Umbilical Hernia Repair

It is also known as the exomphalos/ Omphalocele. It results from failure of part or all of the midgut to return to the coelom during early fetal life. It is classified as those that cause a fascial defect that is less than 4 cm (herniation of the umbilical cord) and those that has a fascial defect that is greater than 4cm.

1. Umbilical Hernia: Natural Course and Management

The good thing about umbilical hernias is that they rarely strangulate and most of them resolve spontaneously before the age of 3, therefore surgery is not necessary. After that age, if the umbilical hernia has not closed off on its own, surgery is indicated to repair the defect. Thus, the reassurance of the parents should be done, not just rushing into surgery.

A primary herniorrhaphy is performed for small defects while other technical approaches such as staged closure, skin flap closure, non-operative therapy, and primary closure are used for large defects involving the herniation of the liver, spleen, stomach, pancreas, colon or the bladder.

2. Indications

This procedure is done for small and large hernial defects involving the umbilicus. The small defects can be closed immediately after birth because the abdominal cavity is large enough to encase the small contents of the hernia. The large defect, which can involve herniation of the liver, spleen, stomach, pancreas, bladder or colon, which on the other hand require special approaches to the umbilical hernia using techniques such as skin flap closure, staged closure, non-operative therapy or primary closure.

3. How is this procedure done?

Large defects

Staged closure
This involves the use of a prosthetic to act as a source of support to the abdominal wall.
Primary closure
Because of the small size of the abdominal cavity in babies, room has to be created before the abdominal contents to be reduced into the cavity. It is done through the evacuation of meconium from the intestines then gradually stretching the skin to cover the ventral part of the hernia. The opening is then sutured after reducing the abdominal contents into the cavity, however, under tension.
Skin flap closure
This form of approach preserves the umbilical hernia like a cling film by stretching the skin over the umbilical hernia so that it can be repaired at a later date.
Non-operative therapy
In this approach, the umbilical hernia is not surgically treated because the risks of surgery outweigh the benefits. This scenario is mainly seen in premature infants that have comorbid conditions in which if the hernia is operated death is likely. Operation rescheduled to a later date when the baby is stable.

Small defects

A primary herniorrhaphy is indicated for small defects after the age of three years because most of them will close spontaneously before then. Reassurance to the parents should be given until the babies grow older. Primary herniorrhaphy involves making an incision below the belly button then reducing the intestinal contents then stitching the abdominal muscles back together.

4. Risk of this procedure

In the primary herniorrhaphy, the surgeon might cut part of the intestine especially because the defect is small, a single loop of the intestine might not be apparent during the surgery. This will cause an umbilico-enteric fistula.
In the primary closure of the large defects, vena cava compression may occur after the repair; therefore, an intragastric pressure monitoring is required to prevent this.
Secondary injury to other intestinal contents can occur.
Infection following completion of the procedure could result. Prophylactic antibiotics are given before the procedure and continued some weeks after the surgery to prevent infections.
In the primary herniorrhaphy, the surgeon might cut part of the intestine especially because the defect is small, a single loop of the intestine might not be apparent during the surgery. This will cause an umbilico-enteric fistula.
In the primary closure of the large defects, vena cava compression may occur after the repair; therefore, an intragastric pressure monitoring is required to prevent this.
Secondary injury to other intestinal contents can occur.
Infection following completion of the procedure could result. Prophylactic antibiotics are given before the procedure and continued some weeks after the surgery to prevent infections.

5. Getting ready for the procedure

The doctor should have assessed if you are fit for surgery. This would include the imaging studies carried out such as the ultrasound scan. Monitoring of the vital signs such as blood pressure. A full haemogram should also be done. Fasting before the surgery should then be done. This entails about 8 hours of no food or water before the surgery is due. This helps to minimize the complications of anesthesia.

6. Recovery after surgery

This surgery offers speedy recovery to the patients, more so with the laparoscopic approach. The patient can be discharged a day or two after the surgery. Within the first week, most of the healing has already taken place and removal of the bandages and sutures can be done at this point.

7. Outcomes

The surgical procedure is normally very successful, but in the case of an inadequately done procedure by the surgeon or failure to adhere to postoperative instructions such as avoiding strenuous activities, a recurrence of the inguinal hernia might occur.

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Hernia Repairs