Umbilical hernia by Dr. kiran maindale

detailed presentation on umbilical hernia for Ug and Pg students

1. Umbilical hernia By, Dr . Kiran Maindale (MS general surgery) Guided by: Dr. Yogesh Badwe ( Ms , PhD)

2. defination An umbilicqal hernia is a health condition where the abdominal wall behind the navel is damaged. The buldge can often be pressed back through the hole in abdominal wall, and may pop out when coughing or otherwise acting to increase intra- abdomial pressure.

3. Umbilical hernia is herniation at the site of umbilicus. Paraumbilical hernia is herniation at the midline 3 cm below or above the umbilicus ..… Europian hernia society

4. anatomy

5. Types Basically there are three types of umbilical hernia are seen: 1. EXOMPHALOS: It is developmental anamoly due to failure of whole or part of the miidgut to return to the abdominal cavity during early foetal life. So the organs remain protruded being covered by membrane ; Which contents 1.amniotic membrane 2. whortans gelly 3. iiner layer of peritoneum

6. 1. exomphalos minor: Where the sac is relatively small and to its summit is attached the umbilical cord. treatment: just twist of cord and retained by ferm strapping. 1. exomphalos major: Umblical cord is attached to the inferior aspect of large swelling containing samll and large intestine and the portion of liver. treatment: emergency surgery advised.to avoid bursting of abdomen.

7. 2. Umbilical hernia in infants and children: This is from weak umbilical scar, neonal sepsis It is symptomless Bulge seen when baby is crying More often in male child than female 2:1 ratio Initially spherical but if size increases it become conical. Strangulation is extrmely rare. Treatment: 90% cases it cures spontaniously within 12 to 18 months If not cured surgical intervention after 5 yrs. Counselling of parents.

8. Paraumbilical hernia of adults Its protrusion through the linia alba just above the umbilicus( supraumbilical ) or infraumbilical Contents: Greater omentum , small intestine transverse colon Majority of cases sac is loculated and adhesions of omentum to fundus . Seldom reducible. Females are far major victims 5:1 ratio.

9. Etiology: infantile/ congenital hernia: Delay in closure of ring Neonal sepsis Failure to return coils Aquired umbilical/ paraumbilical hernia: Obesity Multiple pregnancies Ascitesabdominal tumours Heavy excersise

10. Clinical features Infantile umbilical hernia: Upto 10% of infants higher in premature babies Symptomless and appear within few weeks of birth. Umbilical mass Increase on crying toa classical conical shape Stragulation is extremely rare below 3 yrs.

11. Acquired umbilical/ paraumbilical hernia: Female>males, commonly overweight Mass above and below umbilicus,protruding through umbilicus Crescent shape of umbilicus Painless or dragging pain due tissue tension/obstruction Firm and dull on percussion- omentocele Soft and Resonant on percussion- enterocele Mostly non reducible Sometimes reducible Expansile cough impulse in reducible cases.

12. Complications Irreducibility Incarceration Bowel obstruction Strangulation Skin ulceration Burst abdomen in case of exomphalos major.

13. management Congenital umbilical hernia Parentral reasuareance 90% resolve itself Coin strapping ( outdated) If persist beyond 2 yrs surgical correction advised.

14. Acquired umbilical or paraumbilical 1. if defect is less than 1cm Simple figure eight suture after reducing contents in cavity Repaired by darn technique.

15. 2.defect upto 2cm: Mayo’s vest over pants repair Mesh plasty for tensionless repairand reinforcementof wall. Apronectomy (excision of excess skin after mayos repair)

16. Mayo’s repair Transeverse curviline incison Hernia sac was identified and desected off Adhesions were seperated Sac was opened contents were reduced Non viable tissue removed Peritoneum closed Defect in anterior rectus sheath extended laterallyon both sides. Elevated to create flaps(upper and lower) Double bresting was done Suction drain was kept

17. Defect is more than 2 cm: Mesh repair is recommended. 1.within peritoneal cavity;(UNDERLAY) Tissue seperating meshtrough the defect fixed with overlap of 5cm 2.extraperitonealspace ; ( preperitoneal ) Plane below posterio rectus sheath developed Care to be taken to avoid button holing in peritoneum. Linia alba closed over mesh

18. Retromuscular ( sublay ): linia alba opened vertically. Posterior rectus sheath sutured together Rectus muscle elevatedto form retromuscular space for mesh. Mesh overlaps midline by 5 cm laterally. Maximum diameter of mesh is 10cm Most secure method.

19. other INLAY mesh: applied by plugs Having high recurrence rate. ONLAYmesh repair: Subcuticular Simplest open repair Close linia alba vertically Mesh placed on anterior rectus sheath Prone to infection Seroma is major complication Posterior and anterior componant seperation : I n giant and complex hernia.

20. Laproscopic repair Pneumoperitonum created. 2mm ports were inserted on lateral sides lower abdomen and on on upper 10mm. Contents of hernia were reduced by traction and external pressure. Non adherant mesh for intraperitoneal use was fixed to peritoneum and posterior rectus sheathusing staples, tracks or sutures.

21. Emergency repair In cases of simple incarseration without cliniacal evedence ofstrangulationrepair may be attempted laproscopically Mostly open surgery. Open suture repair. No mesh plasty is advised. 2stage repair may be advised.

22. Recurrence: Large seroma Surgical site infection Patients bmi more than 30 and defect more than 2 cm Cirhosis with uncontrolled ascites Wrong surgical technique.

23. updates Use of mesh repair results decresed recurrence rates for primary umbilical hernias For multiple comorbidity alwys repaire with mesh. There is high possibility of fewest ssi and recurrence in sublay repair. Topical gentamycinin addition to preoperative intravenous prophylaxis to lower infection rates.

24. Thank you