
Open mesh repair of umbilical hernias generally has excellent outcomes with low recurrence rates (typically <5% for primary repairs and slightly higher for recurrent hernias)
Most patients experience significant relief from symptoms and a good return to normal activities.
Follow Up:
Follow-up appointments are scheduled typically at 2 weeks postoperatively to assess wound healing and address any concerns, and again at 3-6 months to evaluate for recurrence
Long-term follow-up may be recommended for high-risk patients.
Key Points
Exam Focus:
Indications for mesh repair in adults (defect size >2-3cm, recurrence)
Types of mesh and their uses
Principles of tension-free repair
Common complications and their management
Differentiating incarcerated from strangulated hernias.
Clinical Pearls:
Adequate mesh overlap is crucial for preventing recurrence
Meticulous dissection is important to avoid injury to bowel or vessels
For obese patients, consider extending the incision or using laparoscopic approaches for better visualization
Always rule out other causes of abdominal distension and pain.
Common Mistakes:
Inadequate mesh overlap or fixation
Insufficient fascial closure, leading to tension
Failure to identify and manage incarcerated bowel
Underestimating the risk of SSI with mesh
Not counseling patients adequately on postoperative restrictions, leading to early recurrence.