Umbilical Hernia Repair Technique

Updated: Aug 27, 2021
  • Author: Dana Taylor, MD, FACS; Chief Editor: Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS  more...
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Approach Considerations

Hernia repair with mesh should be considered for patients with defects larger than 4 cm. (Some would place the cutoff lower--for example, at 2.3 cm. [15]  or even as low as 1 cm. [16] ) The type of mesh to be used is selected on the basis of the surgeon's preference and experience. Open mesh repair of umbilical hernia appears to be associated with significantly lower recurrence rates than suture repair in adults. [17]  

Laparoscopic repair should be considered for obese patients, patients with defects larger than 4 cm, and patients with recurrent hernias. Robotic assistance has facilitated this approach. [18, 19, 20, 21]

Umbilical hernia repair is sometimes performed simultaneously with other abdominal procedures, such as abdominoplasty. [22]


Repair of Umbilical Hernia

The traditional Mayo repair consists of a vertical overlap with adjacent aponeurotic structures. A curvilinear transverse incision is made in a natural skin crease and should not exceed 180°. Additionally, an elliptical incision can be used for large hernias that require excision of excess skin.

With a fine-tipped instrument and electrocautery, abundant skin overlying the hernia is excised to clear fat from the hernia sac and to clear the abdominal wall circumferentially from the edges of the defect.

The incision in the aponeurosis is extended longitudinally on either side of the hernia defect. The hernia sac is encircled and excised from the edges of the fascia. The sac is transected from the base of the umbilicus. The contents of the hernia sac are reduced, and the sac is opened to allow inspection of the contents. All adhesions and scar tissue are lysed.

The contents are inspected for viability, and any compromised adherent omentum is resected.

The peritoneum is closed with an absorbable running suture. Flaps of fascia are raised off the peritoneum and overlapped with a 3-cm overlap. The flaps are closed with a monofilament nonabsorbable or long-acting absorbable 0 horizontal mattress suture. Relaxing incisions are placed 5 cm lateral to the defect. The overlying fascia is fixed to the anterior abdominal wall, and the umbilicus is inverted by fixing the undersurface to the fascia.

For defects larger than 4 cm, a mesh onlay, sublay, or underlay should be used. Sublay mesh should be placed between the rectus muscle and the posterior sheath. For a mesh underlay, adhesions to the peritoneum should be excluded. Nonabsorbable 0 sutures are used to secure the mesh to the anterior abdominal wall.

The peritoneum is then closed with interrupted or running absorbable suture. The undersurface of the umbilicus is fixed to the fascia. If large skin flaps have been raised, the subcutaneous space can be closed with absorbable suture or closed suction drains.

The wound is then closed with a running subcuticular suture. The onlay mesh is sutured to the fascia above the peritoneum with a 3-cm overlap on all sides.

The use of a tentacle-shaped mesh implant (with a central body and integrated radiating arms at its edge) for fixation-free repair of umbilical hernias has been described. [23]



Potential complications of umbilical hernia repair include the following (see Outcomes):

  • Seroma
  • Hematoma
  • Wound infection
  • Bowel injury
  • Paralytic ileus
  • Hernia recurrence

A retrospective study by Shankar et al identified the following factors as predictors of umbilical hernia recurrence [24] :

  • Ascites
  • Liver disease
  • Diabetes
  • Obesity
  • Primary suture repair without mesh

A study by Donovan et al (N = 979) found the following factors to be predictive of recurrence after open umbilical hernia repair [25] :

  • Higher body mass index (BMI)
  • Concurrent laparoscopic inguinal hernia repair
  • Current smoking
  • Diabetes
  • Primary closure repair of hernias ≥1.5 cm
  • Postoperative infection