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

With an incarceration rate of 30% and a mortality of up to 15%, there is no doubt about the indication for surgical repair of umbilical hernias. One exception are small umbilical hernias with a fascial defect of ≤ 0.5 cm and thus a low risk of incarceration.

Small hernias / up to 2 cm

• Open repair
• No mesh required
• Gold standard: Spitzy repair

Moderate hernias / 2–4cm

• Open repair
• Mesh recommended
• Intraperitoneal mesh repair with anchor sutures
• PUMP technique

Large hernias / > 4 cm

• Open or laparoscopic repair
• Mandatory mesh!
• In large defects PUMP repair is not always indicated.
• IPOM
• Sublay technique

This presentation describes the

open preperitoneal umbilical mesh plasty = PUMP-Repair.

Caution is advised in:

• Cirrhosis of the liver with ascites
• Advanced malignancy
• Cardiopulmonary risk, e.g., heart failure (NYHA III and NYHA IV)

Medical history

• Duration and progression of hernia
• If rapidly increasing in size, rule out underlying intraabdominal disease!

Clinical examination

• Palpation with patient standing and supine, possibly Valsalva maneuver

Ultrasound of the abdominal wall

• Entire midline from xyphoid to the pubic symphysis
• Structure of the linea alba: Additional fascial defects, diastasis recti abdominis

• Depilation of the surgical field
• Marking the location of the hernia
• Patient fasting > 6 hours, no liquids > 3 hours

• Secondary healing
• Recurrence
• Hematomas, secondary bleeding
• Bowel injury
• Injury to adjacent structures
• Postoperative ileus
• Infection
• Thrombosis
• Embolism
• Reoperation
• Temporarily impaired postoperative exercise tolerance
• Chronic pain syndrome
• Umbilical skin necrosis

• General anesthesia
• Alternatively: Analgesic sedation in same-day surgery
• Rarely Epidural anesthesia (PDA) or Spinal anesthesia in non-same-day surgery patients

• Supine, possibly one arm adducted.

Surgeon to the right of the patient, with the assistant opposite.
Scrub nurse toward the patient’s feet, ipsilateral with assistant.

Implant:

• Non-absorbable, surface-reduced large pore plastic mesh
• Alternatively, a bio-mesh, as demonstrated in the video

Postoperative analgesia

• Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.
• Follow these links to PROSPECT(Procedures Specific Postoperative Pain Management) and the International Guideline Library.

Postoperative care:

• Inform patients about the reduced resilience of the abdominal wall!

Deep venous thrombosis prophylaxis

• Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.
• Note: Renal function, HIT II (history, platelet check)
• Follow this link to the International Guideline Library.

Ambulation

• Immediate
• Resume regular physical exercise once wound is healed.
• Sports and heavy physical exercise should be possible after 3-4 weeks.

Physical therapy

• Not necessary

Diet

• Immediate, no limitation

Bowel movement:

• Not necessary

Work disability

• Depending on patient’s job: 7-14 days