Umbilical hernia in adults, is surgery necessary?

• Umbilical hernias in adults are a protrusion of the contents of the abdominal cavity through a defect in the wall of the belly.
• Umbilical hernias are usually congenital or incisional in origin, the latter being the most common in adults.
• The only treatment for a definitive solution to umbilical hernias is surgery.

An umbilical hernia in adults is a protrusion of part of the contents of the abdominal cavity through a defect or hole in the layers that envelop the abdomen without penetrating the skin. Umbilical hernias are located around the navel. 

Patients suffering from umbilical hernias notice and feel a mass that increases with physical exertion, coughing and all movements that increase pressure on the abdominal musculature.

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About 5% of the population has or has had an abdominal hernia in any location and 10% of these are umbilical hernias, most of them in the adult population. All abdominal wall hernias, including umbilical hernias, should be corrected by surgical means as the only method for their definitive resolution. 

Not all umbilical hernias should be operated to reduce them; the individual characteristics of each patient, as well as the size and clinical repercussions of the hernia, will determine whether or not surgical intervention is indicated.

Umbilical hernias in adults fall into a specific group of hernias that are medically referred to as ventral hernias. Ventral hernias are those protrusions of abdominal contents that protrude through the layers of abdominal wall tissues through a hernial orifice and are located in the anterior region of the abdomen. 

There is a wide variety of locations where ventral abdominal wall hernias can be found and these can generally be divided into 4 major groups: umbilical, paraumbilical, epigastric and Spiegel's.

Umbilical hernias in adults can be, from the point of view of their origin or etiology, of two types: primary or incisional.

Primary umbilical hernias in adults are those that appear in patients from the moment of birth and are due, among other reasons, to defects in the abdominal wall and the umbilical cord from its formation.

Incisional umbilical hernias in adults are those umbilical hernias that appear in relation to previous surgical interventions that present, over the years, weaknesses in the suture or internal surgical wound and that, after vigorous or prolonged efforts, find a defect through which to protrude.

Adult umbilical hernias are relatively easy to diagnose when they reach moderate or severe size. In this type of case, adult umbilical hernias are palpated as soft masses that may disappear with pressure into the abdomen and usually protrude again when the pressure is removed.

In small adult umbilical hernias, it may not be possible to palpate the contents of the umbilical hernia accurately. In such cases, an abdominal ultrasound may be necessary to certify the diagnosis. However, these types of lesions are the least frequent.

Umbilical hernias in adults generally have no associated symptoms except in severe hernias or hernial hernias with a narrow exit orifice for the volume of abdominal contents protruding through it. In these cases, it is possible that some of the abdominal contents may become obstructed and impede normal blood flow.

Depending on the type of tissue that is trapped in the obstruction, we can speak of a strangulated umbilical hernia. If the entrapment progresses over time and the umbilical hernia is not reduced, it is possible that the entrapped tissue may begin to suffer episodes of pain as a consequence of the lack of blood supply. 

If this occurs, it can lead to ischaemia and destruction of the trapped abdominal contents, requiring urgent surgery for resolution.

If the trapped contents of the umbilical hernia are part of the intestines of the digestive tract, abdominal retention or occlusion may occur. This entity prevents food and faecal contents of the intestines from moving along their normal course through the intestinal tract and becomes trapped at the site of the obstruction. If this situation progresses, it can cause significant pain, nausea and vomiting, and constipation and inability to pass gas are characteristic.

The only definitive treatment for umbilical hernias in adults is surgery.

There are a large number of surgical techniques for the repair of this type of abdominal wall lesion, but they can generally be divided into two: open surgical technique and laparoscopic surgical technique.

The conventional technique is the open technique, in which the umbilical hernia is closed by a simple suture layer by layer of the various structures that make up the abdominal alteration, always after the placement of a prosthetic mesh that consolidates the defect in the abdominal wall.

On the other hand, laparoscopic umbilical hernia resolution is a technique to repair the abdominal wall defect also with a mesh but through 3-4 small incisions in the abdominal cavity so that the laparoscope (a small instrument equipped with a light source that allows visualisation of the inside of the abdominal wall through a television entrance) and the instruments needed by the surgical team to place the prosthetic mesh and suture the hernial defect in layers.

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