Perioperative management - Umbilical hernia repair, open, preperitoneal umbilical mesh plasty (“PUMP” repair)

Considering an incarceration rate of 30% with a lethality of up to 15%, there is no doubt about the indication for surgical treatment of ventral abdominal wall hernias. An exception are small umbilical hernias whose fascial gap is less than 0.5 cm and therefore have only a low risk of incarceration.

Hernia repair by direct suture is possible according to the guidelines of the European and American Hernia Society up to a hernia gap diameter of < 1 cm, provided there is no obesity (BMI > 30) and/or rectus diastasis.

EHS (European Hernia Society) and AHS (American Hernia Society) see the limit for the use of a mesh at > 1 cm. Only for defects of 0 - < 1 cm should a suture procedure be chosen with a margin of discretion for defects between 1 - 2 cm. Up to 4 cm, a preperitoneal mesh plasty is recommended, alternatively, minimally invasive sublay techniques (E/Milos, eTEP, TES) are also used, especially in the presence of rectus diastasis.

Round self-expanding meshes are obsolete because no broad parietalization, which is only possible laparoscopically, occurs. The reason is the anatomy of the plicae converging in the umbilicus, which prevent the unfolding of these meshes. The preperitoneal space is the actual optimal layer for umbilical meshes.

Presented in the article is the open preperitoneal, umbilical mesh plasty = PUMP-Repair.

This is a preperitoneal mesh technique with defect closure after insertion of a mesh that should overlap the defect by 3 cm on all sides. Therefore, the peritoneum must be dissected from the abdominal wall all around 3 cm around the defect.

In the open repair of ventral hernias, the hernia orifice is basically only stretched, but not surgically enlarged. An enlargement of the hernia orifice would transform a primary hernia into an incisional one with a significantly higher recurrence rate.

In obesity, there are data with lower wound complication rates for lap IPOM compared to open procedures.

For defects > 4 cm, proceed as with incisional hernias.

• For elective procedures, infection-free skin conditions are mandatory; pressure ulcers and superficial skin infections should initially be treated primarily conservatively.
• The indication for hernia repair in patients with liver cirrhosis and ascites should be critically weighed; if necessary, preoperative optimization of liver function should be considered. In cases of severe coagulation disorders (Quick < 50 %, PTT > 60 s, Thrombozyten < 50 / nl) and pronounced portal hypertension with caput medusae, surgery should be avoided, especially due to the risk of uncontrollable bleeding from abdominal wall vessels.
• It is also important to have a good respiratory situation that is not compromised by acute infections. In case of respiratory infections, an elective procedure must be postponed.

Medical History

• Duration and progression of the hernia
• In case of rapid increase in size, a pathological intra-abdominal event must be excluded!

Clinical Examination

The abdominal wall hernia is a clinical diagnosis and can usually be easily recognized in the standing patient. It is advisable to additionally examine the patient in a relaxed, lying position. If the patient is asked to lift the upper body, in reducible incisional hernias, the fascial edge, the extent of the fascial defect, and the surrounding muscles can usually be assessed.

Ultrasound of the Abdominal Wall

• entire midline from xiphoid to lower abdomen
• Condition of the linea alba: further fascial defects, rectus diastasis
• CT only in special cases

 Classification of primary ventral hernias

 Classification of secondary ventral hernias (incisional hernias)

The classification of secondary abdominal wall hernias is initially based on a medial or lateral defect location in the abdominal wall.

The defect location of medial hernias is then more precisely delimited into subxiphoid, epigastric, umbilical, infraumbilical, and suprapubic. Laterally, the defects are divided into subcostal, lateral, iliac, and lumbar.

Further consideration is given to the defect width of the incisional hernias: W1 (< 4 cm), W2 (4 - 10 cm) and W3 (> 10 cm).

If there are multiple hernia defects (mesh hernia, Swiss-cheese hernia), their size is determined by the total length and width.

• Control of infection situations
• Medication management in immunosuppression or anticoagulation
• Control of cardiac and pulmonary risk factors
• Single-shot antibiotic i.v. perioperatively (due to use of foreign material/mesh) if necessary continuation of the therapy in case of intraoperative signs of inflammation or bacterial contamination.

• Wound healing disorders
• Recurrence
• Hematomas, postoperative bleeding
• Intestinal injury
• Injury to adjacent structures
• Postoperative ileus
• Infection
• Thrombosis
• Embolism
• Reoperation
• Temporary postoperative activity restriction
• Chronic pain syndrome
• Umbilical skin necrosis