Diagnosis, Treatment, and Surgery for Umbilical Hernias

An umbilical hernia is a weakness in the muscle around the umbilicus, or belly button, that allows the tissues of the abdomen to protrude through the muscle. An umbilical hernia is typically small enough that only the peritoneum, or the lining of the abdominal cavity, pushes through the muscle wall. In severe cases, portions of the intestine may move through the hole in the muscle.

Who Is at Risk

Umbilical hernias are typically present at birth and may seem to appear and disappear, which is referred to as a "reducible" hernia. The hernia may not be noticeable unless the baby is crying, pushing to have a bowel movement, or doing another activity that creates abdominal pressure.

• The umbilical cord, or the cord that delivers nutrients from the mother to the fetus, goes through the abdominal muscles, creating an area where a hernia can form.
  
• When umbilical hernias are present in an adult, it is typically after surgery in that area, during or after pregnancy, or in those who are overweight.

The belly button is often used as a place to insert instruments during laparoscopic surgery because the scar will be hidden in the folds of skin. For this reason, an incisional hernia can potentially form that looks like an umbilical hernia. 

Treatment

For most children, an umbilical hernia will heal itself by the age of three as the abdominal muscles strengthen and grow with the child. In some cases though, surgery may be necessary.

Unlike children, adults are no longer growing, so an umbilical hernia does not heal itself in the majority of cases.

When Surgery Is Necessary

A hernia may require surgery if:

• It doesn't heal on its own by the age of four or five
• It is large and is not expected to heal on its own
• It is cosmetically unappealing
• It occurs in an adult
• There is incarceration of soft tissue, omentum, or bowel
• There is strangulation of the small bowel (requires emergency surgery)

Umbilical hernia surgery is typically performed using general anesthesia and can be done on an inpatient or outpatient basis. Umbilical hernia repairs can be performed minimally invasively (laparoscopic or robotic). This is performed with multiple small incisions away from the hernia to assist with the placement of mesh.

Special care should be taken to adequately prepare children for the surgery.

Surgical Procedure

After anesthesia is started, surgery begins with an incision under the belly button. The procedure can also be done by laparoscopic and robotic techniques, using smaller incisions and inserted tools.

Then, the portion of the abdominal lining that is protruding through the muscle is isolated. This tissue is called the “hernia sac”. The surgeon returns the hernia sac to the abdomen, in its proper position.

• If the defect in the muscle is small, it may be sutured closed. The sutures will remain in place permanently, preventing the hernia from returning in the future.
• For large defects, suturing might not be adequate for repairing the hole in the muscle. In this case, a mesh graft will be used to cover the hole in the muscle. The mesh is permanent and prevents the hernia from returning, even though the defect remains open.

If the suture method is used with larger muscle defects (approximately the size of a quarter or larger), the chance of reoccurrence is increased. The use of mesh in larger hernias is the standard of treatment, but it may not be appropriate for people who are at risk of rejecting surgical implants or who have any condition that prevents the use of a mesh graft.

Once the mesh is in place or the muscle has been sewn, the incision can be closed. The incision is typically closed with sutures that are removed at a follow-up visit with the surgeon.

Recovering From Surgery

Most people are able to return to their normal activity within four to six weeks after umbilical hernia repair.

Your belly will be tender, especially for the first week. During this time, you should protect your incision during any activity that increases abdominal pressure by applying firm but gentle pressure on the surgical area.

The incision should be protected during:

• Rising from a seated position
• Sneezing
• Coughing
• Bearing down during a bowel movement
• Vomiting

When Is Umbilical Hernia an Emergency?

A hernia that gets stuck in the “out” position is referred to as an incarcerated hernia. If you have an incarcerated hernia, you need to get prompt medical care.

An incarcerated hernia can become a strangulated hernia if the tissue that bulges outside of the muscle becomes starved of blood supply. This can cause necrosis (death of the tissue that is bulging through the hernia), and it may also be life-threatening. A strangulated hernia is a medical emergency.

A strangulated hernia can be identified by:

• Deep red or purple color of the bulging tissue
• It may be accompanied by severe pain, but is not always painful
• Nausea, vomiting, diarrhea, and abdominal swelling may also be present