Umbilical and Epigastric Hernia — SAQ

Stem

A 50-year-old obese man presents with a 4 cm reducible umbilical hernia causing discomfort on lifting and bending. He has no features of incarceration. [1]

Questions

a) What is the diagnosis and why does it need treatment? (2 marks) [1]

Adult umbilical hernia, 4 cm, symptomatic. Adult umbilical hernias NEVER close spontaneously and require surgical repair. Left untreated, they progressively enlarge, causing pain, skin changes, and risk of incarceration/strangulation. [1]

b) What is the recommended surgical approach? (3 marks) [1]

Mesh repair for defects over 1 cm. Options for a 4 cm defect:

1. Open sublay mesh repair (retrorectus) — preferred; mesh behind rectus muscle
2. Laparoscopic IPOM — intraperitoneal onlay mesh; good for larger defects over 4 cm
3. Component separation for very large defects over 10 cm [1]

Primary suture repair is NOT recommended for defects over 1 cm (recurrence rate 10-25%). [1]

c) What pre-operative optimisation is important? (2 marks) [1]

1. Weight loss counselling (obesity increases recurrence risk)
2. Smoking cessation (impairs wound healing, increases recurrence)
3. Diabetes control (HbA1c under 8%)
4. Chronic cough/constipation treatment (reduce intra-abdominal pressure) [1]

d) What are the complications of umbilical hernia repair? (3 marks) [1]

1. Surgical site infection (5-10%) — higher in obese patients
2. Seroma/haematoma (10-20%) — common with mesh
3. Recurrence (under 5% with mesh; 10-25% without mesh)
4. Chronic pain (mesh-related nerve entrapment)
5. Mesh infection (1-3%) — may require mesh removal [1]

References

1. [1]Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Simons MP; European and Americas Hernia Societies. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg, 2020.PMID 31916607