Perioperative management - Umbilical hernia, direct suture

Considering an incarceration rate of 30% with a mortality rate of up to 15%, there is no doubt about the indication for surgical treatment of umbilical hernias. An exception is small umbilical hernias with a fascial gap of less than 0.5 cm, which have only a low risk of incarceration.

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

If direct suture is considered, it can be performed continuously or as a single button suture technique end-to-end with slowly or non-absorbable suture material.

In this article, an operation according to Spitzy is applied. After inferior semilunar incision of the navel, the hernia sac is detached from the skin navel, the hernia sac/content is repositioned, and the hernia gap is closed with single button sutures. Some surgeons prefer a left or right lateral incision as it can be easily extended.

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

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

In obesity, data show a lower wound complication rate for lap IPOM compared to open procedures.

For defects > 4 cm, the approach should be as with incisional hernias.

• For elective procedures, infection-free skin conditions are mandatory; pressure ulcers and superficial skin infections should initially be treated conservatively.
• The indication for hernia repair in patients with liver cirrhosis and ascites should be critically evaluated; preoperative optimization of liver function may be considered. In cases of severe coagulation disorders (Quick < 50%, PTT > 60 s, platelets < 50 / nl) and pronounced portal hypertension with caput medusae, surgery should be avoided due to the risk of uncontrollable bleeding from abdominal wall vessels.
• A good respiratory condition, not compromised by acute infections, is also important. Elective procedures should be postponed in the presence of respiratory infections.

Medical History

• Duration and progression of the hernia
• In cases of rapid size increase, a pathological intra-abdominal event must be ruled out!

Clinical Examination

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

Ultrasound of the Abdominal Wall

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

Classification of Primary Ventral Hernias

• Control of infection situations
• Medication management in immunosuppression or anticoagulation
• Control of cardiac and pulmonary risk factors

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

• Intubation anesthesia
• alternatively: Analgosedation for outpatient surgeries
• rarely epidural anesthesia (PDA) or spinal anesthesia for non-outpatient patients

• Supine position
• Arms and legs adducted

• Surgeon stands to the left of the patient (at the level of the navel)
• Assistant opposite him
• Instrumental surgical nurse at the foot end on the surgeon's side.

none

Postoperative Analgesia:
Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, an increase with opioid-containing analgesics can be performed.
Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management).
Follow the link to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up:
Maintenance of basic mobility and light physical activity. Avoidance of sports and lifting loads for up to 4 weeks.

Thrombosis Prophylaxis:
Generally unnecessary; or follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization:
Immediate; resumption of normal physical activities after wound healing; after 3 - 4 weeks, heavier physical exertion and sports should be possible again.

Physical Therapy:
Not required

Dietary Progression:
Immediate, without restriction

Bowel Regulation:
Not required

Incapacity for Work:
Depending on the occupation, 7 – 14 days