Umbilical hernias: Clinical sciences

An umbilical hernia is a defect in the abdominal wall located at the umbilicus. This type of hernia usually occurs through the weakened umbilical fascia or through a defect formed at the site of involuted umbilical vessels. Small hernias often contain an empty sac, while larger ones can encase preperitoneal fat, omentum, or even a loop of bowel.

Most umbilical hernias are acquired in adulthood in individuals with elevated intra-abdominal pressure due to conditions such as pregnancy, ascites, or obesity. Umbilical hernias can present in four different ways: asymptomatic, symptomatic, incarcerated, or strangulated. Keep in mind that incarcerated or strangulated hernias might require urgent surgical intervention.

Alright, when you encounter a patient with signs and symptoms suggestive of an umbilical hernia, your first step is to perform an ABCDE assessment to determine whether the patient is stable or unstable. If the patient is unstable, you should stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, obtain IV access, and administer fluids before continuing with your assessment.

Now that unstable patients are taken care of, let’s talk about stable patients.

If the patient is stable, your first step is to obtain a focused history and physical examination.

First, you might encounter a patient with no symptoms. However, the physical exam might reveal a soft, protruding mass protruding from the umbilicus with some mild tenderness on palpation, but no overlying skin changes. The mass will be easily reducible. This is a classic case of an asymptomatic umbilical hernia.

In terms of treatment, these hernias can often be managed with watchful waiting. However, elective repairs can be considered for defects with high potential for becoming larger, which may increase the risk of incarceration and strangulation. If your patient wishes to wait, advise them to seek medical attention for any new-onset or worsening umbilical pain, or if they are suddenly unable to reduce the hernia.

Alright, let’s go back to our history and physical examination and talk about symptomatic umbilical hernias.

You can expect patients with symptomatic hernias to report some pressure and sharp pain in the umbilical area. On physical exam, you might see a soft, protruding mass in the umbilical area with tenderness on palpation. There will be no skin changes, and the hernia will be reducible. If you find these characteristics, you can diagnose the patient with a symptomatic umbilical hernia. These hernias should be electively repaired, so make sure to call the surgical team for a consultation. In the meantime, counsel your patient to seek immediate medical attention if the pain worsens, or if they are suddenly unable to reduce their hernia.

Okay, let’s move on to patients with signs and symptoms of an incarcerated umbilical hernia.