Umbilical & Incisional Hernia

What is an umbilical hernia?

An umbilical hernia is a defect or weakness in the abdominal wall around the navel (umbilicus). Fatty tissue, and occasionally bowel, can protrude through this opening and produce a visible or palpable bulge.

In adults, an umbilical hernia may become more noticeable with coughing, straining, standing or physical activity. Factors such as obesity, pregnancy, chronic raised abdominal pressure and weakening of the abdominal wall can contribute.

A paraumbilical hernia develops immediately adjacent to the umbilicus and is managed according to similar principles.

What is an incisional hernia?

An incisional hernia develops through an area of weakness in the abdominal wall where a previous surgical incision has healed.

It may appear months or years after an abdominal operation. The hernia can occur after either open or laparoscopic surgery, although the size and pattern vary considerably.

Previous wound infection, obesity, smoking, diabetes, poor tissue healing, repeated abdominal surgery and increased abdominal pressure can increase the likelihood of developing an incisional hernia.

Incisional hernias range from small localised defects to large and complex abdominal-wall defects involving several previous scars.

What symptoms can these hernias cause?

The commonest feature is a bulge or swelling in the abdominal wall.

The swelling may become more prominent while standing, coughing or straining and may decrease when lying down.

Some patients have no pain. Others experience aching, dragging, discomfort or pressure, particularly during physical activity.

Large incisional hernias can interfere with movement, clothing, exercise or daily activity and may alter abdominal-wall function.

Not every abdominal bulge is a hernia. Conditions such as rectus diastasis, postoperative seroma and other abdominal-wall masses can sometimes resemble one.

How are umbilical and incisional hernias diagnosed?

Many hernias can be diagnosed by clinical examination.

Ultrasound can be useful when a small hernia is difficult to confirm clinically.

CT or MRI is particularly valuable for larger or recurrent incisional hernias because it can define the size and number of defects, muscle anatomy, previous mesh, hernia contents and other features needed for operative planning.

For many incisional hernias being considered for reconstruction, cross-sectional imaging helps the surgeon plan the safest and most appropriate repair.

Does every hernia need surgery?

No.

A small, reducible and minimally symptomatic hernia may sometimes be observed after discussion of the expected course and warning symptoms.

Surgery is more commonly considered when the hernia:

• causes pain or persistent discomfort;
• is progressively increasing in size;
• interferes with work, exercise or daily activity;
• becomes difficult to reduce;
• causes recurrent episodes of obstruction or incarceration;
• is cosmetically or functionally troublesome to the patient; or
• has features suggesting an increased risk of future problems.

The decision is not based on the scan size alone. Symptoms, age, fitness, occupation, obesity, previous operations and the complexity of the repair all matter.

When is a hernia an emergency?

A hernia can occasionally become incarcerated, meaning that its contents become trapped and cannot return into the abdomen.

If the blood supply to trapped bowel becomes compromised, the hernia is strangulated. This is a surgical emergency.

Urgent assessment is required for a previously reducible hernia that suddenly becomes very painful, tense or irreducible, particularly when associated with vomiting, abdominal distension, inability to pass stool or gas, fever or general deterioration.

Patients should not repeatedly force a severely painful irreducible hernia back into the abdomen without medical assessment.

Why is mesh commonly used?

Closing a hernia defect only with sutures places tension on tissues that may already be weak.

For many adult umbilical hernias and most incisional hernias requiring repair, mesh reinforcement reduces the risk of recurrence compared with suture repair alone.

Mesh is not identical in every operation. Its type, size and position are selected according to the anatomy and the operative technique.

Very small primary defects and particular clinical circumstances may occasionally be treated differently, so mesh use should be individualised rather than considered an automatic rule for every hernia.

How is an umbilical hernia repaired?

Adult symptomatic umbilical and paraumbilical hernias can often be repaired through an open incision near the umbilicus.

The hernia contents are returned to the abdomen, the fascial defect is dealt with and mesh reinforcement may be placed in an appropriate anatomical plane.

In selected patients, particularly with larger defects, multiple defects or increased risk of wound problems, a laparoscopic or minimally invasive approach may be considered.

The choice between open and minimally invasive surgery depends on the defect, patient factors, previous surgery and the surgeon's assessment.

How is an incisional hernia repaired?

Incisional hernia surgery is more variable because every previous abdominal incision creates a different anatomical situation.

The operation may be performed through an open, laparoscopic or other minimally invasive approach.

Where possible, the aim is usually to restore continuity of the abdominal wall by closing the fascial defect and reinforcing the repair with mesh rather than simply bridging a wide gap.

For many uncomplicated midline incisional hernias, retromuscular or retrorectus mesh placement is an established option.

Large defects, loss of abdominal-wall domain, multiple recurrences or complex previous mesh surgery may require advanced abdominal-wall reconstruction techniques. These operations need individualised planning.

Why is preparation before incisional hernia surgery important?

Unlike many small primary hernias, incisional hernia repair is often elective and provides an opportunity to reduce modifiable risks before surgery.

Important factors include:

• obesity and excess abdominal-wall strain;
• smoking;
• diabetes and poor glycaemic control;
• nutritional problems;
• active skin or wound infection;
• respiratory disease and chronic cough; and
• general cardiovascular and anaesthetic fitness.

Optimization does not mean that every patient must reach an arbitrary target before surgery. The aim is to balance the benefit of improving modifiable risks against the consequences of unnecessarily delaying treatment.

What is recurrence?

Recurrence means that another hernia develops at or near the repaired area.

No hernia operation can guarantee zero recurrence.

Risk depends on the original defect, tissue quality, obesity, smoking, wound infection, previous failed repairs, operative technique and other individual factors.

Following postoperative instructions and addressing modifiable risk factors can improve the conditions for successful healing but cannot completely eliminate recurrence.

What happens after surgery?

Recovery depends greatly on the complexity of the repair.

A straightforward small umbilical hernia repair may be performed as day-care or short-stay surgery.

Larger incisional hernia repairs may require several days in hospital and a longer period before full physical activity.

Early mobilisation is generally encouraged. Pain control, wound care and gradual return to activity are important.

The timing of driving, return to work, lifting and exercise should be individualised according to the operation and the patient's occupation rather than following one fixed timetable for every hernia.

When should medical attention be sought after surgery?

Urgent review is needed for severe or increasing abdominal pain, persistent vomiting, marked abdominal distension, breathing difficulty, fainting or significant deterioration.

Increasing wound redness, pus, fever, rapidly increasing swelling, persistent wound discharge or significant bleeding also requires assessment.

This information is intended for general patient education and does not replace examination or individual surgical advice.