(Also para-umbilical, supra-umbilical and epigastric hernias)
These hernias can all be called primary ventral hernias. Incisional hernias are secondary ventral hernias.
Umbilical (navel) hernias occur actually in the middle of the navel. The inside of the navel sticks out. Sometimes the swelling is just above the navel so you will see a swelling just above the umbilicus. In fact you can get a hernia anywhere down the middle of your abdomen, from navel to breast bone.
When they occur a bit higher up they are called epigastric hernias. So these hernias always occur in the midline, straight down the middle, because they come out between the two rectus muscles. The lump may sometimes seem to be off to one side, but the actual defect (the hole) is always in the midline.
What would I see?
A bulge or lump beneath the skin. It can vary in size, from the size of a small grape to a large grapefruit. It depends how big the hole becomes and how much pushes out.
KEY
1. Epigastric
2. Diastasis**
3. Supra-umbilical
4. Umbilical
When it is a hernia, what is the lump?
It is usually fat that lies beneath the muscle (part of our natural padding). Sometimes though, it may be intestine, and if that gets trapped then you have a problem. (See Strangulated Hernia)
Repair it or ‘wait and see’?
You should repair it as soon as possible.
These hernias can be relatively painless but if left alone they always enlarge. Like all hernias, if left alone they:
a) run the risk of strangulating
b) are more difficult to repair
(See also Is ‘no treatment’ an Option?)
Best repair?
This depends on the size of the hernia defect. Those that are less than 1cm can be repaired without a mesh, using sutures which overlap the edges of the hernia defect (or hole or gap) as a double- breasted jacket. This makes a repair robust, with a negligible risk of recurrence or failure. Using mesh gives the best, most secure repair, for those that are over 1 cm.
Our experience proves that the mesh should be placed beneath the split or hole or defect and sandwiching it between the muscle layer and the lining of the tummy or peritoneum (sub-lay technique). Putting it on top of the muscle layer (on-lay technique), a commonly used approach, can lead to all sorts of problems such as fluid accumulation under the skin and infection. That is another practical reason why a mesh is also difficult to insert when the hernia defect is less than 1cm.
Open or keyhole repair?
Both work well. However, laparoscopic (keyhole) repair though, has three problems:
- Laparoscopic surgery cannot be performed under local anaesthesia. Patients need a general anaesthetic
- You are making three or more holes to fix one. Only worthwhile if the hernia (and the defect) are fairly large, because the mesh that needs to be used to repair the hernia needs to be much larger than the size of the hernia defect. As a general rule, the mesh should be at least 3 times the size of the defect to get a good overlap around the defect
- The mesh is usually inserted in between the muscle layers. But there are some surgeons who insert the mesh inside the abdomen. This can cause problems if the intestine sticks to it.
See also the section comparing Laparoscopic hernia repair and open mesh repair.
