Umbilical Hernia Repair

Overview of Approaches and Review of

Literature

Paul W. Appleby, MD, Tasha A. Martin, MD,

William W. Hope, MD*

KEYWORDS
 Umbilical  Hernia  Repair  Mesh  Primary  Laparoscopic  Robotic  Open

KEY POINTS
 Although umbilical hernias are often thought of as simple to repair, long-term recurrences
and chronic complaints occur.
 Multiple treatment options exist for umbilical hernias, ranging from watchful waiting to sur-
gical repair.
 Open, laparoscopic, and robotic repairs of umbilical hernias have been described and
should be tailored based on clinical characteristics.
 In general, mesh use has been shown to decrease recurrence rates in umbilical hernia
repair; however, mesh can result in an increase in surgical site infections/occurrences.

INTRODUCTION

Umbilical hernias are some of the most common hernias encountered by surgeons;
approximately 175,000 umbilical hernias are surgically repaired annually in the United
States.1 Although umbilical hernias are often thought of as simple hernias, they can be
complex and, if not handled properly, can be irritating to patients and surgeons. A true
umbilical hernia is classified as a primary hernia; however, because the umbilicus is
often used for laparoscopic access, incisional hernias can occur at the umbilicus,
and surgeons should be aware of the distinctions between the 2. Several things
make umbilical hernias challenging, including the heterogeneity of presentation, mul-
tiple options for repair, and potential for complications, including infection and

Dr W.W. Hope’s disclosures: CR Bard: honorarium, speaking, and research support; WL Gore:
research support and speaking; Lifecell: consulting; and Intuitive: speaking and consulting.
Drs P.W. Appleby and T.A. Martin have nothing to disclose.
Department of Surgery, New Hanover Regional Medical Center, South East Area Health Educa-
tion Center, 2131 South 17th Street, PO Box 9025, Wilmington, NC 28401, USA
* Corresponding author.
E-mail address: William.Hope@nhrmc.org

Surg Clin N Am - (2018) -–-

https://doi.org/10.1016/j.suc.2018.02.001 surgical.theclinics.com
0039-6109/18/ª 2018 Elsevier Inc. All rights reserved.
2 Appleby et al

recurrence (Figs. 1 and 2). Debate continues regarding the indications for mesh use
for umbilical hernias, optimal techniques for repair, and the role of robotic technology
for repair.

OPEN TECHNIQUES AND USE OF MESH

A major decision facing surgeons when planning an open umbilical hernia repair re-
lates to mesh use. The use of mesh and precise indications for mesh and nonmesh
repair are debated with no clear consensus. Four prospective randomized trials
have evaluated the use of mesh for umbilical hernias; 3 of 4 reported lower recurrence
rates with mesh use,2–5 with the greatest benefit in patients with cirrhosis4 and pa-
tients undergoing emergent repair of incarcerated hernias.3 A population-based study
from the Danish Ventral Hernia Database reported similar findings.6 Reoperation rates
for recurrence were less in patients undergoing mesh repair compared with nonmesh
repair in 4786 patients undergoing elective open repair of small (2 cm) umbilical or
epigastric hernias.6

Primary Repair
Despite the fairly conclusive evidence supporting the use of mesh to decrease recur-
rence rates in open umbilical hernia repair, approximately 50% of elective umbilical
hernias in the United States are repaired using a primary (suture) repair, indicating a
reluctance among surgeons to use mesh in all cases.7 The Mayo repair, first described
in 1901, was a primary suture repair of umbilical hernias described as a “vest over
pants” fascial closure in a transverse orientation using 2 rows of horizontal mattress
sutures.8 Although this technique was popular for many years and is occasionally
used today, high long-term recurrence rates have limited its use with most surgeons
who use a simple, interrupted or figure-of-8 primary closure in a horizontal fashion
(Fig. 3).
Techniques of open primary repair vary. In general, however, patients should be
prepared similarly to other abdominal operations with general anesthesia and peri-
operative antibiotics. Most umbilical hernias can be approached through a 3 cm to
4 cm curvilinear infraumbilical incision in the infraumbilical fold. Blunt dissection is
begun on either side of the umbilicus to encircle the umbilical stalk and hernia

Fig. 1. Large complex primary umbilical hernia. Although umbilical hernias are usually
small, they can grow to large sizes and can be difficult to fix.
 Umbilical Hernia Repair 3

Fig. 2. Moderate-sized umbilical hernia. Umbilical hernias can be difficult due to the hetero-
geneity of size and associated clinical factors.

Fig. 3. Primary suture closure of a small umbilical hernia. Although the use of mesh is
advised for umbilical hernia repair to decrease recurrences rates, a large number of umbil-
ical hernias are still repaired in this fashion.
4 Appleby et al

sac. Typically, a hemostat is placed above and around the umbilical stalk (Fig. 4),
and the hernia sac is dissected off the stalk (Fig. 5). It is important to avoid
button-holing the skin at this juncture of operation. This can be avoided by placing
a finger or a blunt instrument in the umbilicus to help identify the junction. After the
hernia sac is dissected free, it can be opened to identify the contents. When preper-
itoneal fat or omentum is present, this can be reduced back into the abdominal cav-
ity or simply excised at the fascial level. At this point, the fascial edges should be
clearly identified. Most surgeons dissect approximately 1 cm to 2 cm of subcutane-
ous tissue off the fascia to ensure clear identification for suturing. Because there are
no studies relating to technique of suturing for umbilical hernia repair, this should be
left to the discretion of the surgeon and usually involves interrupted or figure-of-8
sutures. Although there is no convincing evidence as to the type of suture material
that should be used, based on some data from the Danish Ventral Hernia Database,
there seems to be a higher recurrence rate using absorbable sutures compared with
nonabsorbable sutures, so this should be considered when repairing umbilical her-
nias.9 After the fascia has been closed, the wound is irrigated, and the umbilical
stalk is sutured to the anterior fascia to restore the normal umbilical shape. The
skin can then be closed with an absorbable suture and dressing applied. When
the umbilical skin has been stretched from the hernia, a pressure dressing can be
applied to potentially reduce seroma formation.

Mesh-based Repairs
As discussed previously, the decision regarding mesh use is related to many patient
factors and hernia characteristics. In some cases, this decision is made at the time
of surgery after the hernia defect and integrity of the fascia are examined. When the
decision to use mesh is made, the proposed risks and benefits should have been dis-
cussed with the patient preoperatively.
After the decision to use mesh is made, the surgeon must choose the best mesh
type and placement location. In general, most elective umbilical hernia repairs are
clean, so a permanent synthetic mesh is typically recommended. There are few
data related to using biologic or bioabsorbable meshes due to the fairly low wound
and mesh infectious complications associated with mesh-based umbilical hernia re-
pairs. So these expensive mesh technologies are likely of little benefit and only
used for specific indications.

Fig. 4. Blunt dissection is performed to encircle umbilical stalk and hernia sac. Care must be
taken not to button-hole the skin when dissecting the hernia sac off the umbilical stalk.
 Umbilical Hernia Repair 5

Fig. 5. Hernia sac that has been dissected free containing preperitoneal fat.

Mesh choice should be based on the chosen repair technique. As in other ventral
hernia repairs, mesh can be placed as a sublay (an intra-abdominal, preperitoneal,
or retrorectus position), an inlay (mesh plug sewn to fascial edges), or an onlay
(mesh placed over primarily closed fascia). As with mesh repairs for ventral hernias
in general, there is no consensus on the ideal location for mesh placement, and this
should be based on the clinical scenario. Knowledge of the potential advantages
and disadvantages of different mesh products and mesh locations is essential. In gen-
eral, inlay techniques have higher recurrence rates and, therefore, should not be
routinely used. Sublay techniques have the theoretic advantage of using the body’s
forces to help hold the mesh in place and potentially allow wider mesh overlap without
having to create subcutaneous flaps that may increase wound infection rates. Onlay
techniques can be appropriate in some cases but require subcutaneous flap dissec-
tion for adequate mesh overlap and can lead to mesh exposure when superficial
wound infections occur.
Open umbilical hernia repair using a sublay mesh technique begins as described for
a primary suture repair. The patient is prepped/draped and preoperative preparation is
per standard abdominal surgery. A curvilinear incision below the umbilicus is made,
and the hernia sac is dissected off the umbilical stalk. When the mesh is to be placed
in the preperitoneal space, the hernia sac is not opened and can be dissected at the
level of the fascia with blunt dissection. This preperitoneal dissection is accomplished
circumferentially for several centimeters, and holes in the peritoneum are closed with
absorbable sutures. After adequate preperitoneal dissection, mesh of the surgeon’s
choosing is placed and fixed at the discretion of the surgeon. Although flat sheet
meshes can be used for this repair, several commercially available meshes work
well for the sublay repairs. These include the Ventralex ST Hernia Patch (CR Bard,
Warwick, RI), the PROCEED Ventral Patch (Ethicon, Sommerville, NJ), and the
C-QUR V-Patch (Atrium, Hudson, NH) (Fig. 6). Theses meshes have a string-like de-
vice attached to a flat sheet of coated polypropylene mesh to facilitate easy mesh
placement (Figs. 7 and 8). Another option for sublay repair involves the intra-
abdominal placement of mesh, which is technically simpler than the preperitoneal
repair. In this technique, the hernia sac can be opened and contents either reduced
or excised if contents are fat or omentum. The hernia sac is excised to the level of
the fascia, and blunt dissection intra-abdominally (typically with a finger) circumferen-
tially around the defect is used to ensure no other hernia defects. The mesh is chosen,
6 Appleby et al

Fig. 6. Laparoscopic view of remote preperitoneal umbilical hernia repair with mesh during
nonrelated laparoscopic procedure.

placed intra-abdominally, and fixed to the abdominal wall using sutures (Fig. 9). In
both of these repairs, the fascia is closed overlying the mesh after the tails of the
mesh are cut flush with the fascia. Skin is closured, and dressings are applied. The
last option for a sublay repair is the retrorectus repair. This is rarely required for umbil-
ical hernias due to the small size of the defects. In some cases of large umbilical her-
nias, however, this is a viable option. In this repair, a periumbilical vertical incision is

Fig. 7. Mesh prosthetic for umbilical hernia repair in the sublay position (either intra-
abdominal or preperitoneal). This mesh made of polypropylene has a tissue separating layer
so that it can be placed intra-abdominally.
 Umbilical Hernia Repair 7

Fig. 8. The mesh has a mesh string to facilitate placement through a small incision and
fascial defect.

made, and the hernia sac is dissected off the umbilical stalk and reduced or excised
(Fig. 10). The posterior rectus sheath is incised on the right and left sides and closed in
the midline, excluding the abdominal contents from contact with the mesh. Closing the
posterior rectus sheath at the most superior and inferior portion of the incision can be

Fig. 9. Laparoscopic view of an umbilical hernia mesh placed intra-abdominally through a

small curvilinear periumbilical incision. The mesh is typically fixed using sutures, but in
some cases, a hybrid laparoscopic-open repair can be done, and the mesh can be fixed lap-
aroscopically with tacks.
8 Appleby et al

Fig. 10. Large umbilical hernia (approximately 5 cm) approached through a periumbilical
midline incision and retrorectus repair.

difficult, because the incision is usually quite small. This can usually be accomplished,
however, with continued dissection. After the posterior rectus sheath is closed, a flat
sheet of mesh sized appropriately is placed and fixed per the surgeon’s discretion,
usually with sutures (Figs. 11 and 12). The anterior fascia is closed and followed by
skin closure and dressing application.
Onlay techniques for mesh repair of umbilical hernia are viable options in appropri-
ately selected patients. Onlay is likely not preferable in patients with obesity, diabetes,
or smoking. The umbilical hernia is dissected and repaired, as described for a primary
repair. After the fascia is closed, subcutaneous flaps are dissected to allow mesh
placement. Close attention should be directed to the width of the subcutaneous
dissection, because there is a relationship between wide mesh overlap and infection.
The wider the subcutaneous dissection, the more chance for infection. Mesh fixation is
left to the discretion of the surgeon. Suture, glue, and tack fixation have been
described. After mesh placement, the umbilical stalk can be sutured to the mesh
and followed by skin closure and dressing placement.

Fig. 11. Synthetic polypropylene mesh chosen for retrorectus repair and fixed using transfa-
cial sutures.
 Umbilical Hernia Repair 9

Fig. 12. Mesh placed in the retrorectus space and fixed with 4 sutures. The anterior fascia
will be closed overlying the mesh for repair of this large umbilical hernia.

Although there is no definitive literature supporting 1 mesh-based technique for um-

bilical hernia repair, surgeons should know all the potential options and advantages and
disadvantages associated with each repair (Fig. 13). Because umbilical hernias are het-
erogeneous, type and repair technique should be tailored to each clinical scenario.

LAPAROSCOPIC TECHNIQUES

At present, the use of laparoscopy for umbilical hernia repair is fairly low. Studies
have indicated that laparoscopy is used in only one-quarter of cases.7 The American
College of Surgeons National Surgery Quality Improvement Program reported a po-
tential decrease in the total and wound morbidity associated with laparoscopic
compared with open, elective, primary repair of umbilical hernias.10 This came at
the expense of long operative time and hospital stay, with an increase in respiratory
and cardiac complications.10 After controlling for patient factors, including body
mass index, gender, American Society of Anesthesiologists class, and chronic
obstructive pulmonary disease, the odds ratio for overall complications favored

Fig. 13. Laparoscopic view of recurrent umbilical hernia that had been repaired using pri-
mary (suture) repair. Mesh has been shown to reduce recurrence rates in most studies and
series related to umbilical hernia repair.
10 Appleby et al

the laparoscopic approach, which was driven by reduced wound complications.10

Laparoscopic hernia repair is indicated for several reasons, including obesity, large
fascial defects, and previous hernia repair.11 The laparoscopic approach allows the
surgeon to unmistakably define the margins of the hernia defect and identify addi-
tional fascial defects or occult hernias. Some hernias include small facial defects
adjacent to the large defect, and, when missed, this can increase recurrence
rates.12 The laparoscopic approach also allows for wider mesh coverage, because
the mesh is placed in the intraperitoneal position. This technique has resulted in
decreased postoperative pain, shorter return to normal activity, and lower recur-
rence rates.13

PROCEDURE

The technique for laparoscopic repair first involves gaining access to the peritoneal
cavity, which includes many options. Surgeons should use the technique for laparo-
scopic access they feel most comfortable with, because there is no conclusive evi-
dence on the superiority of one technique. The authors place a Veress needle in the
left subcostal region followed by placement of an optical trocar after pneumoperito-
neum is established. Other options include cutdown technique or optical access
without Veress needle. The authors typically place 3 to 5 total ports depending on
the size of the defect and adhesions; however, many surgeons complete this repair
with 2 ports to 3 ports. The authors’ typical port placement involves an 11-mm trocar
in the midlateral left side of the abdomen and 2 additional 5-mm trocars in the left
upper and lower quadrants laterally. Diagnostic laparoscopy is initially performed,
followed by evaluation of the abdominal wall and hernia defect. One potential advan-
tage of the laparoscopic approach is the identification of additional hernia defects
along the linea alba above or below the umbilical hernia, that can be laparoscopically
repaired. Often, these defects are not identified during an open operation, especially
when the umbilical hernia defect is small and does not allow intra-abdominal palpation
of the linea alba (Fig. 14). The operation is begun by lysing adhesions to the abdominal
wall and reducing contents that are present in the umbilical hernia. Although this can
be the Achilles heel for the laparoscopic approach to incisional hernia repair, typically
adhesions in umbilical hernia repair are not too difficult (Fig. 15). After adhesions are

Fig. 14. Laparoscopic view of umbilical hernia with associated hernia above the defect. The
ability to see the entire abdominal wall and evaluate additional hernias is one proposed
benefit of the laparoscopic repair.
 Umbilical Hernia Repair 11

Fig. 15. Often, omentum is in the hernia sac and has to be dissected and reduced to eval-
uate the size of the defect.

taken down and the hernia is reduced, the hernia defect is measured intracorporeally,
and a mesh is chosen that allows at least a 3-cm to 5-cm overlap on all sides (Fig. 16).
Type of mesh and methods of fixation for laparoscopic ventral and umbilical hernias
remain an ongoing debate with no consensus. Due to this, the choice of mesh and fix-
ation technique are left to the discretion of the surgeon with a few caveats. Because the
mesh used is placed intra-abdominally, a mesh suited for intra-abdominal placement
should be chosen. Several mesh options include expanded polytetrafluoroethylene–
based meshes and the so-called coated meshes that include polypropylene or
polyester-based mesh with a tissue separating layer allowing for intra-abdominal
placement (Figs. 17 and 18).
The mesh should be placed and centered appropriately to allow for wide overlap of
the hernia defect. This can be done using sutures or commercially available posi-
tioning devices. Mesh can be fixated using sutures, tacks, glue, or a combination of
these. Aside from the debate about mesh type and fixation, there is disagreement

Fig. 16. The hernia defect should be measured intracorporeal to get an exact measurement
to help size the mesh. The defect can be measured by placing a ruler intra-abdominally or by
simply using a suture that can be stretched across the defect and measured outside of the
abdomen.
12 Appleby et al

Fig. 17. Mesh placement with wide overlap of the umbilical hernia defect (at least 3–5 cm in
all directions). Several tissue separating meshes are available that can be placed intra-
abdominally and fixed with a variety of commercially absorbable and nonabsorbable tacks
and/or sutures.

regarding whether the hernia defect should be closed in laparoscopic hernia repair in
attempts to mimic the open repair and potentially decrease recurrence and seroma
rates. Despite the theoretic advantage of fascial closure in laparoscopic hernia repair,
there has been no conclusive evidence supporting closure, and further study is
needed. When the surgeon decides to close the defect, this can be done using lapa-
roscopic suturing, a suture passer, or a hybrid technique with an open incision to close
the defect and laparoscopically place mesh.

ROBOTIC TECHNIQUES

Robotic technology is gaining widespread adoption in many fields of surgery. Initially

used in urologic and gynecologic surgery, it has now gained momentum in general
surgery, especially hernia surgery. Robotic surgery is similar in many ways to laparo-
scopic surgery with the proposed advantages of improved visualization, dexterity, and
ergonomics for the surgeon.14

Fig. 18. Mesh fixation using a permanent tacker and the aid of a mesh positioning device to
help keep the mesh on the abdominal wall during fixation.
 Umbilical Hernia Repair 13

Because robotic technology is an emerging technology in general surgery, there are

currently more questions than answers about its use for hernia repair. Despite this,
surgeons are increasingly adopting robotic technology for repair of ventral and umbil-
ical hernias. There is little literature to guide discussions related to robotic umbilical
hernia repair; however, several issues should be discussed. The use of the robot for
umbilical hernia repair at first seems like a waste of resources and time; however, if
there are some advantages associated with robotic technology, these should be eval-
uated in the same fashion as other emerging technologies.
Some of the proposed advantages of using the robot for minimally invasive and um-
bilical hernia repair include facilitating suture closure of the fascial defect (Fig. 19), the
ability to place mesh in the preperitoneal or retrorectus position, and the ability to su-
ture fixate mesh without the use of tacks or transfascial sutures (Fig. 20). Although
these proposed advantages may seem to be a step forward in hernia repair, they
require careful evaluation. There is little argument about the improved ability to suture
robotically compared with laparoscopically. Currently there is no conclusive evidence,
however, that suture closure of the defect in minimally invasive hernia repair signifi-
cantly improves outcomes. Despite the theoretic advantage of placing mesh in the
preperitoneal or retrorectus position, there is no good evidence that this is better
than intra-abdominal placement. Lastly, although there are some claims of decreased
pain with suturing of mesh compared with transfascial sutures and tacks, this again
has not been proved. Further study is warranted to evaluate these potential advan-
tages. Robotic surgery likely will find a place in the realm of minimally invasive hernia
repair, but its use should be justified, and it should be used in an economically sustain-
able way.

REVIEW OF THE LITERATURE

Although umbilical hernias are some of the most commonly repaired hernias in the
world, there are still many unanswered questions related to their repair, and the liter-
ature on the topic is sparse, with few well done studies.

TREATMENT OPTIONS

Few studies are available to guide the surgeon on the surgical treatment of umbilical
hernias. In general surgery, treatment is recommended for symptomatic patients. Two
studies evaluated the strategies of surgery and watchful waiting for umbilical hernias

Fig. 19. One proposed potential advantage of robotic hernia repair is the ability to facilitate
suture closure of the fascia. Although to date, this has not proved to significantly improve
outcomes, many surgeons favor closure of the defect to possibly reduce seromas and pro-
duce a more durable repair.
14 Appleby et al

Fig. 20. Due to the improved ability to suture using robotic technology, many surgeons fix
mesh during robotic umbilical hernia repair with a running suture, avoiding the use of tack
fixation and transfascial sutures. In this case, a mesh positioning device helps to hold the
mesh to the abdominal wall to facilitate suturing.

and have differing conclusions.15,16 Strosberg and colleagues15 evaluated a large

administrative database of 279 employees with umbilical hernias and their treatment
of surgery or no surgery. They reported higher financial cost in the surgical group
but significantly more days of health care utilization and more estimated work days
missed in the no surgery group and recommended early surgical intervention to poten-
tially decrease cost and resource utilization.15 Kokotovic and colleagues16 evaluated
569 patients with incisional hernias and 789 patients with umbilical/epigastric hernias.
They reported a 16% probability of patients with umbilical/epigastric hernias to require
surgery over 5 years and a 4% chance of requiring emergency surgery.16 The inves-
tigators also reported no significant outcome differences between the watchful waiting
patients who ultimately required surgery and the patients who underwent surgery
initially. They concluded that watchful waiting is a safe strategy in patients with umbil-
ical/epigastric hernias.

MESH

The use of mesh remains a debated topic for umbilical hernia repair. As discussed pre-
viously, the evidence is clear that the use of mesh reduces recurrence rates but
possibly increases the risk of surgical site infections and occurrences.2–6,17–19

LAPAROSCOPIC VERSUS OPEN

There are few good trials comparing laparoscopic and open repair of umbilical hernia.
Cassie and colleagues10 evaluated the American College of Surgeons National Quality
Improvement Program comparing outcomes for laparoscopic and open repairs of
elective umbilical hernias in 14,652 patients. They reported decreased wound compli-
cations associated with the laparoscopic repair but increased operating times, length
of stay, and respiratory and cardiac complications. This concept of decreased wound
morbidity in laparoscopic hernia repair compared with open has been well docu-
mented; however, it should be taken in context for umbilical hernia repair, because
the wound infection rate is low. One other randomized controlled trial evaluated the
postoperative use of abdominal binders after laparoscopic umbilical and epigastric
hernia repair.20 The investigators reported no difference in outcomes related to
pain, movement limitation, fatigue, seroma formation, general well-being, or quality
of life in the 56 randomized patients.20 They reported an improved subjective benefi-
cial effect, however, of using the binder in most patients.20
 Umbilical Hernia Repair 15

COMPLICATIONS

Although it is generally believed that umbilical hernia repairs are associated with
low recurrence and complications rates, there are few studies that evaluate long-
term outcomes of this common procedure, and several population-based studies
show outcomes that are likely higher than surgeons think. Two studies from
Denmark evaluated chronic complaints after repair of umbilical and epigastric her-
nias.9,21 Westen and colleagues9 surveyed 295 patients who underwent suture
repair of umbilical and epigastric hernias with a median follow-up of 5 years and
reported that 5.5% of patient had chronic complaints, such as pain or work/leisure
restrictions, and this could be explained in part by hernia recurrence. Erritzoe-
Jervild and colleagues21 surveyed 132 patients who underwent suture and mesh
repair of umbilical and epigastric hernias with a median follow-up of 36 months.
They reported 12% of patients had moderate or severe pain and discomfort and
a cumulative risk of recurrence of 11.5%.21 These 2 studies show that umbilical
hernias are not simple hernias, and surgeons should work to improve outcomes
in these patients.

SUMMARY

Umbilical hernias are common and often thought of as simple hernias; however, they
can pose many challenges to the surgeon, and long-term outcomes are still not ideal.
Open, laparoscopic, and possibly robotic techniques all have a role in umbilical hernia
repair, and their use should be determined by the requirements of the clinical situation.
Open techniques are used most often due to the small size of these hernias, and small
incisions typically are used for repair. Mesh repairs have been shown to decrease um-
bilical hernia recurrence rates and should be used in most cases but can result in
slightly higher wound morbidity. Laparoscopic repairs are usually well suited for obese
patients or patients at high risk for wound complications. Robotic surgery, an
emerging technology for hernia repair, may have some potential advantages, but
this must be weighed against the cost of this technology. Further study using robotic
technology is needed. Surgeons should continue to strive to improve outcomes for pa-
tients with umbilical hernias and clarify indications for the use of mesh and various sur-
gical techniques.

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