Section: Abdominal wall and retroperitoneum Sub-section: Hernias Curriculum: Curriculum, page 2
Clinical
- May be asymptomatic or produce localised pain or GI Sx
- Thinning, discoloration +/- necrosis of skin may occur with large hernias
Pathology
- Weakness at the superior rim of the umbilicus due to
- Attachment of the round ligament, urachus & umbilical arteries
- Insertion of the lowest tendinous insertion of the rectus abdominis into linea alba
- Usually have a small neck
- Intra-abdo contents (typically omentum) are often densely fused to sac
Management
- If symptomatic – repair
- Consider non-operative management in
- ++ Comorbidities
- Malignancy or malignant ascites
- Painless irreducible
- Asymptomatic with ascites
- Always warn about risk of losing umbilicus
Open Approach
- Vertical or curvilinear incision over or adjacent to the hernia sac
- Hernia sac dissected to its fascial attachments
- Once the fascia has been cleared, the hernia sac can either be inverted or excised
- Fascia subsequently closed with a non-absorbable suture
- If defect large or if the fascial edges cannot be approximated without tension, mesh should be used
- Consider mesh for all incisional hernias or > 1cm in diameter
- Mesh placed deep to (sublay or underlay) or over the fascia (onlay) and should be sutured circumferentially to the surrounding fascia to prevent migration
- Effort should be made to tack the skin of the umbilicus to the fascia to recreate a cosmetically appealing umbilicus